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Inspection on 21/07/05 for Paks Trust Hatfield House

Also see our care home review for Paks Trust Hatfield House for more information

This inspection was carried out on 21st July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Hatfield House provides a relaxed and homely environment for the residents. There is a stable staff team who are very familiar with the needs and preferences of the residents. The manager and staff work in a professional and quiet manner with the residents. Support and advice is given in a discrete and skilled manner. It is particularly pleasing to note that the residents spend a lot of time talking to the staff and to observe staff and residents working together to undertake general household tasks such as laundry, cleaning and clearing away after meals. The residents said that the food is "good, great, lots of it, and can have what you want". The evening meal sampled by the inspector was homemade and very tasty. There were no unpleasant odours and there were good standards of hygiene and general tidiness throughout the home. The home maintains orderly staff files, risk assessments and other records such as Regulation 37 notifications.

What has improved since the last inspection?

The problems regarding rising damp between the kitchen and ground floor has been addressed. The ground floor bathroom has been completely refurbished and adjoining kitchen wall repainted and retiled. There continues to be an improvement in the development of statutory records residents care plans and accompanying records. The home is continuing to work towards improving the detail and quality of recording in residents` care plans. The manager is continuing with the development work and a meeting has been arranged between the Commission and home in order to monitor the work in progress and to offer further guidance and support as required.

What the care home could do better:

The system for the safe storage and accountability of resident`s money is insecure and must be improved. The home is to reconsider the arrangements for the storage of some of the laundry and cleaning equipment. The furniture in the dining room is to be rearranged in a manner that makes the best of the limited space whilst not presenting a potential trip hazard to residents. Consideration should be given to the possibility of identifying another designated smoking area. The Trust must ensure that statutory records relating to previous or deceased residents are held in accordance with the Care Standards Act 2000:Care Homes Regulations 2001. Subject to consultation with the local Fire Safety Officer and the outcome of risk assessments, 1st floor windows should be fitted with restrictors to minimise the risk of residents falling out of the window. As a result of the lack of secure storage space and some poor professional practice the confidentiality of residents and some staff records were breached. The home must ensure that satisfactory space and storage facilities are made available for the safe and secure storage of statutory records. Any new arrangements must not encroach on the communal living areas or residents` private space. Urgent attention must also be given to ensure that there are appropriate sleeping in arrangements and secure storage facilities for staff`s personal items such as handbags and mobile phones. The home has confirmed that work is in progress to address these concerns. The Responsible Individual must ensure that unannounced monthly visits are made to the home and copies of the written report of the visit forwarded to the Commission.

CARE HOME ADULTS 18-65 Paks Trust - Hatfield House 17 New Road Ash Green Coventry CV7 9AS Lead Inspector Maggie Arnold Unannounced 21 July 2005 14:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Paks Trust Hatfield House Address 17 New Road Ash Green Coventry West Midlands CV7 9AS 02476 362326 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Paks Trust Ms J R Lewis Care Home 5 Category(ies) of Learning Disability1 (5) registration, with number of places Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. NVQ level 4 That NVQ level 4 in Care and Management is achieved by 2005. Date of last inspection 10 February 2005 Brief Description of the Service: Hatfield House is a detached mid twentieth century house situated on a corner of a cul-de-sac in a residential area with garden at the front, side and rear. The house has an entrance porch, which serves as cloakroom and smoking area; dining room, lounge, kitchen and utility/shower room and one resident’s bedroom on the ground floor. Stairs lead off the dining room to the first floor where there are four bedrooms for residents and a bathroom and toilet. There is a very large garage at the back of the property and parking for three cars. The home is close to some local shops and a bus route. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 21st July from 14.30 to 18.30. The home was advised of the visit just a few hours before it took place. The main focus of this inspection was the environment, residents and staff records and safe practice within the home. The manager and two support staff were on duty at the time of the inspection. What the service does well: What has improved since the last inspection? The problems regarding rising damp between the kitchen and ground floor has been addressed. The ground floor bathroom has been completely refurbished and adjoining kitchen wall repainted and retiled. There continues to be an improvement in the development of statutory records residents care plans and accompanying records. The home is continuing to work towards improving the detail and quality of recording in residents’ care plans. The manager is continuing with the development work and a meeting has been arranged between the Commission and home in order to monitor the work in progress and to offer further guidance and support as required. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 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. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) On this occasion no standards were assessed from this section. EVIDENCE: No new residents have been admitted in the last two years. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8-10. Residents’ care plans, also known as individual Plans, require further development to ensure that they clearly reflect the outcomes of the recent multi-disciplinarily reviews. Failure to do so may compromise the well-being and safety of the resident. Subject to risk assessments, residents are encouraged to participate in various aspects of day-to-day life in the home. This promotes confidence and a positive self-image. Not all records of a confidential nature are securely stored when not in use. Such practice does not protect the privacy and dignity of the resident. EVIDENCE: Work had been undertaken to ensure that residents received reviews and that some work had been started to update care plans accordingly. The reviews were multi- disciplinary, involving, as appropriate, residents, family members, day care services, reviewing officer/social worker as well as the manager and resident’s key worker. The review meeting considered areas such as health, community access, relationships personal needs and household tasks. Details of costs were also included. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 10 A sample of a care plan was looked at and constructive feedback given as to how it could be further developed. In order to monitor the development of the care plans a meeting between the Commission and manager has been arranged for late August 2005. Discussions with the residents and home’s staff, combined with records seen and observations made throughout the visit evidenced that residents, subject to risk assessments, were enabled to make their own decisions and participated in various aspects of life in the home. With regards to confidentiality, the home failed to meet the required national minimum standards, records of a confidential nature were not securely stored when not in use. For example, details of accident reports, Regulation 37 reports, some recording individual resident’s challenging behaviour and other such records were stored in an unlocked filing cabinet in the resident’s dining room. All three daily diaries are stored in an unlocked cabinet in the communal lounge. In order to protect the privacy and dignity of the residents and comply with the Data Protection Act 1998, the home must ensure that adequate lockable facilities and storage space that does not impinge on the residents’ shared or private areas, are provided in the home. It was noted that the home’s statutory records relating to a recently deceased resident had been given to his family. The home is reminded that in accordance with the Care Standards Act 2000: Care Homes Regulations 2001: Regulation 17 (4) records referred to in paragraphs (1) and (2) of the same regulation, must be retained by the home for not less than three years from the date of the last entry. It is of concern that general records such as daily records, healthcare details, financial records and so on were released to a family member. In addition to having to comply with the above legislation the home is reminded that it has a common law duty of confidentiality to the residents. Copies of such records should only be released to appropriately authorised persons. Should other people wish to access such records this must be done through the proper legal channels. It is strongly recommended that the home develop a policy and procedure regarding access by third parties to such records. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 & 17. Residents are given opportunities for regular contact with family members and enjoy various leisure activities both within the home and wider community. This works towards a feeling of well being and good quality of life. Residents enjoy healthy and varied meals at the home, which promotes good health. EVIDENCE: Due to a number of circumstances there was not the opportunity for individual interviews but the inspector did talk spend time, including sharing a meal, with two of the three residents. The third resident was unwell and went to bed soon after arriving home from the day centre. Both residents said that they liked living in the home and were encouraged to “do lots of things”. In addition to assisting with day-to-day activities in the home, residents also enjoy holidays, trips out for meals, cinema and so on. At the time of writing this report all three residents are away on holidays with some of the staff. Two residents chose a seaside holiday together with the third resident choosing to go to a different seaside resort. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 12 It is also pleasing to note that the home has supported one of the residents to find a few hours paid work outside the home. The home works towards helping the residents to stay in contact with family members and friends. For example, visitors are welcomed to the home at any reasonable time and may stay for a meal or snack if they so wish. The kitchen was clean and well organised. Work was in progress to replace tiles that had been removed when addressing the problems of rising damp between the adjoining wall of the downstairs bathroom and kitchen. There was a good stock of varied foodstuffs, which was appropriately stored. The staff, with help from the residents, are responsible for food shopping and cooking the meals. Most of the meals are freshly made with ready prepared meals and convenience foods kept to a minimum. The inspector joined two of the residents and a member of staff for the evening meal. The vegetarian lasagne was home made and very tasty. It is pleasing to note that the residents were involved in preparing and serving the meal. In addition to setting the table and brining the food into the dining room, residents also take it in turns to clear away and help with the drying of dishes. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 21 Systems are in place that ensure the security and safe dispensing of medication. There was clear evidence that the home is proactive in dealing with the death of a resident in a sensitive and respectful manner. EVIDENCE: The residents’ personal, physical and emotional healthcare needs are identified via reviews and incorporated into the residents’ care plans. Subject to risk assessments, the residents are encouraged to be as self-caring and independent as possible regarding personal hygiene. Records showed that the home supports residents to access healthcare professionals such as GPs, dentists and psychologists. The home has a monitored dosage system and accompanying daily medication administration (M.AR.) sheets for the management of residents’ medication. Records seen were generally in good order and were securely locked in a cupboard. Although the present storage arrangements are adequate for the present needs of the residents, consideration should be given to providing a specialist medication cabinet that incorporates storage facilities for controlled drugs. Sadly, in April 2005 one of the residents died. There was clear evidence of the home’s consideration and respect given to working with the other residents and his family members to ensure that the situation was handled in a manner as the resident would have wished. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The arrangements for the safe keeping of resident’s monies is insecure and does not protect the resident’s from potential financial abuse. EVIDENCE: The home has not received any complaints since the last inspection. The home maintains records of any complaints or concerns plus action taken and outcome. The present system for the storage and safekeeping of residents’ monies and valuables does not meet the required national minimum standard. For example, the monies are held in the same cupboard used to store various cleaning supplies. Staff need to go into the cupboard on numerous occasions throughout the day. Although the home stores the residents’ monies in separate tins, the tins are stored on one of the shelves in the cupboard with the records and keys to the tins on the shelf above. There is no suggestion of misappropriation of resident’s monies but clear evidence of unsafe practice. The home must store resident’s monies and valuables in a secure manner and procedures are to be put in place to ensure that the key to the storage facility is accounted for at all times. Discussions took place as to how the accounting systems of the resident’s personal allowances could be improved. It is recommended that, subject to risk assessments, residents and a staff member should sign for any transactions, including money returned to the cash boxes. In the event of a resident not having a good understanding of money management, two staff should always sign for any financial transactions. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 Overall Hatfield House is a clean, comfortable and homely environment. Whilst some areas look a little tired, at present this does not have a detrimental effect on the well being of the residents. The ground floor bathroom has recently been refurbished and redecorated making it a pleasant facility for the residents. The dining room is multi purpose and presents a potential trip hazard for residents and staff. The practice of sleeping in staff using the lounge as a bedroom is not acceptable as it impinges on the choice and privacy of the residents. The home has confirmed that work is in progress to address this concern. EVIDENCE: The communal areas, although a little on the small side, were generally clean and comfortable being furnished and decorated to suit the taste and needs of the present residents. Due to the size of the communal lounge there is limited seating (five comfortable seats) which means that staff and residents cannot all sit in the room together. The dining room, which is a thoroughfare to the 1st floor and access to an emergency exit, also has a two-seater bed settee. A television is fitted to the wall. Two small filing cabinets plus an ironing board and vacuum cleaner are stored behind the dining room door. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 16 Consequently the room is very crowded with limited floor space. Quite apart from the fact that it is not acceptable to use the room to store laundry and cleaning equipment plus filing cabinets and to use the dining room as ‘part time’ office space, the room must be laid out in a manner that reduces the risk of trip hazards. This is particularly essential in view of it being the route to an emergency exit. Four of the five bedrooms are of a good size with the fifth one being a little on the small size. Whilst all of the bedrooms seen would benefit from a general updating/upgrading they are acceptable for the present. For example, some of the bedroom furniture, paintwork and décor were looking a little tired and dated. It is recommended that consideration be given to planning the medium term budget to address these concerns. The three bedrooms that were occupied were homely and clearly reflected the individual interests and preferences of the occupant. One set of bedding in particular was a little worn and requires replacing. The home must undertake a full audit of all bedding, including duvets and pillows as well as sheets and covers. In order to ensure an adequate supply of bedding, it is recommended that, each resident should be provided with at least three sets of sheets, duvet covers and pillow cases. It is pleasing to note that the home has adopted the good practice of ensuring that each resident has his own sets of bedding. The recently refurbished shower room and upstairs bathroom were clean and stocked with adequate supplies of soap, towels and toilet paper. At present none of the residents require any specialist aids or equipment. The layout of the home, just one ground floor bedroom and lack of space for a stair or vertical lift would mean that the home could only manage the care of one person with impaired/declining mobility or physical health problems. Laundry facilities have now been relocated to the large garage. The garage is not used to house vehicles, but as extra storage space for the home. The home must ensure that care is taken to ensure that all potentially hazardous substances (COSHH) are risk assessed and appropriately stored in the garage. An additional freezer and refrigerator are also housed in the garage. With the exception of the porch, there were no unpleasant odours and the general standard of cleanliness and hygiene throughout the home were good. It is common practice for the front porch, which is also used for storing coats and jackets, to be used as a smoking area. The present practice means that a smoky environment and the sight and smell of a used ashtray greet residents, staff and visitors arriving/leaving the home. Additionally coats and jackets hung in the porch will inevitably smell of cigarette smoke. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 17 In view of the fact that not all of the staff and residents are smokers this is not a suitable practice. It is recommended that serious consideration is to be given to finding an alternative smoking area. It is of concern that staff do not have an allocated sleeping in room when on night duty. It is usual practice for staff the sleep in the lounge. The home has confirmed that plans are in progress to address this concern. Refer also to the section regarding staffing. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Residents benefit from a well motivated, effective and supported staff team. Plans are in progress for a designated office cum sleeping in room fitted with secure storage space for staff’s personal belongings whilst they are on duty. This will promote the privacy, dignity and safety of both residents and staff. EVIDENCE: Two care staff and the manager were on duty at the time of the inspection. The home does not employ separate domestic, catering or administration staff. Staff spoken to throughout the inspection process were well informed and skilled in working with the residents. They advised that they enjoyed their work and felt they offered a good standard of care and support to the residents. Staff were observed to support the residents in a relaxed and calm manner with gentle and discrete prompting as required. Four staff files seen were and found to be generally well ordered. For example the files contained statements of terms and conditions of employment, sickness and personal development records, references etc. The manager was in the process of ensuring that all of the staff records comply with Schedule 2 of the Care Standards Act 2000: Care Standards Regulations 2001. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 19 There was evidence on file to demonstrate that staff routinely receive formal 11 supervision. The home has the good practice of requiring staff to complete a pro-forma prior to supervision. The document encourages the staff member to raise any concerns or comments that are role related, resident related, and general or with regards to management issues. It is also pleasing to note that, if so required, files staff files also evidenced that Health and Safety risk assessments had been undertaken. General risk assessments were are held in the home. The staff do not have a designated sleep-in room nor storage facilities for their personal belongings whist they are on duty. At present the sleep-in member of staff uses a bed settee in the residents’ communal lounge. Should the staff member wish to go to bed before all the residents are in their bedrooms, residents are requested to sit in the dining room to watch television. This is completely unacceptable to both residents and staff. Staff handbags were seen in the lounge and were left unattended by staff at various times throughout the visit. In accordance with the Care Standards Act 2000: Care Standards Regulations 2001: Regulation 23(3) (a)&(b) the home is required to provide staff working in the home with facilities for changing and storage facilities. Sleeping accommodation is required for staff who are undertaking sleeping-in duties. The home must be mindful that the provision of these facilities do not encroach onto the communal or private space of the residents. The inspector has been informed that work is in progress to meet these requirements and it is hoped that the home will have a designated office cum sleeping in room in the next few weeks. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41, 42, 43 The residents’ rights and best interests are compromised due to the lack of lockable facilities for the safekeeping of confidential records. The lack of a risk assessment regarding unrestricted window opening on the 1st floor places the safety of the residents at risk. The absence of an answer phone facility and details of alternative telephone numbers for use in emergencies compromises the efficiency and accountability of the home. The Responsible Individual does not monitor the well being of the residents and management of the home via Regulation 26 visits. This may have a detrimental effect on the competence and accountable management of the service. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 21 EVIDENCE: An experienced manager who has worked for PACS Trust for approximately ten years manages the home. The manager, who has worked at Hatfield House for the last four years, is well informed regarding the needs and aspirations of the residents and has a good overall view of the service. There was evidence in the home that systems are in place to ensure that resident’s are aware of the information held about them. For example, residents have their own life books that are stored in their bedrooms. The life book covers most the details of relating to the residents care needs and aspirations. As noted in the section regarding Individual Needs and Choices, not all of the records of a confidential nature held by the home are securely stored when not in use. Records and files combined with observations made throughout the inspection process evidenced that, with a few exceptions, the home works towards protecting the health, safety and welfare of the residents. For example, staff receive core training which includes, safe management of medication, health and safety in the work place and emergency first aid. Both individual and group risk assessments are undertaken and routinely reviewed. The home also ensures that, in accordance with the Care standards Act 2000: Care Homes Regulations 2001: Regulation 37, the Commission is notified of any causes of concern such as falls, serious illness, deaths and allegation of manager/staff misconduct. It was noted that not all of the windows on the 1st floor have restricted opening. The manager is required to undertake a risk assessment of all unrestricted windows. Decisions regarding the need for window restrictors are to be made in consultation with the home’s local Fire Safety Officer. The home does not have an answer phone facility. This could cause stress and or difficulties in the event of family members, friends, staff healthcare professionals or statutory bodies, such as the Commission, needing to make contact with the home. In order to improve the accountability and effectiveness of the service, the manager must ensure that the answer phone facility is activated when the home is vacant. It is strongly recommended that consideration be given to providing an alternative telephone number that callers could ring in the event of an urgent message or emergency. Work is in progress to change the use of one of the bedrooms into a designated office/sleeping in room. The home must submit an application to reduce the number of registered places within the home from five to four. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 22 The registered provider is required to ensure that, in compliance with the Care Standards Act 2000: Care Homes Regulations 2001: Regulation 26 that the responsible individual or his/her representative makes an unannounced visit at least once a month to Hatfield House. A copy of the written report arising from the visits is to be forward to the Commission. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 3 3 2 N/A 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Paks Trust - Hatfield House Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score x x x x 3 2 2 E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 24 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 10 Regulation 12(4)(a)& 17(4) (1)&(2) Requirement Records of a confidential nature must be securely stored in a lockable facility when not in use. Statutory records as referred to in Regulation 17(4) must be retained by the home for a period of not less than three years from the date of the last entry. Systems must be put in place which improve the security and accountability of the residents money and valuables. The dining room must be cleared of excess clutter and furniture arranged in a manner that reduces the risk of trip hazards. The home is required to undertake a full audit of residents bedding and replace as nessessary. Subject to risk assessments, potentially hazardous substances should be securely stored when not in use. The home is required to provide suitable staff changing and storage facilities. Staff must have a designated sleeping in room that does not impinge on the residents private Timescale for action 30/09/05 2. 23 13(6) 31/10/05 3. 24 13(4)( c) 31/10/05 4. 25 16(2) (c ) 31/10/05 5. 30 13(4)( a) 30/09/05 6. 28 & 36 23(3)(a) (b) 31/10/05 Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 25 7. 42 13(3) ( c) 8. 43 26 or shared space. There was evidence to demonstrate that work was in progress to provide staff with a designated sleeping in room. Subject to risk assessments and in consultation with the local Fire Safety Officers advice all 1st floor windows should be fitted with restrainers. The registered provider is required to ensure that the responsible individual or his/her representative makes an unannounced visit at least once a month to Hatfield House. A copy of the written report arising from the visits is to be forward to the Commission. 31/10/05 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. Refer to Standard 10 Good Practice Recommendations It is recommended that the home introduce a policy and procedure regarding third party access to residents confidential records. The procedures should be written with regards to both living and deceased residents. Consideration should be given to seek guidance from a legally qualified person to help draw up the protocals. It is recommended that the home purchases a specialist medication cabinet that includes a safe storage facilities for controlled drugs. Subject to residents individual risk assessments, two staff should sign for any financial transactions made on behalf of residents. It is recommeded that consideration be given to the costs of redecoration and refurbishment of residents bedrooms being planned into the medium term budget. It is also recommended that each resident is provided with a minimum of three sets of bedding for his own use. Consideration should be given to an alternative designated smoking area. The present practice of using the porch at E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 26 2. 3. 4. 20 23 25 5. 30 Paks Trust - Hatfield House 6. 43 the front of the house is not particularly ideal and does not foster good first impressions of the service. Consideration should be given to the home aquiring an answer phone facility for use when the staff cannot get to the telephone. It is also recommended that the facility includes a contact number for callers needing to contact the home in the event of an emergancy or urgent message. Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Paks Trust - Hatfield House E53 S4455 Paks Trust Hatfield House V241331 210705 Stage 4.doc Version 1.40 Page 28 - 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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