Inspection on 21/10/05 for Hunters Moon

This inspection was carried out on 21st October 2005.

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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hunters Moon 21/04/09

Hunters Moon 24/04/08

Hunters Moon 05/12/06

Hunters Moon 03/05/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hunters Moon Grittleton Road Yatton Keynell Nr Chippenham Wiltshire Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 21st October 2005 09.30 Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 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 Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 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 Adults 18-65. 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. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hunters Moon Address Grittleton Road Yatton Keynell Nr Chippenham Wiltshire 01452 300025 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) Holmleigh Care Homes Ltd Cheryl Jane Beard Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Hunters Moon is one of a number of care homes owned by Holmleigh Care Homes Ltd, which operates homes in Gloucestershire and Wiltshire. This is a new service that opened in September 2005. Hunters Moon is in the village of Yatton Keynell, close to Chippenham. There is a pub and a shop in the village. The home has a vehicle for service users’ use. This was previously a family home, which has been adapted to include ensuite bathrooms with each bedroom. There are bedrooms on the ground and first floor. Access to the first floor is by stairs only. There is a large lounge, a conservatory, a dining room and separate kitchen and a separate utility area. There are large gardens to the rear of the home. At this time, the home has only one service user. Day care services are offered for two prospective service users. There are at least four staff on duty each day and one staff member sleeping in. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two days, with the first visit taking place on 21st October 2005. A second visit was arranged for 4th November 2005. The following records were seen; care plans and admission documents, staff records, medication, some policies and procedures and fire safety records. There was a partial tour of the premises. The home had been registered only a few months prior to the inspection, during which, the premises had been closely looked at. Service users are unable to comment directly on their care, so time was spent on the second visit observing the interaction between staff and service users. Service users actively sought staff and spoke or approached them with ease. Staff paid great attention to the service users in trying to find out what their needs were and to offer choices and then meet their needs. Three staff were spoken with during these interactions. Service users’ needs were respected and the care provided was given with sensitivity as relationships are still being developed. Staff commented on how enjoyable they found the work and how they feel at ease with each other as part of a new team. They also felt the manager and deputy manager were approachable. An immediate requirement was issued on 21st October 2005 regarding fire safety records. Checks had been made, but wrongly recorded. This was then actioned and resolved by 4th November 2005. What the service does well: What has improved since the last inspection? This is the home’s first inspection. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 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. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users benefit from a full and detailed admission process that is tailored to meet their needs. EVIDENCE: Information about new service users is gathered before admission from the previous placements and care managers or health care professionals. There is a clear admission procedure with an approach that depends on the time and needs of the service users. There is a five step approach with a full needs assessment and a check that the home can meet the service users’ needs. There is a three month trial period when there is a care plan review. There is a period called ‘transition,’ which enables the service user to try out the home and see if it is suitable, through day visits, meals and overnight stays. An assessment completed by the care manager showed a comprehensive assessment of the service users’ needs. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Service user care plans are detailed, reflecting the range of needs they may have. Service users are supported to make decisions and choices based on staff knowledge about their preferences. Service users could be at risk from a lack of documentation surrounding risks in the way medication is administered. EVIDENCE: There is a care plan in place, which was relevant and up to date and signed. Changes had occurred by the time the second visit was made and the care plan had been adjusted. The plan includes details of the actions staff are to follow after a description of the current situation. Staff are asked to say that they have read and understood the care plan and no staff have signed this. At this time, the care plan is not accessible to service users. This was discussed with the manager. There is an activity plan in place and although this may not be followed at this time, the daily record shows what activities have been offered to the service user and what was provided. Staff are becoming familiar with the activities the Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 10 service user likes to take part in and are being guided by the service user’s response to choices. Risk assessments are in place, although for one particular circumstance, no risk assessment or care plan had been written. This relates to medication and the way it is given. Service users are unlikely to have an independent lifestyle as they require a high level of support at all times. There is an expectation within the organisation that staff sign to say they have read risk assessments. Staff from Hunters Moon have not signed the risk assessments to say they have read or understood it. They also relate to a different Holmleigh Care Home and needs to reflect risks that may occur in Hunters Moon. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16, 17 Service users have full and interesting lives. There are close relationships where appropriate to ensure that service users continue to be happy and benefit from long standing relationships. Service users benefit from a staff team who considers their rights and responsibilities. EVIDENCE: All of the above standards were looked but could only be related to one service user at this time. A range of activities are on offer and further opportunities are being investigated, such as horse riding and visiting a hydrotherapy pool. Future seasonal activities were being planned at the time of the inspection. At the point of registration, there was some resistance in the village about Hunters Moon opening. At this time, staff and the service user have used the local facilities occasionally and there have been no issues raised at all. Relationships are developing between service users as they get to know each other. Staff are supporting service users with family contact and any previous relationship that may be important to the service user. Doors are lockable and staff were observed to spend all their time with the service users, either sitting with them, or engaging in a one to one activity. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 12 Service users are able to move easily around the home and were observed to relax in the lounge and garden. Staff support service users with their household tasks and laundry. Daily records are being kept, but the record is not always being signed by the staff member who completed it. Menu records show a wide range of choices available for meals and service users are also offered snacks and drinks at frequent intervals. Where a poor diet or unusual diet has been identified, expert advice from a dietician or nutritionist should be sought. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal care is provided in the way service users prefer. Service users’ healthcare needs are assessed and are continuing to be met. In general, medication is provided with safe procedures, apart from one particular circumstance. EVIDENCE: There are records showing how service users are to receive personal care and all personal care will be provided by female staff. Records show how service users’ health care needs and emotional needs are being met. This includes information on a specific medical need and the staff response to it. This is good practice and also shows a developing understanding of what triggers a change in health, which can then be anticipated and acted upon. Service users are not able to manage their own medication. An issue was raised with the manager over the way medication is given to a service user. Medication cannot be given hidden in food unless this has been particularly identified by the prescriber. A protocol must be written to ensure that all staff follow the same procedure when giving medication. This has to be identified on the care plan and risk assessed, as it may not always be possible to assess if the medication has been taken. Where medication is refused, on a regular or occasional basis, the care plan and risk assessment must identify the action staff are expected to follow. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 14 Healthcare professional have been involved in the care of the service user and work with staff to maintain a level of good health. The medication policies and procedures should be amended to cover these circumstances and any other local practices that may take place in the home. Records are going to be kept for returning medication and a returns book was expected to be delivered. Medication is stored safely in the home. The manager was given the details of up to date guidance available from the Royal Pharmaceutical Society. All staff have received medication training, but have yet to receive their certificates. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users may not be fully protected by the complaints procedure. Service users are partly protected by staff who have some understanding of adult protection policies and procedures. EVIDENCE: There is a complaints procedure, which needs to be amended as it has the CSCI address for Gloucester rather than the local Chippenham office. No complaints have been received by the home, or the CSCI. There is a pictorial complaint procedure on the notice board in the hallway. This is also included in the statement of purpose and the service users’ guide. There is a policy which refers to the protection of service users and to the local Wiltshire and Swindon ‘No Secrets’ guidance. De- escalation of incidents is also described and includes examples of how abuse can occur. The manager has been looking for a suitable training course. The manager was advised to attend the training for managers that is organised by Wiltshire and then train staff in the home. Staff have received the ‘No Secrets’ booklet and when asked stated that they would report concerns to the manager in the first instance. There is a whistle blowing policy and procedure in place. The local CSCI contact needs to be included in this. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Service users benefit from a large and comfortable home that has been well fitted and decorated. Any maintenance to the home is acted on promptly, to ensure service users’ safety. Service users would benefit from risk assessments until this work has been completed. EVIDENCE: Hunters Moon is a detached house, set back from the road in its own grounds. The home fits in with village surroundings. There is parking to the front of the home and level access. There is a key code in use from inside the house and a time delay switch for opening the gates to the driveway. The home is starting to look more homely, with additional furniture on order. Some areas still need lampshades and curtains. Radiators are going to be covered, although no plan has been written and there are no risk assessments in place at this time. An occupational therapist has assessed the premises and there will be a ‘snoozelin’ room installed in part of the conservatory. There is a Jacuzzi bath on the ground floor and a communal bathroom on the first floor. All bedrooms have full ensuites of either a bath or shower with a toilet and hand washbasin. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 17 Bedrooms can be made more personal depending on the interests service users may have. There is a separate utility room with a washing machine and a dryer. Access is separate from the kitchen. At the moment, there is a problem with the lock, which has been reported, so that it can be fixed. The home was clean and tidy on the days of inspection. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Service users benefit from a staff team that has been inducted and trained in meeting their needs. Service users may be at risk from a lack of full information about staff during recruitment. Service users benefit from a supervised staff team. EVIDENCE: The staff team have been trained at the point of their employment and this includes an induction and essential training, such as food hygiene, first aid, fire safety training, health and safety training. Training that enables staff to work with service users’ needs includes epilepsy and positive behaviour management. Staff were being interviewed on the first day of the inspection. Application forms are completed at this point and the inspector discussed this with the manager. It may not be possible to gather full details of previous employment or the skills of prospective staff at this time. CRB applications are completed on the day of the interview. An offer of employment is made subject to CRB and two references. The range of records for all staff recruited were seen. Some records were missing, or parts of records, (for example application forms) not fully completed. In some cases, only one reference had apparently been provided. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 19 CRB records were in place in the form of a letter from the umbrella body, rather than the certificate itself. The manager would see all applicants and interview them as this is done on a visit to the home. Applicants are not short listed. Staff receive supervision on a six weekly basis and are appraised at a three and six monthly interval during their probationary period. After this, staff would receive annual appraisals. Team meetings are taking place monthly. Staff are able to contribute to agendas. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Service users benefit from a well run home. The quality assurance system has not been fully implemented yet. Service users’ safety is checked and responded to as required. EVIDENCE: The home has a manager and a deputy manager in place. The manager has NVQ level 4. Both pages of the registration certificate need to be displayed, as only one page was displayed on the day of inspection. The manager will ensure that policies and procedures are up to date and in place within the structure of the organisation. At the time of the inspection, it was not clear what the quality assurance process was, although references to it were found in the staff newsletter and statement of purpose. Since then, the manager confirmed that a system is in place and will be used. Copies of this policy need to be kept in the home. The owner completes regulation 26 visits and these are sent to the CSCI office. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 21 This includes a check on the fire safety records, which showed that all was in order. Fire safety records were seen on the first day of inspection. On examination it appeared as though several pages were missing from the manual and the records had been completed in error, as the headings had not been used accurately to record the required detail. It then appeared as though staff had not received fire safety training, nor had the fire alarm system been checked. At the subsequent inspection, the correct records were in place and had been completed properly. The fire alarm system should have a test on the call points at regular intervals and this should be identified on the recording sheet. All of the above should have been picked up on the Regulation 26 visit. COSHH records were in place for products in use in the home. Water temperatures are controlled to stay within safe limits. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hunters Moon Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000064634.V257172.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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. 1. Standard YA9 Regulation 13(4) (c) Requirement Timescale for action 30/12/05 2. YA20 3. YA22 4. YA23 5. YA24 6. YA34 Risk assessments for one service user must clearly state risks due to the way medication is being given and what to do in the event of refusal. 13(2) (4) There must be a clear protocol (c) from a healthcare professional with regard to the way medication is being administered for a particular service user. 22 (7) All copies of the complaints procedure must have the details of the local CSCI Chippenham office. 13 (6) The registered manager must receive adult protection training in order to cascade this training to the staff team. 13 (4) (b) Until radiators are covered, all (c) radiators must be risk assessed, based on the individual risk to service users. 17(4)19(1)b A full range of staff records c(4)abc must be held in the home, including a fully completed application form and two references including one from the last employer. 30/12/05 30/12/05 30/03/06 30/12/05 30/12/05 Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 24 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. 4. Refer to Standard YA9 YA16 YA17 YA20 Good Practice Recommendations Where staff are expected to sign risk assessments as read and understood, they should do so. Staff should ensure that they sign the daily record every time it is completed. Where a service user may have a poor or unusual diet, advice should be sought from a nutritionist or dietician. Medication policies and procedures should be amended to reflect any local practices. Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. Extracts may not be used or reproduced without the express permission of CSCI Hunters Moon DS0000064634.V257172.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!