Inspection on 21/02/06 for Ingwood Nursing Home

This inspection was carried out on 21st February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ingwood Nursing Home 04/06/07

Ingwood Nursing Home 06/06/06

Ingwood Nursing Home 27/10/05

Ingwood Nursing Home 04/03/05

Ingwood Nursing Home 03/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ingwood Nursing Home Stainland Road Greetland Halifax West Yorkshire HX4 8BQ Lead Inspector Liz Cuddington Unannounced Inspection 21st February 2006 13:20 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 Ingwood Nursing Home DS0000060152.V255608.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. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ingwood Nursing Home Address Stainland Road Greetland Halifax West Yorkshire HX4 8BQ 01422 374410 01422 375671 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) Philip Bennett (NewCo) Ltd Mrs Cathryn Iqbal Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Ingwood combines the conversion of a period building with a substantial new accommodation block. The accommodation is over two floors. The home provides both personal care and nursing care to men and women aged sixty-five and over. There is a choice of single or shared bedrooms. Ingwood is situated in West Vale, about ten minutes drive from Halifax and twenty minutes drive from Huddersfield. There is ample parking. The home is on a bus route. The main entrance to the home is approached by a flight of steps, however there is a level entrance to the rear of the building. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from 1st April until 31st March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of the home in this year. There have been no further visits to the home until this unannounced inspection. One inspector carried out the inspection and spent approximately six hours in the home. The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Older People. The methods used for the inspection included discussions with 4 residents, 6 members of staff and management as well as examination of records and a tour of the home. Many of the key standards, which must be inspected during the year, were assessed at the last inspection in October 2005. This inspection looked at the remaining six key standards. The seven statutory requirements and four good practice recommendations, made in October 2005, were also assessed to determine the progress made at Ingwood towards meeting these standards. There have been significant improvements since the last inspection. Five of the requirements and three of the recommendations now meet the necessary standard. I would like to thank the people who live and work at Ingwood for taking the time to talk to me during the inspection, and for their welcome and hospitality. What the service does well: What has improved since the last inspection? Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 6 The manager has made a good start on the process of involving service users and their families in developing and reviewing service users care plans. The staff files now show that two satisfactory references are always being obtained before a new member of staff is appointed. All staff have taken Protection of Vulnerable Adults training. The nursing staff are all taking refresher training in medicines administration. Although it is not quite perfect, the secure storage of personal and valuable items is considerably better than at the last inspection. 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. Ingwood Nursing Home DS0000060152.V255608.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 Ingwood Nursing Home DS0000060152.V255608.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): Standard 3 was assessed in October 2005. Standard 6 does not apply. None of the remaining standards were inspected on this occasion. EVIDENCE: Ingwood Nursing Home DS0000060152.V255608.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, 9 & 10 The care plans have improved but need more work in order to meet the standard. Service users healthcare needs are looked after, involving specialist healthcare professionals where needed. The medicines administration is carried out in accordance with the Royal Pharmaceutical Society’s guidance. Service users privacy and dignity is maintained by staff, although some toilets should have locks fitted to ensure complete privacy. EVIDENCE: A number of service users plans of care were examined and improvements have been made since the last inspection. The manager has started contacting service users families to get them involved in the development and reviews of care plans. Eleven families had been involved so far. The manager will continue to try and get input from the other service users families. If this is not possible, or the person has no family, then the Social Services’ Reviewing Officer or an independent advocate could be invited to contribute. Not all the care plans included a social profile or information about the individual’s preferred activities. The plans are regularly reviewed by the home’s staff and contain risk assessments and other healthcare assessments. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 10 A separate assessment of the risks to people who are prone to falling was seen. A referral to the specialist Falls Clinic was seen and a nurse and physiotherapist had been involved. A nurse who specialises in Parkinson’s disease, where people are at greater risk of falling, has been approached to give advice and training to staff. A full audit of the medicines administration systems was carried out. The Medicines Administration Record (MAR) charts were examined. All medicines had been signed for and there was an accurate ‘brought forward’ system, showing exactly how much of each medicine there was at the start of the fourweek administration period. The amounts remaining were checked against the numbers used and the amounts at the start of the period and each one was accurate. The system for recording administration of controlled drugs was accurate. All nursing staff have started refresher training in medicines administration at Park Lane College, Leeds. One nurse told me she was enjoying the course and finding it useful. Service users privacy and dignity was seen to be respected by the staff at Ingwood. Any medical examinations are carried out in the service user’s own room. Privacy screening is used in shared rooms. Not all of the toilets have locks fitted on the doors. This needs to be dealt with in order to ensure service users privacy is maintained. Ingwood Nursing Home DS0000060152.V255608.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): 14 Standards 12, 13 & 15 were assessed in October 2005. Service users are able to maintain control of their finances and other aspects of their lives for as long as they wish and are able to do so. EVIDENCE: Service users are supported and encouraged to handle their own financial affairs for as long as they wish to do so. Information about external advocacy services is displayed on the notice board by the office. Service users and their families can use this service if they wish. Ingwood Nursing Home DS0000060152.V255608.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 & 18 Standard 17 was assessed in October 2005. The complaints procedure is comprehensive and made available to service users, families and staff. Adult protection training and policies and procedures are robust. EVIDENCE: The home’s complaints procedure is displayed on the notice board and is included in the Service Users Guide and the Staff Handbook. There is a book which lists any complaints the home receives. Details of complaints which refer to the care of an individual service user are kept on the person’s own file. All the staff at Ingwood have attended Protection of Vulnerable Adults training and certificates were seen in staff files. The home has robust procedures for dealing with allegations of abuse, including a ‘whistle blowing’ policy and procedures for staff to use if they suspect a colleague of bad practice. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 21 & 26 were assessed in October 2005. None of the remaining standards were inspected on this occasion. EVIDENCE: Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29 Standard 30 was assessed in October 2005. Sufficient staff are on duty to meet the assessed needs of the service users. The home has almost reached its goal of a fully qualified staff team. The recruitment and selection procedure now includes all the necessary preemployment checks. EVIDENCE: The staff rotas were examined. On the day of the inspection there were 21 service users at the home. The staffing levels were sufficient to meet the needs of the people who live at Ingwood. The manager told me that as occupancy increases the numbers of staff on duty will also increase. One of the care staff has changed her role and is now the home’s housekeeper. The manager said this new post is proving beneficial to the service users, the staff and the home in general. From a total of twenty care staff, nine have achieved a National Vocational Qualification (NVQ) level 2 in care, and four of these have also reached level 3. The remaining care staff are taking the NVQ level 2 qualification and 2 are taking the level 3 course. The manager expects that by April 2006 all staff who are taking an NVQ course, except for one new staff member, will have completed their studies. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 15 A number of staff files were examined and all contained two satisfactory references. The rest of this standard on recruitment and selection was met at the last inspection. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Standard 36 was assessed in October 2005. The manager has the necessary qualifications and experience to manage the home. The quality assurance system is comprehensive and provides good information to help the home improve its services. Secure storage of all confidential and other items needs to be improved. The kitchen is hygienically maintained, although the dry store cupboard was still being used to keep personal belongings. EVIDENCE: The registered manager is a qualified nurse and has sufficient experience to manage the home. The managerial lines of accountability are known and understood by staff. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 17 The home has a wide-ranging and comprehensive quality assurance system. Service users, families, healthcare professionals and suppliers are asked to give their views on the home. The home’s administrator collates the information received onto a spreadsheet and the manager responds to specific issues that people have raised. Residents’ meetings are held and the minutes are put up on the notice board. The organisation’s Operations Manager visits the home regularly and talks to service users, families and staff to gain their views. The home has an annual development plan and a training plan for staff. The small cupboard where some service users valuables are kept for them is now kept locked at all times. The manager’s office door has had a lock fitted and I was assured that it is always locked when the room is unoccupied. When I arrived to start the inspection the door was open and the office was empty. During the inspection I saw staff locking the door each time they left the office. This is particularly important as the office contains all the service users files, as well as other items which must be kept secure. I visited the kitchen and looked at the temperature record charts and the storeroom. The records are kept correctly and only one personal item, a handbag, was seen in the storeroom. It is not necessary or appropriate to keep any personal items in food storerooms, especially when there are staff lockers close by. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 1 2 Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 14 & 15 Requirement The personal plans of care must reflect the service user’s current needs. The plans must also show evidence that they have been agreed with the service user or their representative. Carried forward from the last inspection. Original timescale: 31/12/05 Service users personal records must be securely stored at all times. Carried forward from the last inspection. Original timescale: 30/11/05 Timescale for action 30/06/06 2. OP37 17(1)(b) 31/03/06 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 OP10 Good Practice Recommendations To ensure privacy, toilets used by service users should DS0000060152.V255608.R01.S.doc Version 5.1 Page 20 Ingwood Nursing Home 2. 3. OP28 OP38 have suitable locks fitted. More care staff need to complete their NVQ qualification in order to meet this standard. Staff’s personal belongings should not be kept in food storage areas. Ingwood Nursing Home DS0000060152.V255608.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Ingwood Nursing Home DS0000060152.V255608.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. 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!