CARE HOMES FOR OLDER PEOPLE
Newlands Hall High Street Heckmondwike West Yorkshire WF16 OAL Lead Inspector
Tracey South Unannounced Inspection 20th September 2005 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 Newlands Hall DS0000026276.V252581.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.V252581.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.V252581.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th March 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.V252581.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 6 hours. A tour of the home was undertaken. Care documentation and staff personnel files were examined as part of this inspection. Four residents, 1 relative and 3 members of staff were spoken to during the inspection. Comments received from residents and relatives have been included as part of this report. There were 27 residents living at the home on the day of the inspection. What the service does well: What has improved since the last inspection?
Some improvements to the décor of the home have been made. The reception lounge has been redecorated providing a homely and comfortable place for residents to sit. Old furniture, which was surplus to requirements, has been removed from the home. This has created more space within the home.
Newlands Hall DS0000026276.V252581.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.V252581.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.V252581.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): 1,3,5. Thorough pre-admission assessments are not being carried out. There is very little written information recorded about the resident’s needs at the preadmission stage. Prospective residents are able to visit the home prior to them moving in. EVIDENCE: The statement of purpose has not been reviewed or amended for some considerable time. This must be addressed to ensure that prospective residents and relatives are given correct information about the home and the services and facilities they can expect to receive. Information about staffing numbers, experience and qualifications of staff must also be kept up to date. Community care assessments were found to be in place in the four case files examined. Pre-admission assessments are carried out by the manager and deputy managers. Prospective residents are visited at their then place of residence, whether that is home or hospital. Staff carrying out the pre-admission
Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 9 assessments are not using the form to its full potential. The documentation being used is sufficient but the information being recorded is not. Staff are inclined to write down very brief details of the needs of the prospective resident. With very little written information available, staff are reliant on passing over information verbally which could result in important issues not being passed on. It is important that staff carry out thorough pre-admission assessments, the purpose of this is to ascertain whether or not the home is able to meet the needs of the prospective resident. This information should then be used to form the basis of the initial care plan. Prospective residents and their relatives are able to visit the home prior to residents moving in. One relative explained how her mother visited the home and stayed for tea on a couple of occasions before moving into the home. Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 10 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): 7,8,10 Care plans are poor and the information provided is basic. The care plans do not provide staff with the information they require to ensure residents’ needs are met. Residents have access to health care services. Residents are treated with respect. EVIDENCE: Four residents case files were examined, two of which did not contain a care plan. The two residents without care plans had moved into the home in August 2005. The two care plans examined did not meet the required standard. Neither had been signed or dated by the person completing it. There was no evidence to suggest that either of the two residents had been involved in the drawing up of their care plan. Only basic details were recorded. There were no specific details as to the level of support the resident required to ensure their needs would be met. Neither or the care plans had been reviewed since being completed. Daily reports were repetitive and contained very little information about how the resident had spent their day. There was very little evidence of any continuity of care, that is, issues of concern are very rarely followed up. Residents have access to health care services. All residents are registered with a local GP and records of visits are maintained. Some residents receive
Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 11 nursing treatment from the district nurse. The continence nurse assesses those residents with continence problems. Two case files contained Waterlow assessments although neither had been reviewed. Specialist equipment such as pressure relieving mattresses and cushions were seen in place. Two files did not contain a manual handling assessment, nutritional assessment, risk assessment or a Waterlow assessment. It was clear from reading the daily reports referring of one resident that this person was exhibiting challenging behaviour. There was no evidence to indicate how this behaviour was being managed. There was no risk assessment in place. Staff and residents were observed interacting well with each other and it was clear that staff are very respectful towards residents. Residents spoke of how kind and considerate the staff are and that they are always willing to help. Staff were observed knocking on toilet and bedroom doors before entering. Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 12 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): 13 Relatives are welcome to visit the home at any reasonable time. EVIDENCE: Relatives are able to visit the home at any reasonable time and feedback from relatives is that they are made to feel welcome by the staff. One relative explained that she visits her mother on a regular basis and finds the staff very hospitable. She said that staff are always ready to offer a cup of tea. Residents are able to see their visitors in the privacy of their own rooms or in one of the communal lounges if they prefer. Newlands Hall DS0000026276.V252581.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): 16, 18 The home has an effective complaints procedure in place although slight adjustments are needed to ensure that complainants are aware of when they will receive a response. Staff have not been trained in how to deal with adult protection issues. EVIDENCE: The home has not received any complaints since the last inspection in March 2005. The complaints procedure is displayed throughout the home. Each resident has a copy of the procedure displayed on the inside of their bedroom door. It was noted that the procedure does not state the timescale in which the complainant can expect a response. The procedure should be amended accordingly. The manager demonstrated a good knowledge of what to do if an allegation of abuse was made. The manager and 3 senior staff attended a half day training course in February 2005 on elder abuse. There has been no further training on adult protection for the remaining staff. The organisation must ensure that all staff receive adult protection training within the next six months. The organisation does have its own adult protection policies and procedures in place and all staff undergo employment checks prior to them starting work at the home. Newlands Hall DS0000026276.V252581.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): 19, 21 The home is clean and tidy. Communal areas have a homely feel to them and residents are able to sit in a comfortable environment. EVIDENCE: Improvements have been made to the fabric of the building. The reception lounge has been redecorated. New furniture, carpets and curtains have been purchased. The lounge looks homely creating a nice environment for residents. The manager pointed out that further redecoration needs to take place, as areas within the home are looking “shabby”. This will take place in order of priority over a period of time. Some bedrooms were looked at during a tour of the home. Residents are able to bring their own personal possessions with them when they move into the home. There was evidence of this in those bedrooms seen.
Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 15 The home benefits from having a large patio area towards the rear of the home, where residents can sit out in warmer weather. Confirmation that the fire safety work has been completed must be obtained and the CSCI must be notified of this in writing. The self-closure on the door of bedroom 13 needs adjusting as it is closing too quickly. There are no privacy locks in place on the either of the downstairs toilets (near to the new lounge). It was also noted that hand towels are being used in the communal toilets, instead of paper towels. These issues were pointed out to the manager during a tour of the home. Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 16 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): None of these standards were assessed on this occasion. EVIDENCE: Newlands Hall DS0000026276.V252581.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): None of these standards were assessed on this occasion. EVIDENCE: Newlands Hall DS0000026276.V252581.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 1 x 1 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X 2 X x STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Newlands Hall DS0000026276.V252581.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 2 Standard OP1 OP3 Regulation 4,6, 14 Requirement Timescale for action 30/11/05 3 OP7 15 The statement of purpose must be amended to ensure it is current and up to date. Thorough pre-admission 19/09/05 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 30/12/05 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. Appropriate assessments must be in place for each resident. These include,
DS0000026276.V252581.R01.S.doc 4 OP8 13 30/12/05 Newlands Hall Version 5.0 Page 20 5 6 OP18 OP26 13 13 7 OP33 26 8 OP33 24 9 OP37 17 manual handling, risk assessments, nutritional and Waterlow assessments. All such assessments must be kept under regular review. All staff must receive adult protection training within the next six months. Work must be carried out in the laundry to bring it up to standard. (Previous timescale not met). Regulation 26 visits must be carried out. Copies of reports must be sent to the CSCI office. Requirement brought forward from the last inspection report. The home and organisation must have an effective and evaluated quality assurance and monitoring system in place. Requirement brought forward from the last inspection report. All records must be securely stored in accordance with the Data Protection Act 1998. (Previous timescale of 31.1.05 not met) 30/03/06 31/03/06 30/09/05 30/09/05 30/09/05 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 Refer to Standard OP7 OP16 OP19 OP19 Good Practice Recommendations Care plans should be reviewed at least every month. The complaints procedure should be amended to ensure complainants are aware of when to expect a response. Confirmation that the fire safety work has been completed should be sent to the CSCI. The self-closure to bedroom 13 needs adjustment to
DS0000026276.V252581.R01.S.doc Version 5.0 Page 21 Newlands Hall 5 OP21 ensure it does not close too quickly. Privacy locks should be fitted to the downstairs toilets. Paper hand towels should be made available in all communal toilets. Newlands Hall DS0000026276.V252581.R01.S.doc Version 5.0 Page 22 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
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