Inspection on 02/11/06 for Hurst Hall

This inspection was carried out on 2nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13/03/06

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 10:15 2 and 3 November 2006 nd rd 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.V317943.R01.S.doc Version 5.2 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.V317943.R01.S.doc Version 5.2 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 Kathryn Buckle 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.V317943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 50 service users to include: *up to 50 service users in the category of OP (Old age not falling within any other category) *up to 50 service users in the category of DE(E) (Dementia over 65 years of age) *up to 24 service users in the category of PD(E) (Physical disability over 65 years of age) *up to 5 service users in the category of SI(E) (Sensory impairment over 65 years of age). The service must employ at all times a suitably qualified and competent manager who is registered with the Commission for Social Care Inspection. 13th March 2006. 2. 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. At the time of this visit (November 2006) the charges at Hurst Hall were between £343.66 and £353.66. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection six service users were interviewed in private, as was one visitor. Additionally discussions took place with the manager and four staff members were interviewed in private. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. This key inspection included an unannounced site visit to the home. All key standards were assessed. What the service does well: What has improved since the last inspection? The vetting of new staff was being undertaken with more rigour, which would assist in protecting the interests of the service users. The Quality Audit includes information regarding how the home intends to act on feedback from service users to further improve the service. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 6 The good quality of care offered to service users has been maintained. 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. The summary of this inspection report can be made available in other formats on request. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 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.V317943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is, good. This judgement has been made using available evidence including a visit to this service. Service users are only admitted to the home after an appropriate assessment to ensure the home can meet their needs. EVIDENCE: A selection of service users files was looked at. All had a copy of an assessment undertaken by an appropriate professional. There was also documentary evidence that the manager undertook an independent assessment on behalf of the home. There was also documentary evidence that the home confirmed in writing, to the service user, that Hurst Hall could meet their needs. Hurst Hall does not offer intermediate care. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care which are regularly reviewed to ensure they reflect current needs. Service users have access to appropriate community-based medical services, to ensure their health needs are met. The homes procedures in connection with the administration of medication are implemented to the benefit of the service users. Practices in the home promote, the dignity of service users. EVIDENCE: A selection of service users’ files was looked at. All had a copy of a care plan, and there was documentary evidence to confirm that this had been reviewed at regular intervals. Similarly, there was evidence that service users, or their representatives, had been involved in the formulation of the care plan. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 10 Care plans which were seen relating to more recent service users, included a useful getting to know you section including information about the individuals social history and interests. There was also documentary evidence that, when necessary, care plans were amended. Examples were seen where amendments to care plans were not effectively dated. While this had no detrimental impact on the service user, more effective dating would ensure greater transparency of the care planning process. Service users spoken to during the visit, expressed the view that staff involved them in how their care needs were met. One service user commented that staff. want to know if something is not right. The service user also reported that staff were approachable about ‘intimate matters and said it is as though they really wanted you to be content and comfortable. There was good documentary evidence that service users have access to the full range of community-based medical and paramedical services. All service users and visitors who were asked were confident that appropriate medical advice would be sought in a timely manner. Staff who were spoken to also expressed confidence regarding appropriate medical intervention. Hurst Hall uses a pre-dispensed monitored dosage system to administer service users’ medication. Medication was seen to be appropriately and securely stored. A selection of medication administration records was looked at and presented as being appropriately maintained. One example was seen relating to a service user, who was administering their own medication. An appropriate risk assessment had been undertaken and appropriate records were maintained. There was documentary evidence that the manager audited the medication administration records on a regular basis. This is good practice as it would assist the early identification of any problems. Observation and discussion the service users, staff and a visitor indicated that service users were treated with dignity and respect. In a small group discussion with service users. Staff were described as well mannered and very nice with all service users. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate range of activities was available for service users to participate in if they wished, which enhance their fulfilment and social stimulation. Visitors are welcome in the home to maintain community and family links to the benefit of service users. Service users are able to maximise their autonomy within the context of community living. The provision of food to maintain service users’ health and well-being is good. EVIDENCE: A range of social activities is available for service users at Hurst Hall to participate in if they wish. Examples of activities mentioned by the visitor and service users included quizzes, bingo, Dominos, keep fit classes and regular visits from local churches. During the site visit some service users attended a club in a local church. Most service users spoken to expressed satisfaction with the level of activities available, although one wondered if there might be more scope for more visiting entertainers. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 12 The home has a policy of allowing visitors at any reasonable time. This was confirmed by service users spoken to, and the visitor, as being the actual practice in the home. The visitor spoken to commented that she was always made to feel welcome, and appreciated the fact that she could make a drink for herself and her relative. Observation and discussion with service users and staff indicated that service users were able to exercise personal choice and autonomy within the context of communal living. Service users confirmed that they were able to get up and go to bed when they chose. They were also free to use any of the communal areas or their own private rooms. Similarly, subject to a risk assessment, service users were free to leave the building when they chose. One service user spoken to said I use it as I did my home. It is my home! During this visit, one meal was sampled, which was tasty and pleasantly presented. All service users spoken to during the site visit were positive about the provision of food at Hurst Hall. One service user described the food as excellent, and confirmed that there was ample choice and that the food was plentiful. Another service user reported that their only ‘ concern about the food, was that she rarely had the great satisfaction from scraping the plate. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that any complaints they may have would be dealt with appropriately. Service users are protected from abuse or exploitation by the homes policies and practices. EVIDENCE: Hurst Hall has an appropriate complaints procedure, which is made available to service users and relatives. All service users and visitors spoken to expressed confidence that the home would be appropriately responsive to any complaint or concern. One service user said they [staff] want to know if something is not right. Another service user said that making a complaint would be no problem as the staff are very nice. The record of complaints was looked at and presented as being appropriately maintained. Staff who were interviewed demonstrated an understanding of the need to be vigilant about the possibility of abuse, and of appropriate action to take. This included the whistleblowing procedure. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 14 All service users and visitors spoken to expressed the view that service users were protected from abuse or exploitation at Hurst Hall. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. Suitable toilet and bathing facilities are available to enable service users to maintain their personal hygiene in a dignified manner. EVIDENCE: During the visit to the home a tour of the building was undertaken. This included communal areas and a selection of service users’ bedrooms. There were several communal areas where service users could spend their time, or they could access their own room when they chose. All bedrooms were single and the manager reported that service users could have a key to their room if they wished. Service users’ bedrooms had an appropriate degree of personalisation. It was reported that one service user’s Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 16 family had redecorated their relatives’ room to a specific colour at the request of the service user. The home presented as predominantly clean and tidy throughout. The only identified exception to this was the carpeting in several of the communal areas. There have been ongoing problems with the carpets, since they were fitted. The manager reported that she understood that discussions were still being undertaken with the carpet manufacturers, and it was likely the carpets would be replaced shortly. Service users, staff and visitors all confirmed that the home was usually clean and tidy, with no unpleasant odours. All service users who were asked, were positive about the environment at Hurst Hall. No remedial issues relating to the maintenance of the building were identified during this visit. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skills mix of staff on duty promotes the independence and well being of service users. Recruitment and vetting procedures are effectively applied to minimise the risk to service users of inappropriate staff being employed. EVIDENCE: The staff rota for the week beginning the 23rd October 2006 was looked at. This demonstrated that there were usually seven carers on duty in the morning (08:00 -- 14:00), six carers later in the day (14:00 -- 20:00) and three waking night staff. Additionally the home employed cooks, domestic staff and a handyman. The manager’s hours were in addition to those identified above. The manager reported that these numbers were appropriate, having regard to the dependency of the service users. The manager reported that 20 carers had NVQ II. A random selection certificates were seen to confirm this. Two other staff were reported as working towards that qualification. A number of staff were reported as having higher qualifications than NVQ II. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 18 A selection of records relating to the recruitment of new staff was looked at. The documentation demonstrated that appropriate vetting was undertaken before employment commenced. Staff at Hurst Hall have access to a variety of training opportunities. Previous inspections have identified the companys appropriate commitment to training. The manager reported his commitment to training was being maintained. This was also confirmed by staff who were interviewed. Service users were very positive about the staff’s attitude and competence. One service user said, the staff are excellent, fantastic … there is a nice atmosphere … [ the staff are] capable and well trained. Another replied, when asked the best thing about the home, the staff, cant fault them… very helpful. Service users also describes staff as well mannered and very nice with all[ service users]. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is appropriately experienced and qualified to run a care home for the benefit of service users. Quality Audit processes provide a framework to further improve services for the service users. Service users’ financial interests are protected by the home’s procedures and practices. Service users and staff are protected by the implementation of the home’s health and safety procedures. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 20 EVIDENCE: The registered manager, who had been in post since the beginning of 2006, had consolidated her position. She reported that she had successfully completed the Registered Manager’s Award. Staff reported that the management team was approachable and supportive. The company undertakes a range of Quality Audit and Quality Monitoring exercises. A report of the latest Quality Audit, undertaken with service users, earlier this year, had just been received by the home at the time of this visit. The manager forwarded a copy of her action plan, based on the results of the Quality Audit, to the Commission for Social Care Inspection shortly after this visit. Minutes of the last service user meetings were seen. These had taken place in February and August 2006. The manager reported that she aims to hold such meetings at least three times a year. Some service users spoken to queried if more service user meetings might be beneficial, but acknowledged that they “can [at any time] go to carers, who do listen.” A selection of records relating to money held by Hurst Hall on behalf of service users was looked at. The records presented as being appropriately maintained to safeguard the interests of the service users. Staff confirmed the availability and mandatory use of disposable gloves and aprons to minimise the risk of cross infection. The manager reported that there was always at least one First Aider on duty throughout the day and night. Previous site visits to Hurst Hall have confirmed good standards of the maintenance of equipment for health and safety purposes. Similarly there has been a regular routine of testing fire alarm and detection equipment. The manager reported that the company was maintaining all appropriate health and safety testing and compliance. A small sample of this documentation was looked at and indicated these standards were being maintained. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 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 X 3 X 3 X X 3 Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 22 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 Refer to Standard OP7 OP20 Good Practice Recommendations The registered person should ensure that any amendments to written care plans are dated, to ensure clarity about the current needs of the service user. The registered person should ensure that the problem with the communal carpets is resolved. Hurst Hall DS0000005572.V317943.R01.S.doc Version 5.2 Page 23 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V317943.R01.S.doc Version 5.2 Page 24 - 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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