Inspection on 09/08/05 for South Hayes Care Home

This inspection was carried out on 9th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

South Hayes Care Home 04/04/07

South Hayes Care Home 20/06/06

South Hayes Care Home 16/05/05

South Hayes Care Home 22/12/04

South Hayes Care Home 19/10/04

South Hayes Care Home 06/07/04

South Hayes Care Home 16/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE South Hayes Nursing Home 101 London Road Worcester Worcestershire WR5 2DZ Lead Inspector Annie OMara Unannounced 9 August 2005 07:30 am 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. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service South Hayes Nursing Home Address 101 London Road, Worcester, Worcestershire WR5 2DZ 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) 01905 357429 01905 357429 Regal Care (Worcester) Limited Care Home 30 Category(ies) of OP Old age (30) registration, with number PD(E) Physical disability over 65 (30) of places South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Reduction in the maximum number of residents who may be accommodated from 48 to 30 until there is agreement with CSCI that an increased maximum number may be reinstated. 2. As from the receipt of the Notice dated 10th June 2005, no new residents should be accepted or admitted until such time as the CSCI gives written agreement to this. Date of last inspection 16 May 2005 Brief Description of the Service: South Hayes Nursing Home is a large, detached, three storey building, which attracts a listed status. Situated approximately half a mile from Worcester City Centre, it occupies an elevated position set back from the road, and is approached by a short drive leading to a car parking area. The home is registered to provde nursing care for up to 48 elderly residents, who may also have a physical disability. The home is not registered to provide care for residents with dementia or who suffer a mental health problem. The stated aim of the home is to provide the best quality life for residents in an environment which is clean, comfortable, safe and welcoming, and where people are treated as individuals with respect and sensitivity. The home has been owned by Regal Care (Worcester Ltd) since 1998. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home is currently undergoing a change in registration from a nursing home to a care home providing personal care only due to concerns about the standards of nursing care. This has been a time of change and disruption for residents and staff alike. The registered providers have appointed an acting manager who has begun managing this change and all the areas of previous concerns. The inspection took place during a weekday morning and began before the night shift went off duty and continued until lunchtime. The main purpose of the inspection was to look at the progress made by the home in response to the very high number of requirements made at the last inspection. Care records were looked at, day and night staff spoken to and two residents were also consulted. What the service does well: What has improved since the last inspection? The records which are kept to make sure that residents are receiving the care and attention they need have improved and the system for keeping records is being changed. Activities have been provided for the residents. Improvements have been made in the environment including re-decoration and safety procedures. Staffing levels have improved and staff are receiving up to date training. Recruitment procedures have also improved to ensure that residents are protected. An experienced manager has been appointed and she has begun to make changes which benefit the people who live in the home. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.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. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.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 South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.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) 1, 3, Comprehensive information was available for prospective residents to make an informed choice about whether they would wish to move into the home. EVIDENCE: The home provides comprehensive information to prospective residents and their relatives. There have been no recent admissions to the home. The acting manager has plans to change the assessment forms that have been used in the past. The format that will be used will cover all areas of residents care needs although they need to have adequate space on them to record them in detail all residents needs. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.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, 9, 10. Care plans have improved with regular reviews in place although not all aspects of residents needs have been addressed thereby putting residents’ emotional and social needs at risk of not being met. EVIDENCE: Care plans in place currently had been reviewed and updated. Comprehensive records were kept of the current health care needs of residents and how staff were managing them. This included referrals to appropriate health care specialists. The current plans did not adequately address the social and emotional needs of the residents in any detail. A resident who displayed anxious and frustrated behaviours did not have a care plan or risk assessment in place for staff to manage the behaviours consistently. Daily records kept gave no indication as to how the residents had spent their days but concentrated on the physical care they had received. Activities records were not kept. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 10 The acting manager was replacing the current format in place to a more individualised plan. A sample care plan was seen and again did not adequately address the social and emotional needs of the residents. Controlled drugs were not stored in a metal cabinet that met the required standards. Some medications were being over ordered. Hand written medication administration sheets were not checked and signed by two members of staff. Adhesive labels which were provided by the pharmacy could cause confusion if used. Observations made during the inspection indicated that staff upheld the dignity of residents and were respectful of their dignity. Residents who were spoken to praised the staff and confirmed that they were treated very well. The home does have a high proportion of shared rooms. There was no specific information as to how residents were provided with choice about sharing a room with someone they did not know. This needs to be clarified so that all residents have the opportunity not to share a room if they choose. This also needs to be clarified when residents’ rooms are changed for any reason. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.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, 15 The relaxed atmosphere and flexible routines allow residents to live their lives as they choose, and the dietary needs of residents are well catered for and allows for them to have choices. EVIDENCE: The routines observed during the inspection were relaxed and unhurried. This was improved because of the current high staffing ratio and low numbers of residents. Activities were being provided by staff and an activities co-ordinator but these were not being recorded. Outings had been arranged during the summer and residents confirmed that they had plenty to do. There was no activities program on display in the home. Residents spoken to stated that the food had improved and that they had plenty of choice for each meal provided. Menus were provided and residents had a choice of where they ate. The meal time was well organised, although when there are more residents admitted to the home the manner in which it is served will need to be re-organised. The trolley in use is not appropriate for serving as it is hot to the touch, and does not give adequate serving space. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 12 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) None of these were inspected EVIDENCE: South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 13 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, The environment is being improved and already provides a more attractive and safer place for the residents to live. Numbers of shared rooms do not promote the privacy and choice for residents. EVIDENCE: The home has worked hard to improve the environment although there are still outstanding issues which need addressing to ensure the safety and comfort of the residents. Outstanding works include: Locks on residents’ bedroom doors Privacy locks on en-suite toilet doors Two bathrooms are out of action Not all bedrooms have the required furnishings including, bedside lockers, bedside lamps, and curtains. Hospital/nursing beds in the majority of bedrooms The sluice room on the first floor needs to be re-floored South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 14 A sluicing facility on the top floor needs to be taken out Several carpets around the home need to be replaced because of poor odours Call bells were not provided in all communal areas of the home There is an intercom system still in use in the home Glass in the conservatory does not have safety glass installed There is inadequate space and seating in the dining room for all residents when the home is running on maximum numbers. The home currently has four bedrooms which are under 10 Square metres and also has fourteen double bedrooms. The registered provider is currently negotiating the numbers of bedrooms they will provide when the home is reregistered. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 15 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, 30 Staffing levels and improved training promote the welfare and wellbeing of the residents. EVIDENCE: At the time of the inspection the numbers of staff on duty was in excess of the minimum staffing levels and the skill mix was excellent. Recent recruitment files were observed and contained all the required information and police checks. Training for staff has improved. Induction and foundation training provided by the home has not been compared with the Skills for Care specifications. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 16 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, 33, 38 The appointment of an experienced manager has already had a positive impact on the care being provided although further work is needed in health and safety areas to ensure that residents are not at risk. EVIDENCE: The registered providers have appointed a manager to run the home during this time of transition. She is very experienced in management and also has a sound knowledge of the resident group. She has applied for registration with the Commission for Social Care Inspection. Progress has been made with the large number of requirements made at the previous inspection. There was no overall quality assurance program in place that was being used to audit the service. The manager did not have an overall management plan for prioritising and delegating the management tasks that need to be dealt with over the next few months. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 17 Environmental risk assessments in place were not up to date. Fire safety checks were not up to date and records were difficult to check. It was not clear when the last fire drill had been carried out. A complete fire check was carried out during the inspection, and the fire safety risk assessment had been updated. Coshh records, for the safe handling of chemicals were out of date and not all hot water outlets were checked. Electrical safety checks had been carried out. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 1 2 2 2 x 2 x 2 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 x x x 2 x 1 x x x x 2 South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 19 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 7 Regulation 15 Requirement Care plans must be developed to cover all areas of residents lives including social and emotional needs. Staff must be given instructions as to how anxious and frustrated behavious displayed by residents are managed consistently. Residents and their relatives must be involved in the care planning process and sign to show their involvement. A risk assessment and must be in place for residents who display any anxious or frustrated behaviours Controlled drugs must be stored in a metal cabinet that meets the Misuse of Drugs (Safe Custody) Regulations 1973. The responsible person must ensure that medication is not over ordered. The use of adhesive labels on the MAR charts must be discontinued to reduce the potential for errors. Residents who share rooms must be given the opportunity to make a positive choice about sharing and this must be Timescale for action 30/9/05 2. 7 15 Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Page 20 3. 7 15 4. 8 13 5. 9 13(2) 6. 7. 9 9 13(2) 13(2) 8. 10 12 South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 9. 10. 11. 12. 13. 14. 15. 15 20 20 21 21 22 24 13 23 13 23 23,12 23 23, 13 recorded and signed on their care plans. Arrangements for serving hot food must be reviewed before more residents are admitted. Adequate dining space and seating must be made available for all residents. Glass windows in the conservatory must be made safe and shatter proof. Bathrooms and their equipment must be kept in working order. Privacy locks must be provided on ensuite toilet doors. Call bells must be provided in all areas accessible by residents. Recommended locks to be provided on all residents bedroom doors. All the required furniture to be provided for each bedroom. Beds which are more appropriate and domestic to be provided for each resident. Carpets in bedrooms with poor odours to be replaced. The floor of the sluice room on the first floor to be replaced. The sluicing facility on the top floor to be removed from the bathroom. The induction training provided at the home must be checked against the Skills for Care specifications to ensure it meets the required standards. A quality assurance program must be developed in accordance with Regulation 24 and Standard 33. Environmental risk assessments must be carried out for all safe working practices. Fire safety records must be kept which include all the checks 30/9/05 To be agreed 31/10/05 31/10/05 30/9/05 30/9/05 As new residents are admitted 30/9/05 30/9/05 30/9/05 30/9/05 30/9/05 30/9/05 16. 17. 18. 19. 20. 21. 24 24 24 26 26 30 23 23 23 13 23 13 23 13 12, 18 22. 33 24 31/10/05 23. 24. 38 38 13 23(4) Immediate Immediate Page 21 South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 25. 26. 38 38 13 13 carried out and be easy to read and access. Coshh records must be updated and be available for the purpose of first aiders if needed. Hot water outlets must be tested to ensure that hot water is available, day and night at the required temperatures. Immediate Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard 3 7 9 10 23 33 Good Practice Recommendations The assessment format should have adequate space to record in detail residents needs. Daily records should be improved to show how residents are spending their days and this should include activities they have taken part in. It is strongly recommended that two trained members of staff check and sign for any hand written MAR sheets. The reduction in the numbers of double rooms should be considered to ensure residents privacy and dignity are maintained. The use of the bedrooms which fall below 10 sq. metres should be reviewed. A management plan which prioritises all the areas which need further development should be in place to support the acting manager. South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 22 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 South Hayes Nursing Home E52 S4144 South Hayes NH V2425114 090805.doc Version 1.40 Page 23 - 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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