Inspection on 26/01/06 for West Hallam Residential Home

This inspection was carried out on 26th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

West Hallam Residential Home 27/11/08

West Hallam Residential Home 08/08/06

West Hallam Residential Home 27/10/05

West Hallam Residential Home 09/03/05

West Hallam Residential Home 09/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE West Hallam Residential Home 8 Newdigate Street West Hallam Ilkeston Derbyshire DE7 6GZ Lead Inspector Gail Meads Unannounced Inspection 26th January 2006 09:30 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 West Hallam Residential Home DS0000020119.V273927.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. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service West Hallam Residential Home Address 8 Newdigate Street West Hallam Ilkeston Derbyshire DE7 6GZ (0115) 9440329 (01332) 882351 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) Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Mrs Carolyn Edge Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: The West Hallam is a Care Home providing residence for 17 older persons. The Home is situated in a village location near to the town of Ilkeston, and a few miles from Derby. The accommodation provided is predominately single rooms, a small number have en-suite facilities. The services provided are 24-hour staff support, heating, lighting and personal laundry, three meals per day and a range of social activities if required. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a three and a half hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including a residents’ care file, staffing rotas and records; time was spent speaking to a number of residents and their relatives, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the requirements made in the last inspection report 27/10/05 and health and safety issues which were not inspected during the last inspection. What the service does well: What has improved since the last inspection? What they could do better: West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 6 Staffing levels provided must be reviewed against the assessed needs of residents. There has been a change in the staff structure but not the staffing levels provided. The upstairs bathroom must be made accessible to residents the ‘sneck’ must be removed and the bathroom needs to be completely refurbished. 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. West Hallam Residential Home DS0000020119.V273927.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 West Hallam Residential Home DS0000020119.V273927.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): This Standard was not assessed during this inspection they were assessed during the last inspection dated 27/10/05 and found to be satisfactory. EVIDENCE: West Hallam Residential Home DS0000020119.V273927.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): 10. The residents have their privacy and dignity respected at all times. EVIDENCE: A number of residents were spoken to during this inspection as were a number of relatives. All the residents spoken to stated that they believed that staff did respect their privacy and maintain their dignity. Locks are fitted to residents’ bedrooms and toilets and bathrooms. Toilet aids are fitted in the toilet to enable the more independent residents to remain independent. Staff were observed during the inspection knocking at residents bedroom doors and responding to residents needs promptly and in a sensitive manner Relatives spoken to during this inspection stated that they had no cause to complain about how staff treated their relatives in fact they praised the quality of care given to their relatives by all the staff. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 10 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): 12. Routines are minimised where possible in the home. A wide range of leisure activities and social events are on offer to residents. EVIDENCE: A wide range of activities and social events are on offer to residents including movement to music, bingo, crafts and board games however one resident said “ you don’t have to do them if you don’t want to” Residents can go to bed and get up as they wish. There are monthly services held by the Church of England vicar and the Methodist minister. Two residents attend the Derby Cathedral with their relatives. Resident’s social cultural and religious needs are identified as part of the admission process. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 11 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): This Standard was not assessed during this inspection they were assessed during the last inspection dated 27/10/05 and found to be satisfactory. EVIDENCE: West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 12 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): 19.21. The home is generally well maintained internally and externally. EVIDENCE: The home employs a general handyperson who deals with the recording of any required equipment testing and the risk assessments of the premises. It was noted that the upstairs bathroom had been cleared of articles for storage however the bathroom is required to be functional as it is included in the toilet and bathrooms needed to meet the needs of the residents. The ‘sneck’ must be removed from the bathroom door and the bathroom needs to be completely refurbished to make it safe and usable for residents. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 13 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. Staffing levels provided need to be reviewed against the assessed needs of the residents. EVIDENCE: During the inspection it was noted from the staff rotas and through observation that there was only one care worker available and the manager. The manager was taken up with general practitioner and relatives visits, also the telephone and the inspector. It was noted that staff were asking domestic staff and the cook to keep an eye on residents downstairs when there was need for them to go upstairs. It was also noted that at lunch time there were a small number of residents who needed assistance with their food as the manager had to take care of other tasks the resident being assisted by her was left until she was able to return the resident was left dependent and waiting for the assistance to continue. Having just one care worker available on the floor working with resident’s raises health and safety issues for the staff and residents. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 14 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): 31.33.34.35.36.37.38. The manager’s style is one of openness staff express a lot of confidence in her abilities and her support. Records are generally well maintained although there were no Regulation 26’s available for inspection. The homes equipment is serviced as required. EVIDENCE: The manager has a number of years experience in the role as manager she has always shown herself to be competent and supportive of staff and residents. Staff state that they have confidence in the managers ability to run the home and stated that they would have no hesitation in taking problems or concerns to her with the knowledge she would take the necessary action needed. Regulation 26’s had been completed for July and August 2005 and none thereafter. The information given in the completed regulation 26’s was scant with little indication of who had been spoken to and of how issues were raised and what action had been taken. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 15 The homes accounts can be seen if requested. The resident’s financial transactions are recorded as required and two signatures are provided for each transaction. There is a Quality Assurance system in place which is detailed and comprehensive however the feedback report is not written succinctly and in plain English the reports are far too long and detailed for people to be motivated to read them. A number of records were examined during this inspection including staff rotas, risk assessments and night staff records. The home has a comprehensive Policy and procedure manual in place. Staff receive regular supervision every 8weeks the supervision format is being reviewed. All the service records were examined including gas, electric (five year and PAT) hoists and lifting equipment, fire equipment and staff training, waste disposal and water tests all were found to be satisfactory. The home has a current insurance certificate displayed in the front corridor. The registration certificate and complaints procedure are also displayed as required. The handyperson keeps clear records of all the various tests that he is responsible for and the risk assessments were frequently checked and completed. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 16 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 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x 2 x x x x x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 3 3 3 2 3 West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 17 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 OP27 Regulation 18(1)(a) Requirement The registered person must ensure that staffing levels are provided according to the assessed needs and identified risk level of individual residents. An immediate requirement was issued against Standard 27.1 at the last inspection dated 09/03/05. The original timescale was 01/12/05 The registered provider must ensure that all the bathrooms are available for residents to safely use at all times. The original timescale was 01/12/05 Timescale for action 01/04/06 2. OP21 23(2)(j) 01/06/06 3 OP33 26(1) The registered person must carry 01/03/06 out and complete regulation 26 on a monthly basis as required. West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 West Hallam Residential Home DS0000020119.V273927.R01.S.doc Version 5.0 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!