CARE HOMES FOR OLDER PEOPLE
Little Hayes Care Home 29 Hayes Lane Kenley Surrey CR8 5LF Lead Inspector
Alison Ford Key Unannounced Inspection 7th March 2007 09:30 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.V332329.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. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 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 office@littlehayescare.fsnet.co.uk Diplotec Ltd Julia Barbara Christodoulides Care Home 50 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (40) of places Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Daytime staffing levels would have to be:4 Qualified nurses and 8 care assistants between 8:00am and 2:00pm. 3 Qualified nurses and 7 care assistants between 2:00pm and 8:00pm. Night time staffing levels would have to be: 2 Qualified Nurses and 3 Care assistants between the hours of 8:00pm and 8:00am. 20th April 2006 2. Date of last inspection 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 that 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 bedrooms over two floors. There are two passenger lifts for ease of access although the home is very spread out in its layout and it is quite disorientating at first. The stated aim of the home is to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort is of prime importance. Copies of the Statement of Purpose for the home and the latest inspection report can be requested from the home. Inspection reports can also be obtained from The Commission for Social Care Inspection via the internet. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second key inspection of the year 2006 / 2007 and was an unannounced visit, by two regulation inspectors, lasting five hours. During this time a partial tour of the premises was undertaken, records relating to the health and safety of residents and recruitment of staff were viewed and several of the forty-four residents currently in the home, and staff members were spoken with. Six residents care plans were also assessed. At the time of the inspection, fees ranged from £524 - £625 per week with extra charges payable for items such as newspapers and hairdressing. These would be discussed with the home prior to admission. In compiling this report consideration has also been given to other information made available to The Commission throughout the inspection year, which includes complaints and notification of incidents. There is currently one unresolved complaint against the home. This has been ongoing since November 2006, as the Registered Providers have ignored requests to comply with their complaints procedure in an effort to resolve the issues of concern that have been raised. One immediate requirement was issued at this visit in respect of medication administration. The Responsible Person is required to submit an action plan to The Commission explaining the steps that will be taken to try to ensure that this does not happen again. What the service does well:
This home provides comfortable and clean accommodation for its residents, all of whom were complimentary about the staff in the home and the care that they received. Several said, ”its nice living here” “staff are very kind “another commented that she was “so happy that a respite visit had turned into a permanent arrangement.“ All the residents looked well cared for and agreed that they that they were free to exercise choices in their daily lives and were always treated with respect and in a way that respected their individuality. Pre admission assessments ensure that the home is always confident that it will meet the needs of its residents and the way in which support and interventions are given is reviewed regularly to ensure that it continues to meet their needs. Any potential resident would be given copies of the homes
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 6 Statement of Purpose and Service User Guide to take away to read so that they or their relatives could decide whether the home and the services provided will suit them. Daily activities are provided to offer interest and stimulation to residents although these are currently being provided by care staff until a suitable person is appointed. Visitors would always be made welcome into the home and residents are encouraged to retain links with the local community. Residents are protected by the homes recruitment policies however, although there is a complaints procedure in place this is not always adhered to so they cannot be sure that their concerns will be listened to and acted upon. Policies and procedures are in place to ensure that the health and safety of residents and staff is generally well protected although some areas of concern were raised at this visit in relation to medication administration and an immediate requirement was issued in respect of this. The Registered Manager acted promptly to put measures in place to ensure that the risks of this being repeated in the future were reduced. What has improved since the last inspection?
Since the last inspection the majority of requirements that were issued at that time have been complied with. The planned programme of redecoration and refurbishment is almost complete with 1 bathroom and 1 toilet remaining to be done. A new sluicing disinfector is on order. Care plans are now being audited on a regular basis to so that all staff are aware of the support and interventions that residents currently need and they are beginning to reflect their social needs and preferences as well. This will help those concerned with organising activities for residents provide them with a timetable, which will suit their preferences and remaining abilities. Some work is also being undertaken to collect information about resident’s previous lives and achievements. This will also help with offering activities which interest residents as well as enabling staff to get to know them better and understand them. Previous concerns about the safety of residents in the event of a fire have now been addressed and the building complies with current fire safety legislation. For those residents who wish to have more privacy and be able to lock their bedroom doors, locks have been fitted although they will need to be modified to ensure that staff are able to open the doors from the outside in the event of an emergency. The manager of the home has now been registered with The Commission for Social Care Inspection and staff meetings are being held on a regular basis so that everyone is kept up to date about what is happening in the home.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 7 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. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 8 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.V332329.R01.S.doc Version 5.2 Page 9 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): Standards 1,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is information available, which helps potential residents to make an informed choice about the suitability of the home although amendments are still needed to both the Service User Guide and Statement of Purpose to make sure that they have all of the information that they need. Pre-admission assessments are undertaken which judge the homes suitability to meet the healthcare needs of any one considering moving into the home. This home does not offer intermediate care; this standard does not apply. EVIDENCE: Prior to admission, any potential resident would have an assessment done by a senior member of staff to make sure that the home would be able to provide appropriate care and support for them. A care manager’s assessment is also provided for residents whose care is funded by the local authority.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 10 Potential residents and their families are given a copy of the Statement of Purpose and Service User Guide, which has been prepared in format specifically for this purpose. Larger bound copies would be given to them following their admission. This information helps them to judge whether they think that the home will be suitable for them and if they will be happy with the facilities and services that are offered to them. Some amendments are required to this documentation to ensure that it meets with the regulations and these were discussed with the homes manager. It must include a copy of the latest inspection report and details of the total amount of fees payable along with information relating to possible increases in the future. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans generall reflect the support that residents currently require so that they can be confident that care will be delivered in the way which they prefer however, measures must be put in place to ensure that residents are always protected by the homes medication procedures. Residents can be sure that they will be treated with dignity and in a manner which reflects their privacy. EVIDENCE: Six care plans were seen at this visit. These are now being audited regularly and continue to improve. Some of them, especially of those residents admitted more recently, show evidence of life history work which provides information about residents previous lives and helps staff to understand their present needs and behaviour.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 12 Residents individual problems and the supprt that they need have been identified and proposed interventions outlined however, there is limited evidence that either they or their representatives have been involved in this process. In order to ensure that care is being delivered in a way which suits them there must be evidence that residents have been offered the opportunity to participate in the process. Bodymaps are in place in the care plans which provide evidence of the skin integrity of residents on admission in to the home. They are currently only completed if problems are identified and it is recommended that there should be some evidence that this has always been considered. The assessment of medication storage and administration revealed some errors and there was a discrepancy in recording and the amount of medication remaining in a bottle. This meant that the resident had not received the medication in the way that it had been prescribed. An immediate requirement was issued in relation to this. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14,15 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make choices within their daily live as much as their abilities allow and activities are in place to offer interest and stimulation. Their visitors are always welcome and they can be assured that meals are suitable and varied with choices that will suit their preferences. EVIDENCE: There were photographs of various activities that had taken place and an activities programme was on the board. A new activities coordinator is about to start work five afternoons a week; a member of the care staff, with a particular interest in this work, is currently undertaking this role. Residents were able to comment on how much they had enjoyed recent sessions. Relatives and friends of residents are always made welcome in the home and are able to visit whenever they wish.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 14 Residents confirmed that they are able to exercise choices in their daily lives regarding the clothes that they wear and meals that they eat. It was observed that one resident did not wish to get out of bed until much later in the day and this was respected. All those spoken with agreed that the food served in the home was very good; and there was always a choice. Menus are currently being revised and at the time of the inspection did not reflect the food that was being served. This will be monitored at future visits. Records must also be kept of the food that is actually eaten by residents to provide evidence of a nutritionally balanced diet. It is recommended that a list of the preferences of the residents should be available in the kitchen for reference. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 15 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): Standards 16,18 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to ensure the protection of residents however they cannot be sure that their concerns will be listened to and acted upon. EVIDENCE: Staff that were spoken with, displayed knowledge of issues around adult abuse, there is ongoing training within the home and pre-employment checks are in place to ensure residents protection. There is a complaints procedure and copies of this are in the Statement of Purpose and Service User Guide. It is noted that there is still one unresolved complaint, which was first made in November 2006. The Registered Providers have still not replied to this despite requests from both the complainant and The Commission. A requirement is issued to ensure that concerns are addressed according to the homes current complaint procedures. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home offers clean and comfortable accommodation for residents, which suits their needs and capabilities however some concerns are raised about their personal safety. EVIDENCE: A tour of the premises revealed that on the day of the inspection the home was clean and tidy. One corridor was slightly malodourous this is an ongoing problem. The planned redcoration is nearly complete and automatic door closers were seen on doors that residents wished to keep open. Extra handrails have been fitted, sineage has been improved and areas of the home are colour coordinated to help orientate those residents who have dementia.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 17 A new sluicing disinfector has been ordered and will be installed in the near future. Some concerns were raised about the locks on the bedroom doors of the few residents who wished to have a key. These doors would not be openable from the outside if there was an emergency and must be replaced or modified. A call bell in one bedroom and a toilet were found to be broken and must be repaired. A door leading out to the roof still needs a key to open it. While it is acknowledged that this is not a designated fire door it does lead directly outside and therefore it is recommended that an alternative type of closure should be fitted which allows it to be opened easily in the event of a fire. Other concerns, raised previously, about fire safty in the home have now been addressed. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents can generally be satsfied that staff training will ensure that their needs are met, and that recruitment procedures are in place to ensure their protection. Staff are always on duty in sufficient numbers to care for the numbers of residents living in the home. EVIDENCE: Staff rotas were seen. Now that a variation has been agreed to allow more residents with dementai to live in the home staff numbers have increased to meet their needs . These are currently adequate although may need to be increased if numbers of residents increase. Staff training is ongoing and statuatory traininand additional training in dementia awareness has been completed however, there are still less than 50 care staff with an NVQ level 2 qualifiction. This must now be addressed . Recruitment procedures have caused concerns in the past however at this visit the records of those staff member that were seen were all in order. There was one Criminal Records Bureau clearance certificate missing however,there was an explanation for this and a copy will be forwarded to the Commission for Social Care Inspection office.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 19 Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be sure that the home managed by a suitably qualified and experienced person and in their best interests. Policies and procedures are in place to ensure their safety and wellbeing and current health and safety legislation is complied with. EVIDENCE: The current manager is a trained nurse with additional qualifications and previous experience in a similar role and displayed a thorough understanding of the needs of the client group in the home.
Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 21 Staff are informed of changes that are occurring within the home through a newsletter and staff meetings are held regularly so that they have a chance to air their views. Relatives and residents meetings are held every two months to allow them the opportunity to influence the running of the home and The Registered Provider visits the home on a regular basis in accordance with Regulation 26. Staff supervision is still not happening on a regular basis and a requirement to introduce and manage this is repeated and will be monitored at future visits. These sessions are necessary in order to monitor the performance of staff members and identify any future training needs. A selection of certificates of worthiness and other records providing evidence of the homes commitment to the health and safety of its residents were seen. These were all in order. Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 1 X 3 Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4,5 Requirement Timescale for action 30/06/07 2 OP7 15(1) The Responsible Person must ensure that the Statement of Purpose and Service User Guide contain all of the information required by The Care Homes Regulations 2001 so that potential service users have all of the information that they need to make an informed choice as to whether the home will be suitable for their needs. The Responsible Person must 30/06/07 ensure that care plans contain evidence that residents and their relatives have been able to contribute to them and influence the way that care and services are provided. Previous timescale 30/01/07 not met. The Responsible Person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. Errors also found on previous inspection. 3 OP9 13(2) 07/03/07 Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 24 4 OP9 13(2) 5 OP15 Schedule 4 6 OP16 22 (3)(4) 7 OP19 13(4)(c) Immediate Requirement issued. The Responsible Person must ensure that medication storage and administration are audited on a regular basis to identify and minimise any errors. The Responsible Person must ensure that there is a record kept of the food that residents actually eat in sufficient detail to provide evidence as to whether the diet is satisfactory. The Responsible Person must ensure that all complaints and concerns are responded to according to the homes complaints procedures. The Responsible Person must ensure that any bedroom doors that are fitted with locks are operable from the outside in the case of an emergency. 30/06/07 30/06/07 30/03/07 30/03/07 8 9 OP19 OP28 23(2)(c) 18(1)(c) 10 OP36 18(2) The Responsible Person must ensure that all nurse call bells are working The Responsible Person must ensure that there is a plan in place to ensure that at least 50 of care staff are qualified to at least NVQ level 2 The Responsible Person must ensure all care staff receive formal supervision at least six times a year. 30/03/07 30/03/07 30/03/07 Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 25 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 It is recommended that the “ body map “giving details of skin integrity on admission is signed even when no problems are identified, to provide evidence that the issues have been considered. It is recommended that a list of resident’s food preferences should be kept in the kitchen. It is recommended that the door leading out on to the roof can be opened from the inside without needing a key. 2. 3 OP15 OP19 Little Hayes Care Home DS0000019033.V332329.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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
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