Inspection on 16/01/06 for Snapethorpe Hall

This inspection was carried out on 16th January 2006.

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

Snapethorpe Hall 24/11/08

Snapethorpe Hall 02/05/07

Snapethorpe Hall 23/05/06

Snapethorpe Hall 30/08/05

Snapethorpe Hall 29/09/04

Snapethorpe Hall 07/06/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOMES FOR OLDER PEOPLE Snapethorpe Hall Snapethorpe Gate Broadway Lupset West Yorks WF2 8YA Lead Inspector Gillian Walsh Unannounced Inspection 16th January 2006 9.30 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 Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Snapethorpe Hall Address Snapethorpe Gate Broadway Lupset West Yorks WF2 8YA 01924 332488 01924 332499 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) Southern Cross Healthcare Services Limited Mr James Alvin Cranmer Care Home 62 Category(ies) of Dementia - over 65 years of age (62), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (62), Physical disability over 65 years of age (62) Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 31 beds for the combined categories of MD and DE Date of last inspection 30th August 2005 Brief Description of the Service: Snapethorpe Hall is a purpose built home which provides personal and nursing care for up to 62 older people with a physical disability or who are suffering from dementia. The home is divided into two separate units over two floors, one providing care for elderly mentally ill people and one providing general nursing and personal care. All bedrooms are single en-suite and each floor has its own lounge and dining areas. From the hallway and downstairs lounge, a very pleasant patio and garden area can be accessed. The home has a hydraulic passenger lift which allows easy access to both floors. The home is situated on the outskirts of Wakefield, is easily accessible from the M1 motorway and there is a regular bus service to the city centre. Car parking is available to the front of the home. An activities programme, including organised outings, is available and is co-ordinated by the homes activities organiser. The home employs the services of a visiting hairdresser who is available several times each week. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 16th January 2006. Time was spent speaking with residents, staff and management, taking a tour around the home and reviewing records and documentation. On this occasion the manager was only available for a few minutes but the Operations Manager was in the home and was able to provide assistance during the inspection. The inspector would like to thank everybody at the home for their time and hospitality during the visit. What the service does well: What has improved since the last inspection? What they could do better: Care planning and the assessment process in some units needs to be improved. A safe system needs to be implemented for the storage and administration of medications. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 6 Systems need to be put in place to protect residents from suffering abuse. Availability of activities staff needs to be reviewed to prevent residents feeling bored and to provide stimulation. 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. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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 Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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 and 6. Evidence was not available to show that all residents have their needs assessed, and assurance given that these needs can be met, before moving into the home. The home does not provide intermediate care. EVIDENCE: In the care plan files seen, including one for a resident who had only been in the home for a few months, pre-admission assessment documentation could not be found. The Operations Manager said that she was sure that preadmission assessments were always completed but was unsuccessful in finding evidence to substantiate this. The home does not provide intermediate care. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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 and 9. Residents could be put at risk due to plans of care not fully reflecting their health and safety needs. Residents are not protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: New documentation for assessment and care planning has been developed since the last inspection. This documentation is good but, in some of the care plan files seen, had not been properly completed. Specifically, assessments and care plans for residents on the EMI unit were incomplete and in several cases not signed or dated. Assessments for one resident did not mention their predominant need with regard to behavioural problems. Despite a care plan saying that observation of this person was needed in order to protect them and other residents, no note had been made of how this observation was being maintained. No risk assessment had been developed in this regard. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 10 Some assessments were contradictory to other information held within the care plan file, for example in one care plan file an assessment said that the resident was continent although daily records indicated that incontinence was a big problem for this person. Another care plan had been developed for a resident who had a wound to their leg which required dressing. Although wound assessments are included in the new documentation, this had not been completed and the care plan had not been evaluated between 10th November and 13th January. Although the documentation is designed to consider residents’ strengths rather than concentrating on problems and disabilities, this is not being used to good effect. Care plans for people on the residential unit gave good detail in both assessments and within care plans. These care plans also included details of residents’ personal preferences with regard to their lives at the home. Systems for the handling of medication were checked and found to be unsafe. The monthly delivery from the chemist had been made three days prior to the inspection but large boxes of medications were still on the floor in the medications room waiting to be put away. The nurse in charge on the EMI unit had administered the medications that morning but had found a number of anomalies in the recordings made when the medications had been booked in and had also found that no medication had been delivered for one resident. Due to problems with the recording systems it was not possible to accurately check stock balances. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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, 13, 14 and 15. Residents’ social and recreational needs are not always being met which results in people feeling bored. Arrangements are made for residents to remain in contact with families and friends as they wish. Some residents are supported to make choices about their lifestyle within the home. Residents are generally happy with the meals supplied but better arrangements should be made for the supply of suppertime drinks. EVIDENCE: Several residents said that they were bored and had nothing to do with their time. One person said “We get up, have breakfast, have dinner, have tea and then go to bed with nothing else to do” and another said “We have to sit here like a load of stuffed chucks”. Several residents said that they would like to get out of the home more, even just for a walk. Some staff said that there is a shortage of activities available to residents. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 12 Positively, care staff were seen to be assisting residents in activities but this is subject to them having time between delivering personal care. The home only employs one activities organiser, which, on the evidence given by staff and residents is not sufficient to prevent people from feeling bored. During the afternoon, the activities organiser was seen to be playing games with residents on the EMI unit. There was also evidence that the activities organiser may be being asked to do jobs in the home not related to residents activities, ie, checking balances of residents’ personal allowances with the home manager. Residents said that they do maintain contact with friends and relatives and an open visiting policy is operated by the home. Little evidence was available in care plans, other than on the residential unit, that residents are supported to exercise choice and control over their lives. A full inspection of standard 15 regarding provision of a balanced diet was not made on this visit. However, staff and residents said that they had recently changed the mealtime routine so that they were now served a snack meal at lunchtime and their main meal at teatime. This new routine appeared generally to be going down well and residents were complimentary of the food supplied at the home. One problem highlighted was that there are no facilities to provide residents with a warm milky drink at suppertime as the only microwave available is in the staff room which is situated some distance away from the residents’ areas. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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): 18. Policies and procedures are not being followed by staff at the home to ensure that residents are protected from abuse. EVIDENCE: Information was found in residents’ daily records to indicate that there had been several instances of alleged inappropriate sexual behaviour which had been recorded but had not been appropriately reported under Wakefield Metropolitan District Council’s policies and procedures for the protection of vulnerable adults. Neither had these allegations been reported under regulation 37 to the Commission for Social Care Inspection. At the advice of the inspector, this was reported appropriately during the visit. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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 and 26. The home is generally clean, tidy and well maintained although the carpet in the smoke room on Northgate is in urgent need of replacement to ensure that a pleasant environment is available to residents in all areas of the home. EVIDENCE: Since the last inspection there has been a number of improvements made to the environment, these include some new carpets, redecoration, new furniture and new crockery. Carpets seen in two of the bedrooms smelled very strongly of urine despite frequent cleaning but staff said there were already plans in place to replace these carpets. Despite a requirement being made in the last report, the carpet in the smoke room on Northgate has not been replaced and is very badly marked with cigarette burns. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 15 Generally, the home was clean and tidy and provides residents with a pleasant living environment. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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): 27 Staffing arrangements are sufficient to meet residents’ physical needs but staff are not available in sufficient number to meet residents’ recreational and physical needs. EVIDENCE: Staff said that, since the last inspection, things have improved with regard to staffing levels in the home. The majority of residents also said that they are happy with the availability of staff to assist with their physical needs although one person said that there were occasions when they have to wait longer than they would like for staff assistance. Employment of only one activities organiser for up to 62 residents has resulted in social and recreational needs not being met. [See Daily Life and Social Activities section of this report] Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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): 35 Policies and procedures are in place to safeguard residents’ financial interests. EVIDENCE: The home holds small amounts of residents’ personal allowance monies. Procedures and documentation in relation to this were checked and found to be appropriate. The balances checked were correct. Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 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. Standard OP3 Regulation 14(1) Requirement The registered person shall not provide accommodation to a resident at the care home unless the residents needs have been assessed by a person qualified to do so. Care plans must include full detail of how the residents’ needs in respect of his health and welfare are to be met. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall make arrangements by training staff or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. The smoking room carpet on Northgate must be replaced. Timescale for action 31/01/06 2. OP7 15(1) 31/01/06 3. OP9 13(2) 31/01/06 4. OP18 13(6) 16/01/06 5. OP19 23(2)(c) (d) 28/02/06 Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 20 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 OP12 OP27 Good Practice Recommendations The registered provider should give consideration to increasing the provision of activities staff availability within the home. The activities programme should be developed to provide more stimulating activities for those residents who may wish to take part. Residents should be supported to make decisions about their lifestyles and this should be recorded within the care plans. Facilities should be made available to enable residents to have a hot milky drinks when the main kitchen is closed. 2. 3. OP14 OP15 Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 21 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 Snapethorpe Hall DS0000006209.V253805.R01.S.doc Version 5.1 Page 22 - 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. 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