Inspection on 22/11/05 for The Flowers Hall

This inspection was carried out on 22nd November 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

The Flowers Hall 17/07/07

The Flowers Hall 24/08/06

The Flowers Hall 29/06/05

The Flowers Hall 02/11/04

The Flowers Hall 13/07/04

The Flowers Hall 22/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Flowers Hall 80 Lascelles Hall Road Kirkheaton Huddersfield West Yorkshire HD5 OBD Lead Inspector Jacinta Lockwood Unannounced Inspection 22nd November 2005 08:45 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 The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Flowers Hall Address 80 Lascelles Hall Road Kirkheaton Huddersfield West Yorkshire HD5 OBD 01484 424184 01484 424184 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) Mrs Christine Anne Matthews Mrs Christine Anne Matthews Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2005 Brief Description of the Service: The Flowers Hall is a privately run residential home providing personal care and accommodation for up to twenty two older people on the outskirts of Huddersfield. The home is set in its own grounds, reached by a private driveway. There is parking to the front of the building and a garden for service users to the rear. There is a lack of public transport to the care home. Accommodation is provided on two floors with bedrooms on the ground and first floor, which can be accessed by a passenger lift. Both shared and single rooms are available. The home is staffed 24 hours a day. Wakeful night staff are on duty and an on-call system is in operation. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out an unannounced inspection of the home on 22 November 2005. The inspection lasted approximately eight-and-a-half hours. The following inspection methods were used: discussion was held with service users, visiting relatives, staff, management and healthcare professionals. A range of records were inspected including, service user care plans, risk assessments, medication, finances, staff recruitment and training records, some health and safety documentation and the home’s quality assurance audit. A limited tour was made of the premises. The inspectors would like to thank all those who contributed to the inspection for the time and hospitality. What the service does well: What has improved since the last inspection? Operation of the home’s medication system has improved. Although recommendations have been made, these can be easily addressed. Staff have received a range of relevant training since the last inspection so that they are competent to meet service users’ needs. Improvements have been made to care planning documentation although further work is necessary to ensure that specific and detailed information is available to staff. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 6 Standards of hygiene have improved and it is positive to note that advice has been sought from an Infection Control Nurse. 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. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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 The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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): None of these standards were assessed on this occasion. Standard 3 was met at the last inspection and Standard 6 is not applicable. EVIDENCE: The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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, 8, 9 Improvements have been made to care planning, but further work is necessary to ensure that all service users’ needs are planned for. A range of professionals meet service users’ healthcare needs. Improvements have been made to the operation of the medication system so that service users are protected. EVIDENCE: Four care plans were inspected. It is positive to note that care planning documentation has improved since the last inspection and records are now more detailed. Care plans relate to service users’ assessed needs and there was evidence of reviews and involvement from service users’ families. Despite good progress having been made, further work is necessary as not all the care plans seen had been updated to reflect changed needs and some still lack detail. For example, a nutritional risk assessment noted a service user was ‘at risk’, but there was no record as to what action staff should take, or who they should contact should the service user’s condition give cause for concern. Also, the inspectors noted that over half of current service users have a dementia type illness, but there was no plan of care relating to mental health The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 10 needs. Closer attention should be paid to record keeping, ensuring that staff have clear instructions and so that service users’ needs are not overlooked. The level of daily recording varies. Some entries clearly relate to the service users’ care plans but not all entries seen evidenced that the care plan was being followed. For example, where a care plan stated that a service user’s pressure areas should be reported on daily, this was not happening. Also, some record sheets were not being filled in consistently. The registered manager explained that she is now monitoring care plan recording and addressing shortfalls with staff. A new medication system has been introduced and there are clear improvements to the operation of the system. The supplying pharmacist has provided training in the use of the system and a staff member spoken with has an NVQ level 3 which includes medication. The medication for three service users was checked and easily reconciled with records. No current service users take controlled medicines. It is recommend that: bottles of eye drops are dated when opened, so that staff know when to dispose of them and that daily recordings are made of the temperature of the medicines ‘fridge. An inspector was informed that none of the current service users self-medicate. However, should a service user wish to do so, there is no procedure or risk assessment documentation in place. A recommendation is made in this matter. Service users said that they have access to healthcare professionals and records and discussion with staff and management supported this. Healthcare professionals spoken with were satisfied that staff at the home act on any advice given. Service users said that staff treat them with respect and maintain their privacy and dignity when providing care. Staff were observed to knock on service users’ bedroom doors before entering and to obtain service users’ permission before sitting to talk with them. Service users and relatives spoken with commented positively about the care provided at the home. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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): EVIDENCE: None of these standards were assessed on this occasion. Standards 12, 13 and 14 were met at the last inspection. Standard 15 was generally met at the last inspection and only those recommendations regarding the dining area made in the previous inspection report were inspected. These have been addressed. Service users were seen to use table linen, which had been ironed before use. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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 the following standard(s): 18 Processes are in place to ensure that service users are protected from abuse. EVIDENCE: It is positive to note that all staff have received protection of vulnerable adults training. Staff spoken with had a good general understanding of the action to take were they to see or suspect any abuse. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 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 the following standard(s): 19, 25, 26 The registered manager has taken appropriate action to ensure that service users live in a safe, well-maintained and comfortable environment. On the day of the inspection, the home was clean, pleasant and odour free. EVIDENCE: The above standards were assessed to follow up requirements and recommendations made in the last inspection report. These have been addressed. Records show that health and safety checks are carried out as required. Satisfactory certification was available in relation to Legionella. On the day of the inspection the home was clean, pleasant and odour free. The registered manager has ordered commodes to replace those that are showing signs of wear and tear. This will improve the service users’ bedroom environment and help to promote good standards of hygiene. The registered manager has acted on the advice of an Infection Control Nurse who undertook an audit of the home. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29, 30 Staffing levels are sufficient to meet the needs of current service users. Relevant training is provided to ensure that staff are trained and competent to do their jobs. Service users are not fully supported and protected by the home’s recruitment practices. EVIDENCE: Staffing levels were sufficient to meet the needs of current service users. Recruitment records for four members of staff were inspected. It was of concern to note that not all required staffing information is obtained before new staff begin working at the home. An immediate requirements notice was issued for action to be taken to rectify the situation within seven days. A follow up visit was made to the home on 29.11.05. There was documentary evidence to show that Criminal Record Bureau checks had been applied for and verbal references obtained pending receipt of a second, written reference. The registered person has a duty to ensure that staff are safe to work with vulnerable people before they are employed to do so. It is positive to note that a range of training including movement and handling, first aid, medication, food hygiene, adult protection, dementia and TOPSS based induction training has been provided to staff since the last inspection. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33, 35 The home is run in the best interests of service users. Service users’ financial interests are safeguarded. Until staff have received up-to-date fire safety training and practice, service users’ safety and welfare is not fully promoted or protected. EVIDENCE: Monies and accounting sheets for three service users were inspected and found to be satisfactory. It is positive to note that service users and their relatives/friends and the local church, used by service users, are surveyed on a monthly basis to obtain their views about the services provided at The Flowers Hall. The results are collated and displayed on the home’s notice board and discussed with service users at the monthly residents’ meetings. The minutes of which are recorded. It would be useful to include the survey findings within the home’s service user’s guide. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 16 Staff demonstrated both good and poor movement and handling techniques. This was drawn to the attention of the registered manager who should ensure that all staff follow safe movement and handling procedures. Products subject to COSHH (Control of Substances Hazardous to Health) were stored appropriately. A sample of up-to-date safety certification was seen. New staff receive fire safety awareness training as part of their induction, however, staff are not receiving fire safety training as required. All staff must receive fire safety awareness training and practice twice each year and the registered person must address this as a matter of priority. Not all notifiable incidents, for example, accidents to service users requiring medical intervention are being reported to the commission as required. A health and social care professional comment card was received which raised a concern about the number of skin tears sustained amongst residents which may be caused by jewellery worn by some staff. The registered manager was informed of this concern at the time of the follow up visit. The home has a dress code for staff, which precludes the wearing of jewellery. The registered manager should ensure that staff abide by the code. The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15 Requirement Care plans must be put in place for all of the service users’ identified needs. And the plans must be kept under review. All required information must be obtained prior to staff being employed to work at the care home. (Timescale of 05.08.05 not met). Staff must receive basic training in infection control. All staff must receive suitable training in fire prevention twice each year. (Timescale of 21.09.05 not met). Accidents to service users requiring medical intervention must be notified to the commission. Timescale for action 11/01/06 2 OP29 19(1)(b) Sch 2 20/12/05 3 3 OP30 OP38 18(1)(c) (i) 23(4)(d) 31/01/06 11/01/06 4 OP38 37 20/12/05 The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 19 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 Refer to Standard OP7 OP9 Good Practice Recommendations Daily records should clearly evidence whether or not the service users’ needs identified in service user plans have been met and any changes. Medication such as eye drops should be clearly dated on opening so that staff can identify when to dispose of them. Also, daily recordings should be made of the medicine fridge temperature. A self-medication policy and procedure, as well as risk assessment documentation should be produced for service users who may wish to self-medicate. The findings of the home’s quality survey should be included in the Service User’s Guide to the home. The registered manager should ensure that all staff follow safe movement and handling procedures. The registered manager should ensure that staff follow the home’s dress code regarding the wearing of jewellery so as to minimise the risk of skin tears to service users. 3 4 5 6 OP9 OP33 OP38 OP38 The Flowers Hall DS0000026275.V266443.R01.S.doc Version 5.0 Page 20 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. 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