Inspection on 30/08/05 for Snapethorpe Hall

This inspection was carried out on 30th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Snapethorpe Hall 24/11/08

Snapethorpe Hall 02/05/07

Snapethorpe Hall 23/05/06

Snapethorpe Hall 16/01/06

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 WF2 8YA Lead Inspector Gillian Walsh Pat Pedley Unannounced 30 August 2005 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. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Snapethorpe Hall Address Snapethorpe Gate Broadway Lupset WF2 8YA 01924 332488 01924 332499 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) Southern Cross Healthcare Ltd Mr James Alvin Cranmer Care Home with Nursing 62 Category(ies) of Over 65 with a mental disorder - 62 places registration, with number Over 65 with a Physical Disability - 62 places of places Over 65 with Dementia - 62 places Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 29/09/05 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 coordinated by the home’s activities organiser. The home employs the services of a visiting hairdresser who is available several times each week. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 30 August 2005 by two inspectors and took place over 7 hours. The inspection included a tour of the home, discussion with residents, staff and management and examination of records. The inspectors would like to thank the residents and staff for their time and assistance on the day. What the service does well: What has improved since the last inspection? What they could do better: The majority of the problems highlighted in the report are connected to low staffing levels. This situation needs to be reviewed to ensure that residents do not have to wait an unreasonable length of time for assistance. Some improvements in the cleaning and furnishing standards are still needed and a review of the catering service, considering residents needs and choices would be beneficial. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 6 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 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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 Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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) 3 All potential residents have their needs assessed and are given assurance that these needs can be met before they are offered a place at the home. EVIDENCE: The home’s manager said that all prospective residents are assessed by the most appropriate person from the home before a decision is made to offer placement. Evidence of pre-admission assessments was seen within care plan files. The home’s manager also confirmed that copies of assessments are also obtained from the funding authority although these were not included in all of the care plan files seen. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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. Care plans do not include full detail of residents personal and social care needs. Resident’s health care needs are met. Resident’s dignity needs, particularly in relation to personal care are not always met. EVIDENCE: The home’s manager said that new care plan documentation was about to be introduced which would result in a review of current care planning systems. A sample of current care plans was seen. Generally the care plans covered residents assessed needs but in one file a number of discontinued plans were still included in the file but without reading through the review notes it was not clear that these plans were no longer relevant. All of the care plans seen lacked individuality as there was little evidence that individual choice and preference had been considered and they had not been signed by the resident or their representative. One of the care plan files seen was for a resident who had been in the home for three months but the initial assessments remained incomplete and care plans had not yet been fully formulated. Discussion had taken place with one resident who had described some recent events, which had caused them to be very upset. The home’s manager had confirmed that Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 10 these events had taken place but no record had been made within the daily records. Some reviews had taken place but these were not being done on a monthly basis. The home’s manager said that care plans from the funding authority are obtained but these were not included in all of care plan files seen. In view of the plan to change the care planning documentation, a fuller examination of care plans will be made at the next inspection. Evidence was available that resident’s health care needs are met through referral to community health professionals including GP, district nurse, chiropodist, dentist etc although some issues were identified with personal care within the home. Several residents, particularly on the EMI unit were noticed to have very dirty fingernails, some with faeces and one resident had faeces on their feet and legs. During the tour of the home the manager had to ask staff to bring slippers or slipper socks for residents who had been left with bare feet. Generally residents said that staff were kind and helpful in their approach. One resident said that they often have to wait for long periods of time for staff to assist them to the toilet, on one occasion this was over five hours, and they were afraid of being incontinent. Also this resident said that although they would like, and needed due to physical problems, a bath a minimum of twice a week there had been times when they had not had a bath for well over a week and was very conscious of and upset by body odour. Daily records seen for this resident suggested that periods of longer than two weeks had passed between this person being assisted to bathe. None of the residents spoken with had any issues with regard to their privacy needs but whilst inspectors were in a resident’s bedroom having a chat, a staff member entered the room without knocking and made no apology for doing so. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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 standard(s) 12 and 15. Social and recreational opportunities are available within the home but the programme could be developed to provide more stimulating activities. Wholesome meals are provided but choice of meals and snacks are not always available as required by residents. EVIDENCE: An activities organiser is employed at the home and a list of planned activities is available on notice boards. These activities included games and hand and nail care but a lot of the programme was just listening to music or watching television which may not provide the stimulation required by some residents. A record is kept of activities residents have taken part in. The home’s manager said that the activities organiser was shortly to receive further training, which should help in developing a fuller programme of activities. In addition to the weekly activities programme some outings have recently been enjoyed and residents are included in the home’s concert committee to organise outside entertainers coming into the home. Residents meeting are held and minutes of these meetings were seen. Prior to the inspection a concern had been expressed to the Commission for Social Care Inspection that meals at Snapethorpe Hall were of a poor standard Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 12 and insufficient and that neither cooked breakfasts or suppers were available to residents. Residents said that food at the home is all right but confirmed that they did not receive supper other than a biscuit and would enjoy something like a sandwich or bread and jam. Staff said that cooked breakfasts were sometimes requested by residents but were not available from the kitchen. A tin of biscuits is available on each unit to be given out with drinks but these biscuits were broken and unappetising. The lunchtime meal consisted of either home made meat pie or sausages with vegetables and mashed potato followed by home made apple pie. The meal looked appetising and portion sizes were good. Discussion took place with the chef who was unaware of any problems. He said that food wastage is monitored and he often threw a lot of food away. Chef also said that when he had supplied suppers to the units these were not given out to residents by care staff. Chef said that now a full staff team had been employed in the kitchen he would be able to go to the units at meal times and to speak to residents on an individual basis. The home’s manager said that he would work with the chef to look into any issues regarding catering and would ensure that cooked breakfasts and suppers were available as required. Some of the crockery, particularly cups and beakers were heavily stained and in need of replacing. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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 standard(s) 16 Complaints are taken seriously and acted upon. EVIDENCE: The complaints log was seen and showed that 6 complaints have been received since December 2004. Good records had been made to demonstrate how these complaints had been dealt with. The homes manager said that some of the complaints had resulted in disciplinary action and some staff dismissals. The complaints made to the inspectors during the visit were fed back to the home’s manager who said he will look into them as per the home’s complaints procedure. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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 standard(s) 19, 25 and 26. Some improvements are needed to ensure that residents can enjoy a well maintained, comfortable and hygienic environment. EVIDENCE: A tour of the home showed that some redecoration has taken place since the last inspection and that a new lounge carpet has been fitted in Kirkgate unit. The carpet in the lounge on Westgate unit is in a very poor state and in urgent need of replacement and the carpet in the smoking lounge on Northgate is badly stained and burned and also in need of replacement. Dining tables were in need of a more thorough cleaning after meals and several dining chairs were in need of cleaning or replacement. The broken bath side identified to the manager is also in need of replacing, as this could be a risk to residents. Garden areas had been attended to since the last inspection and looked very pleasant, particularly to the front of the home. Plans are also in place to develop the gardens to the rear of the building. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 15 The home’s manager said that water temperatures had been problematic recently and the water temperature in a bathroom at the end of a corridor on the first floor was very low. The home’s manager said that he would ask the maintenance man to flush the system, which should improve matters. Ambient temperatures within the home felt very high and staff said that this had caused a lot of discomfort for themselves and residents over the summer months. The home’s manager said that he was aware of this problem and there were plans to fit a ventilation system on the first floor of the home. All of the bedrooms seen were clean and tidy but tubes of steradent and a stained sheepskin handling sling were seen in bathrooms. The home’s chef said that problems with getting crockery properly clean and de-stained were due to there not being a sink in the main kitchen where crockery could be properly washed instead of just rinsed with the hot hose. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 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 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. Resident’s needs are not being met by the numbers of staff available. Shortfalls within the recruitment policy and procedures could put residents at risk. Some improvements are needed within the staff training programmes. EVIDENCE: Prior to the inspection a concern had been received by the Commission regarding staffing levels at Snapethorpe Hall. Residents said that on occasions they had to wait longer than they would like for staff assistance and staff on the residential and EMI unit also confirmed that there were times when they struggled to meet the needs of residents. The staffing rota for Northgate and Southgate units was seen and showed that on two occasions only three staff had been on duty. The home’s manager said that very low staffing numbers only occurred when staff called in sick at the last moment. A selection of staff files was seen. One file did not include a full employment history and did not include proof of identity or photograph. Another file did not include the employee’s full address or an application form. For overseas staff the Manager said that they rely on the CV from their home country rather than obtain an application form. Staff training records were also seen but these only reflected mandatory training and not the variety of training listed on the home’s training plan. Some updates are needed for mandatory training particularly First Aid, but the manager said he hoped to be rolling this out soon. Some discussion took place Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 17 about the level of food hygiene training needed for care staff, currently the staff only receive food awareness training but chef had said that care staff are involved in some basic food preparation such as making sandwiches. NVQ training for care assistants is ongoing with almost fifty per cent now having achieved the award and others currently studying or waiting to start the programme. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 18 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) 33 and 38. Quality monitoring is in place to ensure that the home is run in the best interests of the residents. The health, safety and welfare of staff and residents is protected by systems in place at the home. EVIDENCE: Some quality monitoring takes place at the home, the manager said that he was about to start a new quality monitoring programme and would send a copy of the results of the survey to the CSCI. This will be fully inspected at the next visit. Regulation 26 reports are not being sent to the Commission on a monthly basis, but the manager said that visits had been taking place. Documentation to support the home’s procedures in relation to maintaining the health and safety of residents and staff was seen. This included fire safety Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 19 records, gas certificates, hoist and lift maintenance, PAT testing and waste removal. All of these records were appropriate and up to date. Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 20 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 1 x x x x x 1 2 STAFFING Standard No Score 27 1 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 3 Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 21 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 OP10 Regulation 12(4)(a) Requirement Timescale for action From 30 August 2005 2. OP15 3. OP19 4. OP25 5. OP27 6. OP29 The home must be conducted in a manner which respects the privacy and dignity of residents. Appropriate and timely assistance must be given with personal cleansing and toiletting needs. 16(2)(i) The registered person must ensure that food is available to residents at such time as may reasonably be required 23(2)(c) The lounge carpet on Westgate (d) and the smoking room carpet on Northgate must be replaced. The broken bath side must be replaced. 23(2)(p) The registered person must ensure that water temperatures and ambient temperatures are safe and comfortable for residents. 18(1)(a) The service provider must ensure that at all times suitably qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of service users. 19(1)Sche Staff files must contain the dule 2 information required in Schedule 20050830 Snapethorpe IR OP J51 v247008 s6209.doc From 30 August 2005 31 October 2005. 31 October 2005. From 30 August 2005 31 October 2005. Page 22 Snapethorpe Hall Version 1.40 2 of the Regulations. 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 OP7 Good Practice Recommendations Care plans should be developed to give full detail of individual needs, preference and choice. Care plans should be reviewed on a monthly basis. Daily records should include detail of how residents have spent their day and any significant events that may have had an effect on their wellbeing. Staff should be reminded to knock on residents bedroom doors before entering. The activities programme should be developed to provide more stimulating activities for those residents who may wish to take part. Stained crockery and drinking beakers should be replaced. Cleaning schedules should be reviewed to ensure that dining furniture is cleaned following each meal. Bathroom areas and equipment should be kept clean and tidy. Consideration should be given to providing more suitable washing up facilities in the main kitchen. The registered person should ensure that all staff receive training relevant to their position and that records log this training is made within their individual training file. The registered person should seek the advice about the level of food safety training required for care assistants from the appropriate authority. 2. 3. 4. 5. OP10 OP12 OP15 OP26 6. OP30 Snapethorpe Hall 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 23 Commission for Social Care Inspection 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 20050830 Snapethorpe IR OP J51 v247008 s6209.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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