Inspection on 02/11/05 for Hurst Hall

This inspection was carried out on 2nd November 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 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 13/03/06

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 11:30 2 & 10 November 2005 nd th 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.V263518.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 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.V263518.R01.S.doc Version 5.0 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 Lynn Mary Davidson 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.V263518.R01.S.doc Version 5.0 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) 3rd March 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.V263518.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection 7 service users were interviewed in private, as was 1 relative of a service user and 2 staff. Additionally discussions took place with the manager and deputy 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, including staff rotas, maintenance records and the complaints log. This inspection was unannounced on the first day. The inspector returned by appointment to speak with more service users. What the service does well: What has improved since the last inspection? Amendments required to some policy documents have been addressed. The good standard of care offered by Hurst Hall has been maintained. Hurst Hall DS0000005572.V263518.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. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 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.V263518.R01.S.doc Version 5.0 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): 2, 3, 4, 5 and 6. Service users are appropriately assessed before being offered a place at the home. Service users, or their representatives, are able to visit before making a decision to move in and are given the home’s written terms and conditions. This decision is appropriately reviewed within a few weeks of living at Hurst Hall. EVIDENCE: A random selection of service users’ files was scrutinised. These all had a signed and dated copy of the home’s terms and conditions. Similarly all had a copy of an assessment undertaken by an appropriate community based professional. It is the policy of the home to undertake their own assessment of prospective service users to ensure they are able to meet their assessed needs. There was also documentary evidence that service users are given written confirmation that the home can meet their needs. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 9 There was documentary evidence that a review is undertaken at the end of the ‘trial’ period and that an independent advocate is involved if appropriate. The manager reported that it is the home’s policy to encourage service users or their representatives to visit the home before making a decision to move in. Not all service users spoken to could recall if any visit had been made. However all who could recall were able to confirm that the opportunity was made available. Hurst Hall does not offer intermediate care. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 10 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 10. Service users’ care needs are appropriately documented and reviewed. Service users’ health needs are appropriately met through community based services. Service users are treated with respect and dignity with their right to privacy being respected. EVIDENCE: All files scrutinised had a copy of a written care plan. There was also documentary evidence that these plans were regularly reviewed. Care plans were signed by service users who had the capacity to do so. One example was seen where the service user had amended the plan herself, demonstrating a good level of involvement in the process. Some examples of ‘personal histories’ were seen which would serve to reinforce the individuality of each service user. While this is good practice, increased detail could offer more insight into the previous experiences of Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 11 service users which could further inform the appropriately individualised delivery of care. Four relatives comment cards were received by the Commission for Social Care Inspection. All confirmed they were kept informed of important matters affecting their relative, and that they were appropriately consulted about their relative’s care. Ten service users’ comment cards were received and all but one (who reported “sometimes”) said they liked living at Hurst Hall and felt well cared for. Seven service users were interviewed in private and all reported positively on their experience in the home. One commented that “they do look after you here. I’d leave if they didn’t.” Another described it as a “wonderful place”. The one visiting relative spoken to was also positive, describing the care as “smashing”. Staff who were interviewed were also positive about the care offered by their colleagues Records indicated that service users had access to the full range of medical and para medical services available in the community. Service users and the relative spoken to confirmed that they were confident that appropriate and timely medical support and intervention was obtained. Observation throughout the inspection indicated appropriate relationships were maintained between staff and service users. Relationships presented as relaxed. Several service users cited ‘the atmosphere’ as a positive aspect of the home. Service users spoken to confirmed that they were treated with respect and that their dignity was maintained. One service user reported that “staff communicate with you and have a laugh, which is important”, another said the best thing about the home was “they listen to you … do care how I want it”. Comment cards received by relatives all confirmed that they could visit in private and service users’ comment cards all confirmed that their privacy was respected. All bedrooms are single and service users spoken to confirmed they were free to use either their own room or the communal areas as they wished. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 12 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, 14 and 15. The home provides a range of appropriate social and cultural activities. Service users are encouraged to maintain control over their lives and can exercise choice within the context of a communal setting. Visitors are welcome. The provision of food in the home is good. EVIDENCE: The manager reported that a range of social activities were available at Hurst Hall, both within the home and occasional outings. This was confirmed by staff who were spoken to, and the visitor spoken to. Service users who were asked also confirmed appropriate activities with one citing the “concerts and singing” as the best thing about the home. Of the service user comment cards returned eight reported satisfaction with the home’s provision of suitable activities (including one who added “a lot” to their response), one responded ‘sometimes, and one ‘no’. There was documentary evidence that activities were discussed at service user meetings, with a view to facilitating appropriate activities. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 13 Hurst Hall has a policy of allowing visitors at any reasonable time. Service users and the visitor confirmed this was the practice at the home. Similarly all relative comment cards which were returned confirmed that “staff welcome you in the home at any time”. One relative reported “ … excellent that can visit any time”. Observation and discussion with service users and staff confirmed that service users are able to exercise choice and control over their lives within the context of communal living. One service user commented “[they] let me be myself – [there are] no restrictions. Its your home you do what you like”. Discussion with the manager indicated a strongly held belief that Hurst Hall was the home of the service users and consequently it would be unreasonable to place any restrictions on service users, other than those required for health and safety reasons. One service user noted that the manager had reinforced his “right to grumble”. During the inspection a meal was sampled which was pleasantly presented and tasty. All service users interviewed expressed satisfaction with the food. One service user commented about the food “they do a wonderful job, good variety and good hygiene”. Another commented that today’s lunch was “really very tasty” and always looked forward to the fish chips and peas on a Friday. A third service user described the food as “excellent”, and another as “very good”. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 14 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. Service users are enabled to complain and are confident any complaint would be dealt with appropriately. The home protects service users from abuse or exploitation. EVIDENCE: Hurst Hall has an appropriate complaints procedure which is made available to service users. The record of complaints presented as being appropriately maintained, including one record where the service user did not wish to make a “formal” complaint. The inclusion of ‘informal’ complaints is appropriate to enable the record to contribute to quality monitoring. All service users who were asked expressed the view that any complaint they may make would be listened to and appropriate action would be taken. Staff also expressed confidence that complaints were taken seriously. All service users’ comment cards confirmed that the service user knew who to talk to if they were unhappy with their care. All service users who were interviewed expressed the view that they were safe at Hurst Hall. The home has appropriate procedures regarding the protection of vulnerable adults. Staff who were interviewed demonstrated an understanding of the importance of vigilance regarding adult abuse and were aware of their responsibilities regarding ‘whistle blowing’. All relatives comment cards expressed satisfaction with the overall care offered by Hurst Hall. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 15 Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 16 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): 19,20,21,22,23,24,25 and 26. Hurst Hall is appropriately maintained, clean and tidy. There are appropriate communal facilities available. Service users’ bedrooms are comfortable, well maintained, decorated and personalised. Appropriate toilet and bathing facilities are provided. EVIDENCE: At the time of this inspection, extensive building work was underway replacing the roof. This was inevitably causing a degree of disruption to the home, but the impact on service users was being minimised. Because of the building work, for health and safety reasons, service users were temporarily unable to access the patio area. A tour of the building was undertaken, including a random selection of service users’ bedrooms. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 17 All bedrooms are single and many have en suite facilities. There was ample evidence of bedrooms being personalised to the individual taste of the occupant. Service users who were asked, expressed satisfaction with their accommodation. Appropriate bathing and toilet facilities are available, including a range of aids for people with limited mobility. Communal areas are appropriately decorated and furnished. One service user particularly mentioned how much she liked the conservatory and patio area. Whilst the décor and standard of furnishings were generally of a good standard, some of the carpets looked as though they were stained. Discussion with the manager indicated this was thought to be a fault with the carpets, which marked when trolleys or wheelchairs were used. This was reported by the manager as being under investigation by the manufacturer as the carpets affected were relatively new. One relative’s comment card suggested the cleaning should be improved. Another described Hurst Hall as “Lovely place, very clean, …”. All service users spoken to reported that the home was always clean and tidy. One said “clean? they are always cleaning.”, another described ” good cleaning throughout the home” and another said one of the best things about the home was “the smell, – there is no smell”. The absence of unpleasant smells was also confirmed by the visitor spoken to. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 18 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. Adequate numbers of appropriately trained staff are provided at the home. Appropriate recruitment procedures are followed to protect the interests of the service users. EVIDENCE: A copy of the staff rota for the week beginning 31st October 2005 was scrutinised. This demonstrated that staffing was normally maintained at seven carers during the day (08:00 – 20:00) and three at night (20:00 – 08:00). Occasionally staff levels were lower than this, but only for relatively brief periods during any given day. The manager reported that she was able to adjust the staffing levels if necessitated by the dependency of service users. Discussion with the Manager and staff as well as documentary evidence of training undertaken indicated that the home was maintaining its commitment to offering an appropriate range of training to the staff team. The manager reported that 23 of the 31 care staff held NVQ II or higher (74 ). A random selection of staff records was seen to confirm this. A selection of staff files relating to ‘newly’ appointed staff was inspected. There was documentary evidence of appropriate vetting procedures having been followed before a carer starts working at the home. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 19 There was documentary evidence of staff receiving a period of induction when starting employment. This was confirmed by staff who were interviewed. All service users spoken to were complimentary about the staff team, describing them as “very nice carers”, “good”, “[you are] treated so well it is unbelievable”, “the carers do look after you”. The relative spoken to also described the staff as “brilliant”. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 20 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): 31,32, 35,36, 37 and 38. Hurst Hall benefits from strong leadership offering a clear sense of priority. Appropriate procedures are in place to safeguard service users’ financial interests. Staff are appropriately supervised and record keeping promotes the best interests of service users. The health and safety of service users and staff are promoted and protected. EVIDENCE: The manager has several years experience in a management position. Service users and staff who were interviewed reported very positively on her management style, being open and approachable. One service user said of the manager “nothing is too much trouble”, another said “ if you want anything Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 21 doing she gets it done. She’ll go out of her way” and a third said “she is very helpful (for a boss)”. Discussion with the manager, as well as observation, demonstrated a strong ethos of putting service users at the heart of the (i.e. their) home. This was reflected in discussion with staff members who presented as understanding and valuing this underpinning philosophy and speaking highly of the management team. One member of staff cited, as the best thing about the home -“carers are carers. Seniors are there for you and Lynn is a brilliant boss.” There was documentary evidence of regular staff and service user meetings. These presented as covering an appropriate range of issues. Staff confirmed that they were able to raise any issues at their meetings and believed that any ideas they had for improving the service would be welcomed. The most recent service user meeting had been used as an opportunity to explore the outcomes of the latest Quality Monitoring exercise. Staff who were spoken to, confirmed that they received regular one to one supervision at approximately six weekly intervals. A random selection of records relating to money held by the home on behalf of service users was inspected. The records presented as being appropriately maintained with evidence of receipts for expenditure made on behalf of the service user, and the service user’s signature when being given cash. Other records relating to service users presented as being appropriately maintained, with evidence of service users being involved subject to their wishes and capacity. No obvious safety hazards were identified during this inspection. Records relating to the routine maintenance of equipment in the home presented as being appropriately maintained. These included fire detection, warning and fighting equipment. Staff who were interviewed confirmed the availability and mandatory use of disposable gloves and aprons to minimise the risk of cross infection within the home. Hurst Hall DS0000005572.V263518.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 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 3 Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 23 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 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that as full a ‘personal history’ as possible is obtained for each service user, with their consent. Hurst Hall DS0000005572.V263518.R01.S.doc Version 5.0 Page 24 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.V263518.R01.S.doc Version 5.0 Page 25 - 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. 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