Inspection on 13/06/05 for Smalley Hall Residential Home

This inspection was carried out on 13th June 2005.

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

Smalley Hall Residential Home 22/12/09

Smalley Hall Residential Home 05/06/07

Smalley Hall Residential Home 29/06/06

Smalley Hall Residential Home 04/10/05

Smalley Hall Residential Home 17/11/04

Smalley Hall Residential Home 30/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE SMALLEY HALL SMALLEY DERBYSHIRE DE7 6DS Lead Inspector MARIE BONYNGE Unannounced Inspection Monday 13th June 2005 at 10:00am 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 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. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Smalley Hall Address Main Road Smalley Derbyshire DE7 6DS 01332 882848 01332 882351 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) Ashmere Care Homes Mrs Rosamund Morley Care Home only 27 Category(ies) of OP registration, with number of places SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered Manager to attend the Derbyshire adult protection training for managers 2. The registered Manager to have access to the Department of Health Protection of Vulnerable Adults Schemes in England and Wales for Care Homes and Domiciliary Agencies - A Practical Guide Date of last inspection 17TH November 2004 Brief Description of the Service: Smalley Hall is a large building, that was extended and re-furbished in 1988/89. The home is in attractive surroundings on the outskirts of the village of Smalley. the home is registered to provide personal care and accommodation for older people. 27 places are provided with 23 single bedrooms and 2 double bedrooms. The home is on 2 floors with a passenger lift provided. There is a large lounge area and a connecting dining area with a smaller sitting room in addition. A spacious conservatory overlooks the patio. Car parking space is provided. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in June 2005. The main focus of this visit was to follow up progress made regarding the requirements and recommendations made at the previous inspection. The manager has undergone the fit person process since the last inspection and is now registered with the CSCI. Inspection methods used included the examination of care plans and associated records, staff rotas, sampling of policies and procedures and a tour of the building. Discussions took place with residents, relatives and care staff. What the service does well: What has improved since the last inspection? There is a new kitchen. Most of the bedrooms have been redecorated and new bedding and curtains have been provided. Residents reported that the level and provision of activities has improved with more variety and regular trips out. Formal supervision of staff is now well established and the appointment of a Registered Manager has provided stability. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 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. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4, 5 Clear and useful information is provided to assist prospective residents and their visitors to make an informed choice about the home. Needs assessments are completed so that staff can plan care accordingly. EVIDENCE: The statement of purpose and service user guide had been updated to reflect the changes in the manager and the company. These were available in the reception area of the home and provided clear and concise information about the services offered. 3 residents’ care plans were examined. These indicated that assessment information had been obtained for residents prior to their admission to the home. Discussions with care staff indicated that they were aware of the content of care plans and referred to these for information regarding the needs of residents. A rolling programme of training was in place that included dementia care and some staff had attended this. Discussions with relatives and residents indicated that residents could visit the home prior to their admission and respite care has also been offered at the home. Two requirements and one recommendation made at the previous inspection have therefore been met. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 The general health and personal care needs of residents appeared to be met, residents spoke of being treated with respect and their privacy being maintained. EVIDENCE: The 3 care plans examined were generally well maintained and ordered. These indicated that the care plans were being reviewed monthly and covered monthly weights and risk assessments. Two requirements made at the last inspection have therefore been met. Where problems were identified on the care plans these were not always followed through with the action taken and it was therefore difficult to assess the outcome. A requirement has been made in respect of this. Residents spoken with reported that they felt their privacy and dignity were maintained and that staff showed kindness and consideration towards them. Staff were directly observed to knock on bedroom and toilet doors before entering. Standard 9 was not inspected on this occasion. The requirements made at the last report have been carried forward and will be monitored at the next inspection. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13, 14 and 15 Residents confirmed that the lifestyle they experienced generally matched with their expectations and provided a satisfactory range of recreational activities. EVIDENCE: Discussions with residents and relatives indicated that a range of activities was provided. This included arts and craft, board games and bingo. Regular trips out were being arranged and residents said that they appreciated these. An open visiting policy was in place where visitors could attend the home at any reasonable time. Visitors confirmed that they were afforded privacy when they came to the home. Information was provided to inform residents of their right to access their personal records. Resident’s bedrooms contained a number of personal possessions that they had been able to bring into the home with them subject to prior agreement. Residents spoken with said that the standard of food provided was good and they always had a choice if they did not like the menu. The menu was displayed in the dining room. One resident said that ‘they will make you what you want’, another resident suggested having fish and chips or a take away one evening. The senior person on duty that day agreed to follow this up for further discussion. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 and 18 Systems were in place for residents to voice their concerns and the home took all issues raised seriously, this contributed to the protection of service users. Further training of staff will underpin these policies and procedures. EVIDENCE: A written complaints procedure was displayed in the entrance and also contained within the statement of purpose. A record of complaints was kept. Residents and relatives spoken with said that they could raise concerns if they had any and would speak to the manager or other member of staff. A vulnerable adults procedure was in place and some training had taken place for staff regarding these procedures. Further training was planned in the near future. A requirement in respect of this has been carried forward from the last inspection report. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The home provided generally comfortable and homely accommodation for residents that contributed to the satisfaction expressed by residents. EVIDENCE: A number of improvements had been made to the environment since the last inspection including the complete refurbishment of the kitchen. A number of bedrooms had been decorated and new bedding and curtains had been provided. Residents commented positively about these changes and one resident said that they had been involved in the choice of the décor of their room. The gardens were well maintained and attractive. One resident said that they liked the addition of the bird table and enjoyed watching the squirrels from the conservatory. The premises were generally clean and free from offensive odours and a programme of maintenance was in place with records kept. Some minor repairs were needed to radiator covers and chipped paintwork. The flooring in the upstairs bathroom was worn and in need of replacement. The carpets in the main corridor were also in need of SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 13 replacement. The Inspector was advised that these improvements had been noted and were in the homes development plan. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home was staffed in accordance with the recommended guidance to meet with the assessed needs of residents on this visit. Further development of the training plan based on individual staff needs will contribute to a well trained staff team. EVIDENCE: A sample of staffing rotas was examined for the month of June 2005. These indicated that there was one senior care staff and two care workers on duty each morning and each afternoon. Where holidays and sickness occurred, the existing staff group had covered these shifts. There had not been any cover in the kitchen in the afternoon, however an appointment had been made for a kitchen assistant to work 2 hours at tea time that had recently commenced. Residents said that if they needed anything a member of staff would always come. Two staff files were examined, these were generally well ordered and contained two written references and a completed Criminal Records Bureau check. A training plan was in place and certificates of training were examined for individuals. An overall plan that identified the individual and collective training needs of staff had not been developed. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37 and 38 Systems were in place for the supervision of staff however without the completion of all the required training the health, safety and welfare of residents cannot be fully maintained at all times. EVIDENCE: The manager has undergone the fit person process with the CSCI and is now the Registered Manager of the home. Both residents and staff spoke highly of the Registered Manager and of the positive changes that she had made. A supervision policy and procedure was in place. Records indicated that formal supervision sessions were being held with a designated agenda. Staff spoken with confirmed that they received supervision and that they felt supported from the management. Records were generally well kept and maintained. Further training had taken place since the last inspection although not all mandatory training had been completed including moving and handling and infection control. SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x 3 3 2 SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 17 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. 2. Standard OP7 OP9 Regulation 15 13 (2) Requirement Where a problem is identified on the care plan the follow up action taken must be recorded. There must be no gaps in medication administration records. Staff must initial each record or use the appropriate code (informed at the time of the inspection). Where an optional medication dose was stated, staff must record what dose had been administered. (Informed at the timeof the inspection). All medication including medication that is refrigerated must be returned to the pharmacist when not required. There must be a written policy and procedure as well as a system to record administering of homely remedies. The recording system to return medication must state the dosage of medication returned. Timescale for action 01.09.05 01.07.05 3. OP9 13 (2) 01.07.05 4. OP9 13 (2) 5. OP9 13 (2) 6. OP9 13 (2) Previous timescale 30.12.04. New timescale 01.07.05 Previous timescale 30.01.05. New timescale 01.08.05 Previous timescale 30.12.04. New timescale Page 18 SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 01.08.05 7. OP18 13 The remainder of the staff group must undertake adult protection training. From inspection report 17.11.04. Previous timescale 30.02.04 and 30.03.05 New timescale 01.09.05 30.12.05 8. OP19 23 (2) 9. 10. OP19 OP30 23 (2) (d) 18 11. OP38 13 (5) 18 (1) The programme of replacement of the bathroom floor and corridor carpets must be completed All areas that require redecoration must be completed. An overall training and development plan must be developed to include the individual training needs of staff. All staff must undertake mandatory training / guidance relevant to their work. this includes moving and handling, basic food hygiene and infection control. From inspection report 17.11.04. 30.12.05 01.10.05 Previous timescale 30.03.05. New timescale 01.10.05 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 Good Practice Recommendations SMALLEY HALL C52 CO2 S20215 Smalley Hall V234019 130605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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. 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