Inspection on 17/08/05 for The Old Hall

This inspection was carried out on 17th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

The Old Hall 28/05/08

The Old Hall 11/07/07

The Old Hall 21/08/06

The Old Hall 02/02/06

The Old Hall 20/01/05

The Old Hall 09/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Hall Malpas Cheshire SY14 8NE Lead Inspector Maureen Brown Unannounced 17 August 2005 10:00 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. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Old Hall Address Malpas Cheshire SY14 8NE 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) 01948 860414 Mrs Mary Kathleen Friend & Mr Thomas Friend Mrs Mary Kathleen Friend Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20.01.05 Brief Description of the Service: The Old Hall is a care home providing care and accommodation for up to 18 older people. It is a privately owned family run business. The home is in a rural setting in the Cheshire village of Malpas, situated close to a small range of local shops and other village facilities and amenities. The Old Hall is a two-storey adapted building and residents are accommodated on both floors. Access between floors is via a stair lift or the stairs. Residents accommodation consists of ten single and four double bedrooms, all but one have en-suite toilet and bathroom facilities. There are separate lounge and dining areas and a conservatory that overlooks the garden. The Old Hall has gardens to the rear with steps leading down to the lower levels. Hand rails are provided and the top level is fully accessible to service users. Car park spaces are available to the front of the property. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out during 17th August. The total time on site was six hours. The inspector spent an hour and half planning the inspection by reviewing previous inspection reports and the service history. The inspection included a full tour of the home, inspection of records and discussions with ten residents, the owner/manager, care assistants and the cook. Nineteen out of thirty-eight standards were assessed and all were met. At the time of the inspection fourteen residents were living at The Old Hall. Feedback from this inspection was given to the owner/manager at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 6 The room number should be included on the contract agreement for residents, so that any room changes are noted. This enables people to track the movement of a specific person within the home. The pharmacist should update the sheets on the back of the monitored dosage system boxes. This would ensure that accurate information is available for the staff when administering medication. Recommendations were made regarding these issues. 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 Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.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 The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.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, 2 & 3 Sufficient information is provided for residents to make a decision about moving into the home. Full assessments of needs are carried out to make sure that the home can meet the residents’ needs. EVIDENCE: The statement of purpose was presented in a bound folder and included aims and objectives, philosophy of care, information about the home’s manager and owners, organisational structure, staff training, accommodation, admission process, financial arrangements and fee, fire safety, religion, contact with family and friends, complaints, bereavement and therapeutic activities. A copy of the most recent inspection report was available. Residents and relatives confirmed that they had a copy of this document. Copies were available in the hallway and a copy is available in each residents bedroom. The service users guide is also produced in a bound format and was produced in an A to Z format, which was easy to use, understand and read. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 9 A sample of four care plans examined showed that assessments had been carried out with each person before moving into the home. Residents confirmed that they or their relatives had visited the home prior to admission and the manager said that admissions were planned. Each resident had a contract agreement with the home and this included information about the overall care and services covered by the fees, additional services, rights and obligations of the resident and provider and the terms and conditions of occupancy. The room number is not included on this document. (See recommendation No. 1). The manager said that she visited prospective service users before admission and completes a pre-assessment document. The home had an admissions policy. The manager encourages prospective residents and their families to visit to the home prior to admission. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 10 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 The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Samples of four residents’ care records were seen during this inspection. These were comprehensive and well presented in individual folders. Each contained basic information covering all areas of personal care, risk assessments, visiting professionals sheet and a copy of the daily report sheets. The care plans seen were drawn up in consultation with the residents and family and were based on their assessed needs and risks. The care plans were reviewed on a monthly basis, in conjunction with the residents. The residents or their relatives had signed the care plans to show that they agreed with the contents. Daily record sheets seen showed day-to-day activities of each resident. They were written clearly, easy to follow and were signed by carers. One record showed that a resident had recently had an accident. Examination of the accident reports showed that this incident had been recorded. Information regarding bathing and weights were recorded within the care plan. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 11 Medication records examined showed that this was recorded and administered appropriately. Medication was kept secure and appropriate storage for controlled drugs was available if required. No controlled drugs were stored on the premises at this time. The home used a monitored dosage system, which described the medication within the system by use of a sheet on the rear of the box. These were not up to date. (See recommendation No 2). The home had a medication policy and also had the Royal Pharmaceutical Society’s guide to control and administration of medicines for care homes and children’s services and also other books in relation to medication administration, which the manager said was used for reference purposes. During discussions with the residents they commented, “The care was very good” and “The manager worked alongside the staff” also “The home had a lovely atmosphere”. Other comments included “The food is good” and a resident said their “privacy and dignity was respected by the staff”. Relatives spoken to said, they were “very happy with the care and support given to their relative” and were “kept informed of changes in the residents health needs”. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 12 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, 13, 14 & 15 Residents were able to take part in a range of activities of their choosing. Personal and family relationships were encouraged by the home and the staff team supported people with this. Residents’ dietary needs were well catered for with a balanced and varied selection of food that met peoples’ tastes and choices. EVIDENCE: A range of activities was undertaken which included playing cards, draughts, scrabble, manicures, painting, armchair exercises, reading and ball games. Staff chat to residents, go for walks with residents and help with choosing library books. Activity sessions are daily from 11.30 to 12.15 and 3.30 to 4.30. At the time of the inspection many residents were involved in a reminiscence session. Outings included drives out in the countryside, afternoon tea in a local hotel, visits to the ice cream farm, garden centre, pantomime and Christmas lights. Staff go shopping for residents on a Monday and Friday each week and purchase items on their behalf from local shops. The manager and staff encourage visits from family and friends. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 13 lounge/dining area. Relatives said that they were always made very welcome by the staff and were offered refreshments. They said that they could visit their family in the privacy of their own bedroom, in one of the lounges or sit in the courtyard. Many of the residents had their own private phones, which helped them to keep in touch with family and friends. The menu was seen and these reflected people’s personal choices. Residents confirmed they liked the meals. Special diets were catered for such as diabetic, vegetarian and “soft” diets. The main meal of the day was observed being served and the food was hot, appetising and well presented. An alternative was always available. During the meal staff were assisting residents as necessary in a friendly and in obtrusive manner. After the meal residents said that “The meal was lovely”. The kitchen was clean and tidy and fridge, freezer and hot food temperatures were recorded. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 14 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 Residents and relatives were satisfied with the support they received from the manager and staff. EVIDENCE: The policy on complaints was seen and no complaints had been received at the home or by the Commission since the previous inspection. All relevant paperwork was available in the event of a complaint being received. Residents and relatives confirmed that they were aware of the complaints procedure and to whom they would direct their complaint. Residents and relatives were confident that any complaint would be dealt with swiftly. Residents confirmed that they had received a copy of the complaints procedure and a copy was available in the statement of purpose and service users guide. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 15 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 & 26 The home provides a clean and comfortable environment for the people to live in. EVIDENCE: The Old Hall is furnished in a domestic style with additional equipment such as grab rails, raised toilet seats and hoists provided as necessary to meet the residents’ needs. The standard of décor was good. The heating and lighting was sufficient throughout the home. The garden was presented in a formal manner in a tiered style. Access to this area was through the lounge and patio furniture was available. Residents and relatives were using this area during the afternoon and commented on how pleasant it was. The home was clean, tidy and free from any unpleasant smells. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 16 The home had a separate laundry room, which was clean and tidy. This was well equipped and met the needs of residents. Cleaning materials were stored appropriately and basic information on hazardous materials was available to the staff team. Staff stated they were aware of this file and that chemicals must not be mixed with other chemicals. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 17 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, 28 & 30 The manager provides clear leadership. Records were well maintained. Staff receive support to enable them to meet residents’ needs. EVIDENCE: Agreed staffing levels were being maintained and the duty rota showed two waking night staff were on duty, one of which acts in a senior capacity. Senior care assistants support the manager and ancillary staff support the care team. The manager said that one staff member had obtained NVQ level II in care and that four staff were starting this course. Two more staff had agreed to start in September. The manager is aware that she is well below the expected level of 50 of staff trained to NVQ level II in Care and is working towards this. Staff need to have sufficient qualifications and experience to make sure that residents are in safe hands at all times. One of the ways this is demonstrated is by the numbers of staff with NVQ qualifications. All new staff completes a two day induction course which includes manual handling and fire safety awareness. The new staff member would work alongside a member of staff for a week to get to know the residents and the home’s procedures. An induction checklist would be completed. All staff had undertaken moving and handling, fire safety awareness and medication training. Other courses that had been completed by some staff included first aid, food hygiene and risk assessment training. The manager said that she had booked other courses for the staff to attend that included The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 18 Adult Abuse awareness and safer handling courses. Confirmation of this was seen. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 19 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, 36 & 37 Residents’ views are used to inform future planning within the home. Decisions about changes to the service are influenced by the information obtained from satisfaction surveys and conversations with each resident. Staff received support to enable them to meet residents’ needs. Residents’ records were kept safe and secure. EVIDENCE: The manager is in the process of completing her Registered Managers Award. She anticipates it will be completed within eighteen months. The manager is a co-owner of the home and took over eighteen months ago. She is a Registered General Nurse. Residents and relatives said that they felt the home was well run and that the manager and staff were very welcoming and friendly. This was confirmed The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 20 during the inspection. professional manner. Relatives said that the staff worked in a very Residents’ surveys are conducted on an annual basis and information gathered is used to influence the future service provided. Copies of these were available. On discussion with residents and relatives they confirmed they had recently completed a questionnaire. The manager said that one to one staff supervision was given on a regular basis. Records seen were up to date and staff spoken to confirmed that supervision was given regularly. Observed day-to-day supervision of staff was good and the staff team confirmed they were supported by the manager and the senior staff in their delivery of care to residents. All records, policies and procedures seen were up to date and accurate. These were kept secure within the home. Residents confirmed that they had access to information kept about them. During discussions with the residents they said that the manager was easy to approach and that they saw her regularly. Residents said that they “liked living in the home”, they “liked their bedroom” also that “the home was run well”. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 21 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 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x x 3 3 x The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 22 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 Regulation None Requirement Timescale for action 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 2 9 Good Practice Recommendations The registered person should include the room number on the contract agreement. The registered person should ensure that sheets on the back of the monitored dosage system boxes are updated by the pharmacist. The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 The Old Hall F51 F01 S54820 The Old Hall V244366 170805 Stage 4.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. 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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