Inspection on 14/12/05 for Newlands Hall

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Newlands Hall 01/05/07

Newlands Hall 17/08/06

Newlands Hall 20/09/05

Newlands Hall 30/03/05

Newlands Hall 30/11/04

Newlands Hall 01/03/04

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 Newlands Hall High Street Heckmondwike West Yorkshire WF16 OAL Lead Inspector Tracey South Unannounced Inspection 09:30 14 December 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Newlands Hall DS0000026276.V254482.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. Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Newlands Hall Address High Street Heckmondwike West Yorkshire WF16 OAL 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) 01924 284202 01924 284285 Tri-Care Limited Ms Paula Jane Oldroyd Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Newlands Hall is owned by Tri-care Limited. The home offers care and accommodation for older people and is situated just out of Heckmondwike town centre on the main road. Standing in its own grounds, the home has been extended since it was first opened increasing the accommodation and services it can provide. The house still retains some of its original features and these add to the character of the home. There is a small complex of flats in the grounds providing individual accommodation for older people. Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. Care documentation, staff personnel files, staffing rotas, training records, medication records, residents financial records, quality audits and health and safety certification was examined as part of this inspection. There were 29 residents living at the home, 4 of which were spoken to and their comments have been used as part of this inspection. What the service does well: What has improved since the last inspection? As recommended in the last report case files are kept securely. Privacy locks have been fitted to the toilets on the ground floor. Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Newlands Hall DS0000026276.V254482.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 Newlands Hall DS0000026276.V254482.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 Prospective residents are assessed prior to them moving into the home. EVIDENCE: Information about prospective residents is provided by the social worker making the referral to the home. This is done in the form of a community care assessment (CCA). The CCA outlines the resident’s needs in respect of their health and welfare. In addition to this the management staff at the home also undertake their own pre-admission assessment. During the last inspection the pre-admission assessments examined had not been completed to their full potential. Although there has been some progress made, the staff need to continue improving this further. It is important that staff undertake thorough pre-admission assessments, as the information they collate should then be used in conjunction with the Community Care Assessment, to form the basis of the initial care plan. Newlands Hall DS0000026276.V254482.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, 11 Not all residents have a care plan in place. Medication procedures are not being followed by all staff. EVIDENCE: During the last inspection it was noted that two residents did not have a care plan in place. Therefore a requirement was made to rectify this and a generous timescale of three months was given. However, on returning to the home to carry out the second statutory inspection this year, the same two residents, admitted in August 2005, were still without a care plan and a further three residents were found to be lacking care plans. This is unacceptable. The CSCI are deeply concerned about the absence of care plans and as a result a requirement is made to ensure that each person living at the home has a care plan in place by 14th January 2006. A follow up visit to the home will take place in January 2006 to ensure this issue has been dealt with. Failure to do this will result in enforcement action being taken. Three resident’s medication records were checked. There were a number of signature omissions apparent. One person’s medication had not been booked Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 10 in when received. Not all medication stocks could be reconciled as staff had either not signed for it or not used the correct code to explain why the medication had not been given. It was difficult to reconcile PRN medication (i.e. medicines that are given as and when required), as there was no “brought forward” system in place. Those staff who are responsible for administering medication must take greater care and must make sure they sign for medication at the time it is given to the resident. Staff were able to give a good account of the care given to residents who are dying. Their accounts would confirm that residents are treated with dignity and respect. Care plans in place do not contain information about residents’ wishes regarding the care and support they want during illness and following death. This needs to be addressed. Newlands Hall DS0000026276.V254482.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, 14, 15 There is a good range of activities provided. The meals on offer are good and provide residents with a balanced diet. EVIDENCE: Residents spoke of how much they enjoyed the exercise classes that take place in the home. They said they are good fun and although it’s not a strenuous workout it does keep their joints moving. Residents also explained how outside entertainers visit the home to sing to them. Posters are displayed in the home, advising residents of forthcoming events As recommended in the last inspection report the residents’ case files are now securely stored. Residents are able to bring their personal belongings with them when they move into the home. Evidence of this has been seen during previous inspections. Residents commented on how good the food is. The meal on offer during the inspection was roast beef, Yorkshire puddings, potatoes and vegetables. The dessert was jam sponge and custard. Diabetic diets are catered for. Tables were set appropriately and meals were presentable. Those residents who prefer to eat in their own rooms are served their meal on a tray along with Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 12 condiments and napkins. There is one criticism to make with regards to the positioning of the dining table in the front lounge which means when residents are seated at the dining table they are facing the wall. This does not make for the most congenial setting as residents are limited as to who they can talk to. Those residents affected should be asked whether or not they are happy with these seating arrangements. Newlands Hall DS0000026276.V254482.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): None of these standards were assessed on this occasion. EVIDENCE: Newlands Hall DS0000026276.V254482.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 home is clean, tidy and a pleasant environment for residents. EVIDENCE: The home is clean and tidy and free from unpleasant odours. A requirement was made in the last inspection report to ensure that the laundry facilities at the home are brought up to current standards. The timescale for completion was 31/3/06. Newlands Hall DS0000026276.V254482.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, 28, 29, 30 There are sufficient numbers of staff on duty. Very few staff have received refresher training in relation to mandatory training. EVIDENCE: There are at least four staff on duty during the morning and afternoon shift. Two staff work wakeful nights. Care staff are supported by domestics, laundry and kitchen staff. The manager explained that her hours are to be supernumerary in the New Year. The home will benefit from this, as the manager will be able to concentrate on her managerial responsibilities including ensuring that all documentation relating to residents, is kept up to date. There are 16 care staff employed at the home, 6 (37 ) of which are qualified to NVQ level 2 in care. In accordance with the National Minimum Standards for Older People, 50 of the home should be qualified to this level by 31st December 2005. As this time has almost expired, the organisation must let the CSCI know as soon as possible how they intend to meet this target. No new staff have been employed at the home since the last inspection and therefore it was difficult to assess standard 29 in full. Existing staff files were checked and there was evidence in place to suggest that the necessary employment checks had been carried out prior to the person starting work. The manager is reminded that in accordance with the Data Protection Act, Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 16 copies of birth certificates and passports are no longer required to be kept on file. It was clear whilst examining the training data that the majority of staff need refresher training in relation to mandatory training, such as food hygiene, basic first aid, health and safety and manual handling. The manager explained that she is aware of this and this information has been passed onto the area manager at Tri Care Ltd. Newlands Hall DS0000026276.V254482.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): 31, 33, 35, 38 Quality assurance systems could be better. Resident’s financial interests are safeguarded. EVIDENCE: The manager is both respected and well-liked amongst staff and residents. She has been in post for 18 months and is qualified to NVQ level 4 in management. The manager demonstrates a caring and thoughtful attitude, but requires support to develop confidence in her role as manager. With the right level of support and a willingness to learn the manager has the ability to do well. Questionnaires were sent out to residents and staff in September 2005, to date there has been no evaluation report produced. This issue has been referred to in previous inspections although it appears very little has been done to address this. The senior staff undertake quality audits every month whereby they Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 18 complete their own assessment in accordance with the National Minimum Standards. Although the staff have indicated that particular standards are met, they don’t refer to how evidence has been sought. One audit indicated that care plans are put into place within 5 days of admission when it is clear that this is not the case. This needs to be addressed as a matter of urgency. Small amounts of monies are kept on behalf of residents. Residents’ monies were checked, all of which were correct. The home has good health and safety procedures in place. It was noted that the last recorded fire drill was dated 16.12.04 and that the weekly fire alarm checks, including emergency lighting had not been done since 16.11.05. Both of these were addressed during the inspection. Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 1 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 20 yes Are there any outstanding requirements from the last inspection? 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 4,6, Requirement The statement of purpose must be amended to ensure it is current and up to date. A copy must be sent to the CSCI by 20.1.06 2. OP3 14 Thorough pre-admission assessments must be carried out. Written records must be maintained and the information collated should be used to form the basis of the initial care plan. All residents must have a care plan in place. Residents must be involved in the drawing up of the care plan unless it is not appropriate. The care plan must include the needs of that person and include the action required by staff to ensure those needs are met. Care plans must be signed and dated by the person completing it. Care plans must be kept under regular review. Failure to comply will result in enforcement action being DS0000026276.V254482.R01.S.doc Timescale for action 20/01/06 14/12/05 3. OP7 15 14/01/06 Newlands Hall Version 5.0 Page 21 taken. 4. OP8 13 Appropriate assessments must be in place for each resident. These include, manual handling, risk assessments, nutritional and Waterlow assessments. All such assessments must be kept under regular review. Brought forward from the last inspection. Staff must take greater care and follow medication procedures correctly. All medication must be signed for contemporaneously. A brought forward system must be used in order to easily reconcile all stocks. All medication entering the home must be accounted for. Timescale 14/12/05 and continuing All staff must receive adult protection training within the next six months. Brought forward from the last inspection. 6. OP26 13 Work must be carried out in the laundry to bring it up to standard. (Previous timescale not met). Brought forward from the last inspection. 7 OP33 24 The home and organisation must 30/12/05 have an effective and evaluated quality assurance and monitoring system in place. Brought forward from the last inspection. 31/03/06 31/12/05 5 OP9 13 14/12/05 6. OP18 13 30/03/06 Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 22 The evaluation report in respect of the September 05 questionnaires must be sent to the CSCI by 30/12/05 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. 3 4. 5 6 Refer to Standard OP7 OP11 OP15 OP19 OP28 OP30 Good Practice Recommendations Care plans should be reviewed at least every month. The specific wishes of residents during illness and following death should be recorded in the resident’s case file. Residents in the front lounge should be consulted about the seating arrangements when dining. Confirmation that the fire safety work has been completed should be sent to the CSCI. The organisation should forward an action plan outlining when 50 of the workforce will achieve NVQ level 2 in care. Refresher training should be made available to all care staff. Such training should include, basic food hygiene, first aid, health and safety, manual handling, infection control. The manager should receive the appropriate she needs to undertake her role. The manager should ensure that fire drills take place at least twice a year incorporating all staff. Weekly checks should be carried out on a weekly basis. 7 9 OP31 OP38 Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 Page 23 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 Newlands Hall DS0000026276.V254482.R01.S.doc Version 5.0 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. 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!