Inspection on 07/02/06 for Huntercombe Hall Care Home

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Huntercombe Hall Care Home 23/07/07

Huntercombe Hall Care Home 30/05/06

Huntercombe Hall Care Home 04/08/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Huntercombe Hall Care Home Huntercombe Hall Huntercombe Place Nuffield Henley on Thames Oxfordshire RG9 5SE Lead Inspector Annette Miller Unannounced Inspection 7th February 2006 13:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Huntercombe Hall Care Home Address Huntercombe Hall Huntercombe Place Nuffield Henley on Thames Oxfordshire RG9 5SE 01491 641792 01491 641761 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Huntercombe Hall Limited Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named under age resident Date of last inspection 4th August 2005 Brief Description of the Service: Huntercombe Hall is registered to provide nursing care for up to 48 male and female service users aged 60 years and over. Registered nurses are on duty 24 hours a day. The home is in a rural part of Oxfordshire and public transport is limited. There is a country bus service, but the bus stop is some distance from the home. The public rooms are spacious and are on the ground floor. There are 40 single and 4 double rooms situated on the ground and first floors with each room having its own en-suite facilities of toilet and washbasin. Two single rooms have an en-suite shower suitable for infirm residents. There is a pleasant patio with garden tables and chairs accessible from the conservatory that overlooks the home’s extensive grounds. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 1 pm to 6 pm. During this time a tour of the building took place and documents were examined. A discussion was held with four residents, four relatives and one member of staff to obtain their views of the home and the services provided. The home does not at present have a registered manager and the company has provided an experienced manager (Ms Felton-Scott) to manage the home until the vacancy is filled. Ms Felton-Scott was on duty and was present throughout the inspection. A regional manager from the company was also at the home with a new regional manager who was being introduced to the home. These managers also stayed until the end of the inspection. The inspector was made to feel welcome by all staff and appreciated their cooperation. In order to gain an overview of the standards inspected during 2005/6 the previous inspection report dated 4th August 2005 should also be read. What the service does well: What has improved since the last inspection? Action to deal with the one requirement and two recommendations made at the last inspection regarding care plan records has been taken and senior staff are keeping this under review to ensure good record keeping is maintained. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected during this inspection. Standard 6 does not apply as intermediate care is not provided at this home. EVIDENCE: Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected during this inspection. EVIDENCE: Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. The staff have a good understanding of residents’ support needs. This is evident from the positive relationships that have been formed between the staff and residents. Residents’ choices are respected and acted on by staff. EVIDENCE: Residents said they liked the relaxed atmosphere in the home and that staff understood their needs. Residents choose whether to be in their rooms or in one of the lounges and can have meals served in the privacy of bedrooms if they wish, although there is a large separate dining room where most residents prefer to eat. There are two lounges and a large conservatory, all very nicely decorated and furnished. The large conservatory has ceiling blinds to keep the room cool during the summer months and this room is used for recreational activities. A full-time activity organiser is employed and art and craft materials were left out on one of the tables ready for the next day. One resident was asleep in the conservatory with one of the home’s two cats asleep on her lap, and in a lounge a TV was on with a number of residents watching it. A member of staff was present to provide assistance when needed. Two residents have a regular arrangement to meet in the ‘quiet’ lounge after lunch for a game of cards, which they said they enjoyed very much. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 11 There is a programme of social and recreational activities and information about daily events is displayed in the home. The chef is planning to hold monthly meetings to provide an opportunity for residents to discuss menus, likes and dislikes, etc. The first meeting is scheduled to take place on 22nd February 2006. The home operates ‘open’ visiting. A daughter and son-in-law said they were able to ‘come and go’ as they pleased. Another visitor said he appreciated the friendliness of staff and that he was made to feel welcome. He commented that he was always offered a hot drink when refreshments were served to his mother, which he appreciated. Residents handle their personal finances and affairs for as long as they can, but when this is no longer possible this responsibility is passed to a next-ofkin. It is company policy that residents can bring in personal possessions for their rooms and there was evidence of this in the bedrooms seen. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints procedure that ensures anyone wishing to make a complaint is provided with the information needed. The home has systems in place to protect residents from abuse. EVIDENCE: The home has a complaints policy that sets out the stages and timescales for making complaints, and where complaints should be sent within the company. The address and telephone number of the Commission for Social Care Inspection (CSCI) is also provided for any person to refer a complaint directly to CSCI if this option is preferred. Information about the complaints policy is provided in the terms and conditions and in the Service User Guide. These documents are issued to residents prior to admission. However, the complaints procedure was not prominently displayed in the home and this is recommended. The Oxfordshire multi-agency guidelines on the protection of vulnerable adults were not available and should be obtained. These guidelines contain comprehensive information about the protection of vulnerable adults, as well as setting out the guidance on how any concerns or allegations are investigated in Oxfordshire and reference to the information provided should be used in staff training. Training records showed that adult protection training had occurred throughout 2005. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected during this inspection. EVIDENCE: Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing numbers meet the levels considered adequate to meet the care needs for the current residents. The number of carers with a national vocational qualification (NVQ) in care has not yet reached 50 of the total number of carers employed, but good progress is being made towards achieving this ratio. The required recruitment information and checks for new workers are obtained. There was evidence of a planned programme of training in place for staff. EVIDENCE: There were two registered nurses and seven carers on duty throughout the day for 45 residents, and two registered nurses and three carers overnight. The manager was also on duty and was not included in these numbers. This level of staffing was one carer above the minimum number of staff required. No concerns were raised with the inspector during the inspection about staffing levels. One visitor thought the present staff were very good, saying they were the “best bunch” since her relative had moved into the home. One carer out of 15 has a NVQ in care. Four carers have an equivalent qualification. This gives a ratio of 33 of care staff with the required level of training. Twelve carers are registered on the NVQ training programme, but to Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 15 achieve a fully met score for Standard 28 the home must have 50 of care staff with a care qualification at least to level 2 NVQ, or equivalent. Three staff files were inspected and the information and checks required for new employees had been obtained. However, the files were not well organised and had many loose leaf documents jumbled together. A better system of filing should be put in place to ensure documents are easily accessible and to reduce the risk of documents being misfiled. The manager should ensure that the professional identify number (PIN) of any nurse appointed is verified with the Nursing and Midwifery Council (NMC) before the nurse starts work in the home. One of the files inspected was for a nurse and the PIN details had been photocopied, but there was no record of verification with the NMC. The inspector was assured this had been done, but that a copy of the verification details had not been placed on file. New employees are provided with a period of induction and during this time they are not included in the staff numbers. During the first week in the home they are provided with mandatory training and shadow a senior member of staff to gain an understanding of residents’ care needs. The home’s induction programme is based on the Skills for Care Council approved induction training programme and workbooks are issued to new workers to complete. The person supervising the new worker signs the workbook when each element of learning has been satisfactorily completed. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 There are systems in place to obtain residents’ views of the services provided ensuring improvements can be planned and implemented. EVIDENCE: The company has a quality assurance department that arranges for questionnaires to be sent to residents and other key people involved with the home to obtain feedback about the care and services provided. Questionnaires were last distributed in January 2006 and the company was collating the results at the time of inspection. The manager said she would receive feedback about the outcome of the survey from a regional manager as soon as the results were known. Questionnaires are also sent out during the year on specific topics, for example during February 2006 it was planned to send out menu questionnaires to residents. The present relief manager has an ‘open-door’ style of management that enables people using the home’s services to see her without an appointment. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 17 Residents’ meetings are held and minutes are taken and displayed. The next meeting was scheduled for 22nd February 2006. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP16 OP18 OP27 Good Practice Recommendations Display a copy of the complaint’s procedure in a prominent position within the home. Obtain the Oxfordshire multi-agency guidelines on the protection of vulnerable adults. ●A copy of the verification details of a nurse’s professional identity number with the Nursing and Midwifery Council should be placed on file. ●The system for storing recruitment documents within staff files should be improved to ensure the required information and checks are easily accessible and to reduce risk of documents being misfiled. Huntercombe Hall Care Home DS0000063474.V282627.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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