Inspection on 27/10/05 for West Hallam Residential Home

This inspection was carried out on 27th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

West Hallam Residential Home 27/11/08

West Hallam Residential Home 08/08/06

West Hallam Residential Home 26/01/06

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 27th October 2005 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.V261413.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.V261413.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 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.V261413.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 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.V261413.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 six 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 residents’ care files, staff files and records; time was spent speaking to a number of residents, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the care arrangements for two residents for the purpose of case tracking. What the service does well: What has improved since the last inspection? New carpets have been fitted to the corridor areas and a number of residents’ rooms have been redecorated. Radiator guards have now been fitted to all the radiators throughout the home. A new format has been developed for risk assessments and care plans. Documents needed for inspection are being kept within the home. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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. West Hallam Residential Home DS0000020119.V261413.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.V261413.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): 1.2.3.4.5. The home has a Statement of Purpose and Residents’ information Guide in Place. The home offers trial periods to potential residents. EVIDENCE: The home has a Statement of Purpose in place, which was examined and found to be satisfactory. Residents are provided with a Residents’ Information Guide however there was not a copy of the residents’ Contract/Terms and Conditions of residency provided. Contract/Terms and Conditions of residency are now held at the home and available for inspection. Full needs assessments are carried out by the manager with the potential resident prior to being offered a trial period at the home, the need assessments were examined and found to address all the areas of care West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 9 identified in Standard 3. The information was clear and informative. The manager stated that residents/relatives are always involved in the assessment process when appropriate. Trial periods are offered to all potential residents, there was a clear indication that a resident had had a trial period in the home in one of the residents files examined for the purpose of case tracking. Intermediate care is not provided at this home. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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 the following standard(s): 7.8.9.11. The admission and assessment process was clear and accessible. The home offers a good range of health services. EVIDENCE: Two residents files were assessed during this inspection one had a care plan in place the other did not this was discussed with the manager who stated that staff were in the process of transferring to a new care plan format and although the care plan was not on the residents’ file evidence of a care plan being developed on the new format was given. The new care plans are informative all areas of care including record of medication, eating and sleeping, communication, mobility and social needs are identified. Risk assessments were in place for pressure sores, nutritional scoring, falls and moving and handling. Appropriate action had been taken where a risk was identified. All residents are given the opportunity to handle their own finances and to self medicate, a signed declaration was found on residents’ files stating if they chose to self medicate or not this was the same for dealing with their own finances. There is a policy in place for the care of residents who are dying and West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 11 it was noted that the residents’ funeral arrangements were recorded on their care plan. There is a visitor’s room where drinks and snacks can be made that could be used by relatives of residents who may be very ill. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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 the following standard(s): 13.14.15. Residents are encouraged to take part in a number of leisure activities, however many of the residents are still unmotivated and uninvolved. The food provided is varied but not well presented. EVIDENCE: The needs assessment completed prior to admission identified residents hobbies and interests. The home does not restrict visiting but identifies between 8.00am and 10pm as reasonable visiting times. Lunchtime was observed and found to be quiet and calm staff assisted residents when needed. The food provided was well presented, alternatives meals were provided and each resident was asked at the time of serving them what they wanted staff serve residents’ their meal individually. Likes and dislike are noted on the needs assessments and this information is passed to kitchen staff. The menus were looked at and found to satisfactory. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 13 All residents are given the opportunity to handle their own finances and to self medicate, a signed declaration was found on residents’ files stating if they chose to self medicate or not this was the same for dealing with their own finances. At the time of the inspection there were no residents who had elected to administer their own medication or handle their own financial affairs. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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 the following standard(s): 16.17.18. Complaints are dealt with appropriately and promptly. EVIDENCE: There is a complaints policy in place, which is displayed in the entrance and can also be found in the ‘Residents Information Guide’ No complaints had been recorded since the last inspection 09/03/05. Previous complaints made had been dealt with promptly and appropriately. Residents are encouraged to exercise their right to vote. The manager stated that a solicitor or and independent advocate would be found for any resident who needed legal advice. Staff had received ‘Protection of Vulnerable Adults’ (POVA) training apart from two new members of staff. The manager has just completed a two day training course and is hoping to go on the three day course to enable her to train staff. Two staff files were examined and the appropriate police checks had been sought prior to the employee commencing employment. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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 the following standard(s): 19.20.21.22.23.24.25.26. The home presents as warm, light, clean, quite ‘homely’ and comfortable. EVIDENCE: The downstairs and upstairs corridor carpets had been replaced and a number of bedrooms had been redecorated. All the radiators have now been fitted with guards. A random number of residents’ bedrooms were assessed met the requirements identified in Standard 24 apart from two that did not have two easy chairs provided. There was a record on residents individual care plans identifying the furniture they had bought with them. All the bedrooms assessed were personalised and reflected the interests of the occupant. The home provides three bathrooms it was noted that the third bedroom is used for the purpose of storage. The extractor fan in the upstairs bathroom was not working. The home provides wheelchair access throughout and a shaft lift is provided. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 16 All the residents spoken to during this inspection stated that they liked the home and liked their own bedrooms. There was good ventilation throughout the premises and the home was warm and light. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 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 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): 27.28.29.30. Minimum staffing levels are provided. Training opportunities are provided for staff. An immediate requirement was issued against Standard 27.1 at the last inspection dated 09/03/05. EVIDENCE: Staff rotas were examined and found to be according to minimum staffing levels required, however it was noted that there are a number of high dependency residents in the home and the staffing levels must be reviewed against the assessed needs and risk assessments of the individual residents. Mandatory staff straining is taking place; training programmes have been developed for staff. Staff supervision is taking place but not consistently a number of staff supervisions had not taken place since May the manager stated that this was due to staff shortages. Staff are now achieving National Vocational Qualifications (NVQ) and the manager stated that the required 50 of care staff achieving NVQ level 2 and above will be achieved early next year. Two staff files were assessed during this inspection there was clear evidence that the homes recruitment procedure had been followed. The documentation as identified in Schedule 2 were in place and found to be satisfactory. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32. These Standards were not fully assessed during this inspection. EVIDENCE: There is no quality assurance document published to provide feedback from the questionnaires and audits that are carried out by the home. Regulation 26 reports had not been completed from August 2005. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 x x x x x x West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 01/12/05 1 OP27 18(1)(a) 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 registered provider must ensure that all the bathrooms are available for residents to safely use at all times. The registered person must provide a copy of the residents Contract/Terms and Conditions of Residency in the Residents Information Guide. 2 OP2123(2)( 23(2)(j) j) OP1 5 01/12/05 3 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 21 No. Refer to Standard Good Practice Recommendations West Hallam Residential Home DS0000020119.V261413.R01.S.doc Version 5.0 Page 22 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. 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