Inspection on 15/09/05 for Little Hayes Care Home

This inspection was carried out on 15th September 2005.

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

Little Hayes Care Home 22/12/09

Little Hayes Care Home 10/03/09

Little Hayes Care Home 07/10/08

Little Hayes Care Home 15/01/08

Little Hayes Care Home 29/06/07

Little Hayes Care Home 07/03/07

Little Hayes Care Home 20/04/06

Little Hayes Care Home 27/06/05

Little Hayes Care Home 12/11/04

Little Hayes Care Home 24/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Little Hayes Care Home 29 Hayes Lane Kenley Surrey CR8 5LF Lead Inspector Margaret Lynes Unannounced Inspection 15th September 2005 09:50 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 Little Hayes Care Home DS0000019033.V250379.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. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Little Hayes Care Home Address 29 Hayes Lane Kenley Surrey CR8 5LF 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) 020 8660 6626 020 8668 2449 Diplotec Ltd Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27 & 28 June 2005 Brief Description of the Service: Little Hayes is a 50 bed home, which offers nursing care to the elderly. The home is situated in Kenley, an attractive semi-rural area which is in close proximity to a mainline rail station and good road and bus links. The only potential difficulty with access is that the visitors on foot would have to climb a short, but steep hill to the home. The home offers 36 single bedrooms and 7 double spread over two floors. There are two passenger lifts for ease of access. The stated aim of the home is to provide its service users with ‘a secure, relaxed and homely environment in which their care, well being and comfort is of prime importance’. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of a morning, and undertaken by two inspectors. The focus of the visit was twofold. Firstly to examine if the home had taken steps to comply with the 15 requirements that were made following the June inspection; and secondly, to determine if the manager had started to work on the action plan she drew up as a result of a recent adult protection investigation following which two allegations of verbal abuse of residents were upheld. What the service does well: What has improved since the last inspection? What they could do better: Given that there remain outstanding requirements, there are still areas in which the home needs to advance. While there were improvements in the accuracy and substance of a lot of the recording, continued gaps in some of the audit sheets meant that the hard work of some staff was being undermined. There remains an ongoing need for staff, in general, to pay more attention to detail. It was of concern to find that yet again it appeared that a member of staff had commenced work in the home without the appropriate vetting having taken place. This is in spite of a Statutory Enforcement Notice, re recruitment, being served on the home towards the end of last year. The home did comply with the Notice, so a further breach is surprising. A requirement regarding this matter has been made in this report and, subject to additional information being provided by the home, the Commission will consider what further action needs to be taken. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 6 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. Little Hayes Care Home DS0000019033.V250379.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 Little Hayes Care Home DS0000019033.V250379.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): 3 Improvements in access to services need to be made to ensure that the needs of respite clients are being met as they often a GP service was not available. This not only places the service user at risk, but may result in an unsatisfactory use of the emergency services. EVIDENCE: At the previous inspection concerns were raised regarding the lack of GP access to service users placed in the home for respite care. This had resulted, on one occasion, in staff having to call the emergency services for one client as a GP could not be persuaded to call. This remains an ongoing issue, as the manager confirmed that most respite clients would not have a GP available to them whilst they were at Little Hayes. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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 and 10 While there had been some improvement in the service user plans, only half of those examined included reference to their social care needs. This means that the staff team may still not be fully aware of the differing needs of their residents, or know what specific care should be given. In a similar vein to the comment above, while there had been some improvement in completion of wound care documentation, there were some gaps on the audit sheets. This means that it is feasible that not all staff will be following the agreed plan of care, which in turns can have a detrimental effect on the service user. There could also be further improvement in catheter care, particularly with regard to staff communicating with service users. The medication administration records were examined, and found to be in order. This improvement in recording means that the service users are protected by the home’s good practice in this regard. Service users are treated with respect and their right to privacy is being upheld. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 10 EVIDENCE: Daily notes examined included detailed accounts of support and personal care given to residents thus indicating that the resident’s needs are being met as detailed in their care plans. This was a notable improvement on previous visits, and the requirement made at the last inspection with regard to evidencing the health and personal care given has been met. What was still lacking however, in some of the files examined, was reference to social care needs, and how they were to be addressed. There was a file containing information on Wound Care Assessment and Treatment. There were plans for the treatment of six residents, indicating the areas requiring treatment. The plans indicated Aims, Actions, Client/carers Participation, review Date and Evaluation Date. A sheet for recording daily treatment given to residents had been completed however these were marked with signatures, ticks, the letter H for hospital and there were gaps in the recording. The registered manager must ensure that records detailing wound care treatment given to residents are appropriately completed using an identified method of recording which indicates that treatment has been carried out. A key indicating what letters stand for would also be useful. Catheter care information is also recorded in the Wound Care Assessment and Treatment record. One residents care plan indicates what staff should do to support the resident with a catheter. It is recommended that this information is completed as guidance for staff to follow and kept in the resident medication profile. The care plan indicated that staff should communicate with the resident before supporting him with catheter care and personal care however there was no evidence of verbal communication recorded in the daily Notes. Medication administration record were checked and found to be up to date and accurate however three of the thirteen residents records did not include a photograph. One resident’s record indicates that he shares a room with another resident however there are no photographs. The home manager said that this resident does not have anyone sharing with him at the moment but agreed that it would be advisable to have photographs on file. From observation the Inspectors were, on this visit, satisfied that Service users are treated with respect and their right to privacy is being upheld. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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): 12, 13 and 14 The home does have a designated activities co-ordinator, and of late a more detailed activities plan has been drawn up. This should ensure that there is sufficient stimulation for service users. The home welcomes visitors at any reasonable hour. More effort has been made recently to involve relatives in planned two-monthly meetings which should enable adequate contact and exchange of views to take place. Staff are expected to complete a resident’s ‘lifestyle and interests’ information sheet, with assistance from both service user and relatives if possible, so that they can be aware of each individual’s wishes and preferences. There remained some gaps in the completion of these sheets, thus it was not felt that staff helped service users to exercise choice and control over their lives as much as they could. EVIDENCE: The manager was able to show inspectors a revised activities plan, which, if followed, should provide adequate choice and a sufficient quantity of activities for service users. The home shares an activities co-ordinator with its two sister homes, but is still hoping to recruit an individual specifically for Little Hayes. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 12 The regular two-monthly meetings (the first of which has already been held) should provide an adequate forum for relatives and service users to become involved and to discuss any issues of concern. A monthly newsletter is also being produced, two of which were available for inspection. They were colourful informative documents, produced in large print to make the reading of them easier. Within the service user files are sheets specifically designed for staff to use to record each service users personal interests and accustomed lifestyle. These would be useful documents and the manager should ensure that they are completed for each client. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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): 26 The entire building was not assessed on this visit however from observation of parts of the home it was not felt that the standard of cleanliness was acceptable. This means that the environment for the service user is not as pleasant as it could and should be. EVIDENCE: The home still has an odour. This was discussed with the home manager who said that she has tried various methods to eliminate the odour but will review it again. The requirement previously made regarding this matter is therefore repeated. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 15 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, 29 and 30 There are ongoing negotiations between the proprietors and the Commission, and the Lead Inspector for this home is awaiting an analysis of staffing levels from the recently appointed manager with the anticipation that finally this issue can be resolved. Up to this point the Commission has not been satisfied that the staffing levels have been adequate to meet the needs of the service users. Following an enforcement notice the recruitment practice in the home had considerably improved. Unfortunately on this visit there was a gap in one staff member’s documentation, which again means that the service users are potentially placed at unnecessary risk. On this visit there was evident that new staff had received an appropriate induction. This should provide them with the skills needed to provide a good quality service. This will then have a beneficial effect on the care being provided to service users. EVIDENCE: The staffing notice for this home, issued when the establishment was inspected by the local Health Authority, stated that there should be 3 qualified staff with 7 carers on duty in the morning; 3 qualified staff with 5 carers on in the afternoon/evening; and 2 qualified staff with 3 carers on duty overnight. The home has consistently failed to ensure that the night qualified staffing levels in particular are maintained, although allowances have been made for the less Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 16 than maximum occupancy level. The new manager is to provide an analysis, as mentioned overleaf, which will then be examined by the Commission. It was both surprising and disappointing to find that a new member of staff had apparently commenced work in the home before the necessary vetting had taken place. This once again jeopardises the well-being of service users, and can so easily be avoided. The Commission is waiting for a further explanation from the home before deciding what further action (in addition to the requirement in this report) will have to be taken. It would be good practice to ensure that staff files contained evidence of verification of qualifications – i.e. PIN numbers. It was required in the previous report that all new staff receive appropriate induction and that this be evidenced. On this visit the induction records for two new staff were produced and found to be satisfactory. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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): 38 Improvements have been made in respect of fire safety and first aid, this means that the health, safety and welfare of the service users and staff is being promoted as it should be. EVIDENCE: Two requirements were made following the last inspection with regard to health and safety. The first related to the need for the manager to ensure that fire alarms were being checked on a weekly basis and that this was recorded; the second concerned the need to have more staff trained in first aid. Both of these requirements have now been met. Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X 2 STAFFING Standard No Score 27 1 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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 OP3 Regulation 13 Requirement The registered person must ensure that all service users, including those admitted for respite care, have access to a GP. The previously set timescale has not been met. Service user plans must include reference to social care needs. The previously set timescale has not been fully met. Staff must ensure that catheter care is carried out, documented and explained to the service users involved. The previously set timescale has not been fully met. The registered manager must ensure that records detailing wound care treatment given to residents are appropriately completed using an identified method of recording which indicates that treatment has been carried out. The previously set timescale has not been fully met. All staff must ensure that service users are enabled to exercise DS0000019033.V250379.R01.S.doc Timescale for action 31/10/05 2 OP7 15 30/09/05 3 OP8 13 15/09/05 4 OP8 13 15/09/05 5 OP14 12 15/09/05 Little Hayes Care Home Version 5.0 Page 20 6 OP26 16 7 OP27 18 8 OP29 19 choice and control over their lives. The previously set timescale has not been fully met. Steps must be taken to ensure 15/09/05 that the home is odour free. The previously set timescale has not been met. The proprietors must ensure that 15/09/05 there is an adequate number of staff on duty at all times. The previously set timescale has not been met. The proprietors must ensure that 15/09/05 all required vetting takes place before new staff commence work in the home. 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 OP8 Good Practice Recommendations One residents care plan indicates what staff should do to support the resident with a catheter. It is recommended that this information is completed as guidance for staff to follow and kept in the resident medication profile. It would be helpful if an explanation for the codes being used could be added to the wound care documentation. It is advisable that a photograph of each service user is kept with their medication administration records. It would be good practice to ensure that staff files contained evidence of verification of qualifications – i.e. PIN numbers. 2 3 4 OP8 OP9 OP29 Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Little Hayes Care Home DS0000019033.V250379.R01.S.doc Version 5.0 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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