Inspection on 02/02/06 for The Old Hall

This inspection was carried out on 2nd February 2006.

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

The Old Hall 28/05/08

The Old Hall 11/07/07

The Old Hall 21/08/06

The Old Hall 17/08/05

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 The Old Hall Malpas Nr Chester Cheshire SY14 8NE Lead Inspector Maureen Brown Unannounced Inspection 09:30 2 February 2006 nd 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 Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Old Hall Address The Old Hall Malpas Nr Chester Cheshire SY14 8NE 01948 860414 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 Mary Kathleen Friend Mr Thomas Friend Mrs Mary Kathleen Friend Care Home 18 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (18) of places The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 18 service users to include:* Up to 18 service users in the category of OP (Old age, not falling within any other category) * No more than 3 agreed named service users in the category of DE(E) (Dementia aged over 65 years) Staffing must be provided to meet the dependency needs of the service users at all times and shall comply with any guidance which may be issued through the Commission for Social Care Inspection 17th August 2005 2. Date of last inspection 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. Handrails 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 DS0000054820.V278245.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 2nd February 2006. The total time on site was four hours. The inspector spent half an hour planning the inspection by reviewing the previous inspection report and the service history. The inspection included a tour of the communal areas, inspection of records and discussions with ten residents, the owner/manager and staff on duty. Thirteen out of thirty-eight standards were assessed and most 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? Recommendations from the previous report with regard to room numbers being included on the contract agreement and the pharmacist updating the sheets on the back of the monitored dosage system boxes had been considered and implemented. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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): 2&6 Full assessments are carried out to make sure that the home can meet the residents’ needs. Intermediate care is not provided. EVIDENCE: 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. Since the previous recommendation the room number is now included on this document. The manager stated that intermediate care was not provided at The Old Hall. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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, 9 & 10 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 three 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, GP visit sheets 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. The use of red pen for night care records throughout these sheets was seen. The manager was advised to not use red pen to make the reading easier and for photocopying purposes. Information regarding other visiting professionals The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 10 such as chiropodist, optician and dentist were also recorded. It was suggested that this information be kept on a separate sheet to enable staff to track visits made. Information regarding bathing and weights were recorded within the care plan. 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 had been brought up to date following a previous recommendation. 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 were 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”. See recommendation Nos. 1 & 2. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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): 13 Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: 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 areas. 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 Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 If clear policies, procedures and training were in place residents would be protected from abuse, neglect and self-harm. EVIDENCE: The home had a copy of Cheshire’s Social Services policy on Adult Protection and the manager said that they were signed up to this. The policy was available within the home and was accessible to staff. Staff said that if they had concerns they would contact the manager. The staff team had not undertaken training on Adult Protection. See requirement No. 2. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 & 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. Patio furniture was available and residents said they liked using this area in the better weather. The home was clean, tidy and free from any unpleasant smells. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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): 28 & 29 The manager provides clear leadership. Records were well maintained. Staff receive support to enable them to meet residents’ needs. The residents are protected by the robust recruitment polices and procedures used by the home. 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 out of fourteen staff and that four staff currently undertaking this course. 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 complete 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 and an induction checklist would be completed. All staff had undertaken moving and handling, fire safety awareness and medication training. Some other courses had been completed, The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 15 however some staff training was out of date. Mandatory training in manual handling, fire awareness, first aid, abuse awareness and food hygiene must be completed by all staff and other courses undertaken as appropriate. The recruitment procedure ensures that the staff are suitable to work with vulnerable people. Two staff files were examined and these showed that all relevant pre-employment checks were carried out. This included application forms, two references, Criminal Record Bureau checks and terms and conditions of employment. The staff files were organised and presented in a well-documented way. See requirement No. 3. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 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): 35 & 38 The arrangements in place do not minimise the risk to resident and their safety and welfare is not promoted. The procedures in place safeguard residents’ financial interests. EVIDENCE: Safe working practices include fire safety in which all weekly checks are carried out and recorded, portable appliance testing and tests and servicing for all equipment for moving and handling. The gas safety and electrical safety certificates were not available and immediate requirements were made. The manager said that invoices are produced on a monthly basis for each resident as necessary for personal account funds. All records relating to residents finances were seen and up to date. See requirement No. 1. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 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 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 1 The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 23 Requirement Timescale for action 2 OP18 13 3 OP28 18 Immediate requirement 16/02/06 The registered person must ensure that gas safety and electrical safety certificates are obtained. The registered person must 31/03/06 ensure that all staff have training in protection of vulnerable adults. The registered person must 31/03/06 produce a plan to ensure that staff undertake mandatory training. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should not use red pen on daily DS0000054820.V278245.R01.S.doc Version 5.1 Page 19 The Old Hall 2. 3. OP7 OP28 record sheets. The registered person should keep details of other visiting professionals on a separate sheet rather than on daily record sheets. The registered person should ensure that 50 of the staff team obtain NVQ level II in care by 2008. The Old Hall DS0000054820.V278245.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Northwich Local Office 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. 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