Inspection on 13/03/06 for Hurst Hall

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hurst Hall 31/10/07

Hurst Hall 02/11/06

Hurst Hall 02/11/05

Hurst Hall 03/03/05

Hurst Hall 13/07/04

Hurst Hall 29/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hurst Hall Kings Road Ashton-under-Lyne Tameside OL6 9EG Lead Inspector Steve Chick Unannounced Inspection 13th and 14th March 2006 12:00 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 Hurst Hall DS0000005572.V280440.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. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hurst Hall Address Kings Road Ashton-under-Lyne Tameside OL6 9EG 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) 0161 330 4772 0161 330 8195 Tameside Care Limited Care Home 50 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (50), of places Physical disability over 65 years of age (24), Sensory Impairment over 65 years of age (5) Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 50 OP up to 50 DE(E) up to 24 PD(E) and up to 5 SI(E) 2nd November 2005 Date of last inspection Brief Description of the Service: Hurst Hall is a single storey, detached building which was purpose built several decades ago. It has benefited from a continuing programme of improvement to reflect changing standards and expectations. It offers accommodation in single rooms for up to 50 older people and is run by Tameside Care Ltd, a not for profit organisation, which also runs other homes in the Tameside area. The home is located on the outskirts of Ashton under Lyne, with public transport links to central Ashton. The home has, in addition to service users’ bedrooms, four lounges, two dining areas, a large conservatory and a dedicated hairdressing room. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection four service users were interviewed in private, as were two relatives of service users, a visiting professional and two staff members. Additionally discussions took place with the manager. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, medication records and the complaints log. This inspection was unannounced on the first day. The inspector returned by appointment on the second day to interview service users and staff. Not all key standards were assessed at this inspection and it is strongly recommended that this report is read in conjunction with the report of the inspection which took place in November 2005. What the service does well: What has improved since the last inspection? The good standard of service user centred care has been maintained. Hurst Hall DS0000005572.V280440.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. Hurst Hall DS0000005572.V280440.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 Hurst Hall DS0000005572.V280440.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): EVIDENCE: None of these standards were assessed at this inspection. Hurst Hall DS0000005572.V280440.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): 7, 8 and 9. Written plans of care are created and reviewed to ensure staff are aware of, and can meet, service users’ care needs. The home works well with health care agencies to promote the health of service users. Medication procedures are appropriately followed to ensure the health needs of service users are met. EVIDENCE: A random selection of service users’ files were scrutinised. All had a copy of a written care plan that gave appropriate information in relation to how an individuals assessed care needs should be met. Staff who were interviewed confirmed that these written plans were used as a resource for care staff, and were found particularly useful in the initial period of getting to know a service user. Not all care plans were signed by the service user or a representative, to confirm their involvement in the process and agreement with the outcome. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 10 There was documentary evidence that the care plans were regularly reviewed. Service users who were spoken to reported a high level of satisfaction with the way their care needs were met. Relatives spoken to also expressed satisfaction with the care offered. There was documentary evidence of service users having access to the full range of medical and paramedical services available in the community. A visiting medical professional reported favourably on the home’s commitment to working, with appropriate agencies, on maintaining the health care needs of service users. Service users and visitors spoken to, expressed confidence that the home sought medical support in a timely manner. One service user was able to cite an example when an emergency doctor had been called for her during the night. One relative was pleased to note that it was Hurst Hall who had instigated a reassessment of their mother’s medication resulting in a reduction in her sedatives The home has an appropriate medication procedure and policy. This was not scrutinised at this inspection. Medication was seen to be stored appropriately. Medication administration records presented as being appropriately maintained and were subject to regular audits by the manager. Documentary evidence was seen of risk assessments relating to service users who were administering their own medication. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 11 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): EVIDENCE: None of these standards were assessed at this inspection. Hurst Hall DS0000005572.V280440.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 an appropriate attitude to complaints that enables service users to feel confident that they will be listened to. Appropriate adult protection procedures and training are in place to maximise the safety of service users, to enable them to live free from the fear of exploitation or abuse. EVIDENCE: The home has an appropriate written complaints procedure which is made available to service users and their representatives. Scrutiny of the complaints record indicated that it was appropriately maintained. All service users and visitors who were asked expressed confidence that any complaint would be taken seriously and dealt with appropriately. One service user said “I know I can tell [the manager] about complaints, I was told so by [the manager] who said – if there is anything you don’t like, you must speak out.” Another service user cited the best thing about the home as having been told “if you have any problems come and see us.” A third service user believed the staff to be “genuine” about complaints “which gives you confidence in them.” One visitor confirmed that “anything we say is taken on board.” Staff who were spoken to also expressed the view that the management team at the home would treat any complaint appropriately. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 13 Hurst Hall has an appropriate procedure for the protection of vulnerable adults. All service users and visitors spoken to during the inspection expressed the view that service users were safe at Hurst Hall. None could recall observing any staff behaving in an inappropriate manner to any service user. Staff who were interviewed demonstrated a good understanding of the need to be vigilant about poor practice. Staff also demonstrated a good understanding of the company’s ‘whistle blowing’ policies. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 14 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): 19 and 26. Hurst Hall presents as being clean, tidy and well maintained, to enable service users to live in a comfortable environment. EVIDENCE: A tour of the building was undertaken. This included a random selection of service users’ bedrooms. The home presented as being appropriately maintained, with no items identified which required remedial action that were not already being addressed by the manager. The building work on the roof, identified at the previous inspection had been completed. There had been no improvement in the ‘stained’ look of several carpets in some communal areas. The manager reported that this had not yet been resolved with the carpet manufacturer, but she understood the company was planning to replace them. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 15 At the time of this unannounced inspection the home presented as being clean and tidy with no unpleasant odours. Service users and all visitors spoken to confirmed that this was the usual state of the home. One visitor felt that sometimes there were dirty cups lying around unnecessarily, but was also clear that, apart from that observation, the home was maintained in a clean and tidy condition. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 16 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): 29. Recruitment procedures are not applied with sufficient rigour to minimise the risk to service users of inappropriate staff being employed. EVIDENCE: A selection of files relating to recently recruited staff was scrutinised. Most vetting procedures presented as being appropriately followed. However there was an example where a CRB (criminal record bureau) disclosure (or POVAfirst statement) had been received after the staff member commenced employment. Another example was seen where the applicant’s employment record was in insufficient detail to establish a satisfactory explanation for any gaps in employment. Service users spoken to were very complimentary about the staff team’s attitude. Staff were described as “very pleasant and helpful”, “friendly and helpful”, “ … I can laugh with them which I think is very important.” Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 17 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. Written outcomes from quality audits do not include information on how issues will be addressed, which would enable service users to monitor progress on improvements. EVIDENCE: Since the previous inspection the registered manager had resigned and a new manager appointed. At the time of this inspection the new manager’s application to the Commission for Social Care Inspection was being processed. The company has a range of Quality Monitoring and Quality Audit procedures. A Quality Audit had taken place in 2005 which included ascertaining the views of service users. The results of this survey had been ‘published’, but without a written action plan indicating how any issues identified in the process were to be addressed. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 18 The manager reported that this was an administrative oversight as issues had been addressed in service users’ meetings in October 2005 and followed up in February 2006. Documentary evidence of the minutes of these meetings, which confirmed this, was seen. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 19 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 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 20 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. 1. Standard OP29 Regulation 19 Requirement Timescale for action 01/05/06 2. OP33 24 The registered person must ensure that the procedure for the vetting of new staff is rigorously followed before that person commences employment. The registered person must 01/07/06 ensure that quality audits include an action plan that identifies how areas for improvement are to be addressed. 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. Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that service users personally sign to confirm that they are in agreement with their care plan unless there are documented reasons why this is not appropriate. Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Hurst Hall DS0000005572.V280440.R01.S.doc Version 5.1 Page 22 - 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. 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