Inspection on 07/07/05 for Hallaton Manor

This inspection was carried out on 7th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Hallaton Manor 02/12/09

Hallaton Manor 07/07/09

Hallaton Manor 03/06/08

Hallaton Manor 11/07/07

Hallaton Manor 01/06/06

Hallaton Manor 19/10/05

Hallaton Manor 15/03/05

Hallaton Manor 27/07/04

Hallaton Manor 25/02/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE St Bernards Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ Lead Inspector Keith Charlton Unannounced 7th July 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. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Bernards Address Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ 01858 555271 01858 555332 Ms Elaine Farrall, St Bernards hallaton Manor Limited, Cranoe Road, Hallaton, Mkt Harborough, Leicestershire LE16 8TZ 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) CRH 41 Category(ies) of PD(E)- Physical Disability 0ver 65yrs - 33 places registration, with number A - Alcohol dependence past/present- 41 places of places OP - Old Age - 41 places MD- Mental Disorder - 41 places PD- Physical Disability - 33 places MD(E) - Mental Disorder over 65yrs - 41 places D - Drug dependence past/present - 41 places LD Learning Disability - 6 places LD(E) - Learning Disability over 65yrs - 6 places A(E) Alcohol dependence over 65yrs - 41 places DE(E) Dementia over 65yrs - 41 places\\ D(E) Drug dependence over 65yrs - 41 places St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The minumum age of admission to the Home of persons falling within any of the categories PD, A, D or LD is 55 years of age. The minimum age of admission to the Home for persons falling within category MD is 50 years of age. No person falling within categories PD or PD(E) may be admitted to the Home when there are 33 persons in total of the combined categories already acc. No person falling in categories LD(E) or LD may be admitted to the Home when there are 6 persons in total of the combined categories already admitted To be able to admit the person of category PD named in variation applicated number 37503 received on 29th July 2002. To be able to admit the named person of category A named in variation application number 39453 dated 17th October 2002. Date of last inspection 15th March 2005 Brief Description of the Service: St Bernard’s is a care home that is registered to accommodate 41 service users. The home holds the following categories of registration, older persons, mental disorder, past or present drug dependence, past or present alcohol dependence over 65 years, dementia over 65 years, learning disability and physical disability. The home is a converted large country house, which is situated in beautiful countryside approximately 1 mile from the village of Hallaton. Accommodation is on two floors that can be accessed via a passenger lift. The majority of the rooms are single occupancy, many of them with en suite facilities. The home has undergone a major programme of refurbishment with only a few areas still requiring attention. There are a variety of lounges for service users to choose from. The home has ample gardens and outside areas. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection. The Home’s Registered Manager was on duty to assist with the inspection process. Planning for the Inspection included assessing notifications of significant events sent to the Commission for Social Care Inspection by the home, looking at the outcome from a complaint made in April 2005 and reading the findings from the last Inspection Report. There was no Pre-Inspection Questionnaire or Comment Cards returned by service users, relatives, GPs etc. The Inspection took place between 9.40 and 14.50 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with eight residents, four members of staff and the Registered Manager. The inspection was completed on 14/7/05 with the Registered Manager and the Deputy Manager. A relative spoken with who said staff were kind and helpful and were always welcoming to visitors. What the service does well: It keeps up to date Care Plans. It ensures that staff read the Care Plans. Service users reported that staff were attentive and helpful. Staff welcome visitors to the Home. Service users liked the food provided to them. Facilities are kept in a clean and tidy condition and have been upgraded. The grounds are well maintained and look attractive. Statutory records are kept to a generally high standard. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. St Bernards C51 C08 S1825 St Bernards 070705 V233005 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 St Bernards C51 C08 S1825 St Bernards 070705 V233005 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) 3 Service users needs are fully assessed at the time of moving into the Home. EVIDENCE: The assessments seen for service users who were case tracked included all essential information regarding service user’s conditions, health needs, interests and hobbies, food preferences etc St Bernards C51 C08 S1825 St Bernards 070705 V233005 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) 7,9,10 The Registered Manager covers health and personal care issues for service users. EVIDENCE: Care plans for three case tracked service users were inspected; these appeared to meet all assessed needs. Social worker care plans were seen and risk assessments including nutritional risk assessments and moving and handling assessments were included. Medication was observed to be issued to service users - this was carried out correctly and medication records were signed up to date with medication security in place at times of issuing. Eight service users were spoken with and all except one confirmed that staff treated service users with respect and maintained their privacy and dignity. This service user said that some staff were curt with her, staff don’t knock on doors before entering and night staff ignore call bells. This was disputed by the Registered Manager and care records indicated continuing difficulties regarding behaviour, which was assessed prior to admission. The Registered Manager stated that he would monitor these issues and bring them to the attention of staff. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 10 Another service user stated that younger service users harassed him. On investigation the service users named were not young and the Registered Manager said that the mental health condition of this service user resulted in such allegations. This appeared borne out by the Care Plan. Nevertheless the Registered Manager is to monitor these issues to ensure that they do not occur and take appropriate action if they do. Training for staff regarding privacy and dignity is included in staff induction training. Interaction observed between staff and service users appeared positive. This was also supported by the relative spoken to who said staff were kind and helpful to service users. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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) 15 Service users receive a choice of good food and were satisfied with current activities. EVIDENCE: Service users stated that there were enough activities. No activities were in evidence at the time of the inspection. Staff said that there were games played on three to four days per week. Service users all said that the food was very good. Lunch was observed. Service users had a choice of food and menus also indicated this. The meal looked and smelled appetising. Staff assisted some service users to eat. A service user said that he was able to have all his meals in his room at the time he chose. The cook was spoken with who was very enthusiastic about her work. She receives information regarding service users food needs so is able to incorporate these into food provision. She said that she also makes a point of speaking to service users about the food. The inspector tasted the dessert. This was of excellent quality and flavour. In terms of equipment the Registered Manager is to look into fly netting for the back door and an additional fan. The mechanical vegetable chopper has just been repaired according to the Deputy Manager. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 12 St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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) 16,18 Practices and policies generally protect service users interests. EVIDENCE: The Registered Manager has a complaints file for written complaints. The Registered Manager stated that general complaints are recorded in a service user’s file. For ease of access to ensure that this information is available to check the Registered Manager needs to keep a central complaints file. The Complaints Procedure is to receive amendments to state the complainant can go directly to the Commission for Social Care Inspection and that complaints received by the home will be dealt with within twenty eight days. Staff were asked as to the whistle blowing procedure if abuse was occurring or suspected. Staff were aware of this procedure. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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 Facilities continue to be upgraded to a high standard. Safe systems need to be fully in place to protect service users. EVIDENCE: Service users all said that they liked their bedrooms. One service user does not like staff to go in his bedroom so staff have to negotiate with him to carry out cleaning, linen changing etc. This is documented in his Care Plan. Facilities continue to be improved. Bedrooms have been decorated and furnished to a high standard. A first floor bathroom has recently been finished and looked attractive and well tiled. Bed rail covers were needed to room 25 – the Registered Manager is to obtain these. A toilet en suite door was damaged to room 24 – this is to be repaired. The smoking room is in need of upgrading – the Registered Manager is to order works to carry this out. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 15 The Environmental Health Officers Report of June 2005 has asked for a small number of improvements to be carried out within six months. The Registered Manager needs to look into obtaining an extra fan, and fly netting to the back door. The automatic chopping machine for vegetables has just been repaired according to the Deputy Manager. Paintwork to doorways and skirting has been damaged and needs to be attended to – the Registered Manager said this would be carried out. There was an odour on the first floor corridor by room 12 – the Registered Manager is to look into effective cleaning solutions – most of the home was completely odour free. The grounds are well maintained and attractive. Service users were seen sitting out in them. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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 Staffing levels do not meet required standards. Staff need to be able to fully communicate with service users. EVIDENCE: The rota was inspected and found to be short of the care staff needed for each daytime shift, which should not include the Registered Manager as his time is predominantly spent managing the home. Staff hours are calculated from the Requirements of the previous Registration Authority = 37 service users, 370 hours 100 hours x 2 hours per dependant service user = 544 hours from 7am –10pm. The rota from week ending 8/7/05 had 472 hours, a deficit of 72 hours. It is not recommended that there a long shifts – 14 hour shifts are worked, that all staff have at least one day off per week, and that staff do not work in excess of sixty hours per week, as this could lead to impaired staff performance. There were a number of comments from service users that they did not understand some staff whose first language is not English. The Registered Manager needs to ensure that staff can communicate with service users. Staff said they had not read all the Policies and Procedures – this is strongly recommended. Recruitment procedures were discussed with the Registered Manager and Deputy Manager. Two references are obtained and satisfactory Criminal Records Bureau checks undertaken prior to care staff commencing employment. One record did not have a copy of a birth certificate or passport – this is to be followed up, as is a Criminal Records Bureau check for the cook. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 17 St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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) 38 Current Health and Safety arrangements do not fully protect service users. EVIDENCE: The Registered Manager keeps a Health and Safety folder and said the maintenance man was presently going through the home to ensure that all Risk Assessment issues are covered. Not all radiators have covers affixed, which could be a scalding danger for the service users, accommodated. The Registered Manager is to order more radiator covers to prevent this risk. The hot water temperature was measured and found to be tepid – the boiler subsequently fired up again. Water temperatures are tested by the maintenance man on a weekly basis. The Registered Manager is to ask that action be recorded if it measures above the National Standard of close to 43c. There had been no recorded fire bell test since 15/4/2005 and no recorded unannounced fire drills for staff since February 2005. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 19 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 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 20 No 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 19 Regulation 16 Requirement Paintwork to doorways and skirting has been damaged and needs to be attended to – the Registered Manager said this would be carried out. The Registered Provider must ensure that care staffing levels meet requirements. On this inspection the deficit was 72 hours. The Registered Provider needs to ensure that all health and safety issues are covered - risk assessments for all safe working practices, further provision of radiator covers etc. There needs to be recorded weekly fire bell tests quarterly fire drills for staff. Timescale for action 14/10/05 2. 27 18 25/7/05 3. 38 13 14/10/05 4. 38 13 15/7/05 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 37 Good Practice Recommendations Staff said they had not read all the Policies and Procedures C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 21 St Bernards 2. 3. 4. 16 27 27 5. 6. 29 27 – this is strongly recommended. For ease of access to information relating to complaints the Registered Manager needs to keep a central complaints file. The Registered Manager needs to ensure that staff can communicate with service users. It is not recommended that there a long shifts – 14 hour shifts are worked, that all staff have at least one day off per week, and that staff do not work in excess of sixty hours per week, as this could lead to impaired staff performance. Supply the General Social Care Council Code of Conduct booklets to each staff member and translate where necessary. It is recommended that there is a designated on call staff member on call at night. St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Newland House, First Floor Campbell Square Northampton NN1 3EB 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 St Bernards C51 C08 S1825 St Bernards 070705 V233005 stage 4.doc Version 1.30 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. 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