CARE HOMES FOR OLDER PEOPLE
West Hallam Residential Home 8 Newdigate Street West Hallam Ilkeston Derbyshire DE7 6GZ Lead Inspector
Bridgette Hill Unannounced Inspection 8th August 2006 09:15 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.V304923.R01.S.doc Version 5.2 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.V304923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service West Hallam Residential Home Address 8 Newdigate Street West Hallam Ilkeston Derbyshire DE7 6GZ (0115) 9440329 0115 9440329 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) www.ashmere.co.uk 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.V304923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th January 2006 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 available includes 1 double bedroom with the remainder being single occupancy. There are a range of communal areas including a smaller lounge near the entrance which offers a quieter area where some service users choose to see visitors. The services provided are 24-hour staff support, heating, lighting and personal laundry, three meals per day and a range of social activities. The range of fees charged at the home was currently £298.20 – £ 670.00 the range is dependent on the type of room to be occupied and the assessment of dependency. The fees charged include a top up fee of £30.00 for this the services of the hairdresser, chiropodist and the Company physiotherapist are included. Personal newspapers are not included in the fees. This information was gained during the inspection. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced visit which took place over 6 hours which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A partial tour of the building was conducted. During the visit opportunity was taken to have discussions with management, informal discussions with staff and service users. The person in charge at this visit was the Registered Manager Carolyn Edge. What the service does well: What has improved since the last inspection? What they could do better:
Some aspects relating to health and safety were identified during this visit including an uncovered radiator in one bathroom and chemical cleansers being insecurely stored. Whilst a stable staff team was in place not all staff records had 2 references or photographs.
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 6 There appeared to some potential structural problem to part of the building causing significant cracks and damage to some walls. This was being explored by appropriate services but needs to be rectified as service users were aware the walls were in a ‘bad way’. It is positively acknowledged that some work is underway on updating the protection of vulnerable adults procedure and the care planning format. 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.V304923.R01.S.doc Version 5.2 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.V304923.R01.S.doc Version 5.2 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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service Service users needs were assessed and opportunities given to visit the home prior to admission in order to ensure the home will be able to meet their needs. EVIDENCE: Two service users care files were examined to assess if service users were assessed prior to admission. The dates on the pre admission records confirmed that assessments were completed prior to admission and recorded. It was also established that service users were offered the opportunity to visit the home before admission. The Manager said that a number of service users used the home as a respite placement this was another opportunity for service users to try the home before deciding to reside permanently. The home does not offer intermediate care as defined by National Minimum Standard 6.
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care plans in place were descriptive of how service users assessed needs were to be met. EVIDENCE: A sample of two service users care files were examined to assess how standards were being met. The format for writing the plan of care was found to be lengthy and repetitive in style. It had been used with discretion by staff at the home and was individually written for each service user. The format used by the company’s homes was under review and a new format was briefly viewed. The care plans in place included details of service users preferences and wishes for example if they required privacy at nights and were choosing not to be checked by staff. They also detailed the capabilities of service users as well as areas of need. There was no evidence either recorded or from service users that they were involved in the care planning process.
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 10 The storage and administration of medicines was examined at this visit. All medication administration records were handwritten but did not contain any signatures or verification from staff that these had been checked against the prescription for accuracy. Records of drugs received in the home and those returned to pharmacy were kept. An up to date drug reference book was available. Where variable dosages were prescribed actual dosages administered was recorded. For one service user a drug was found to out of stock and the item was being administered from another service users supply. Systems for ensuring supplies of drugs were available for service users were not robust. One service user had medication administered to them by an external healthcare professional. Staff at the home were unaware what this medication was or the dosage of it. The health needs of service users were considered to be met as care files included recorded visits by Doctors, dates of out patient appointments, chiropodists, opticians and dentists. Staff were observed to knock on bedroom doors before entering. Service users spoken to said that staff responded as quick as they were able when they used the staff call system. Generally staff also appeared knowledgeable on service user preferences and needs. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Some activities were offered to service users, however these were found to be sporadic in frequency with little evidence of how these met service users needs. EVIDENCE: All care staff had a responsibility for providing activities to service users. A book was maintained which indicated that there was some infrequency evident in the organisation of activities. Records were also held collectively for service users on who had taken part. This is not in keeping with data protection legislation and individual records should be introduced. The sample of two care plans viewed were found to be poor in documenting the social/leisure interests of service users and there was no evidence that the activities offered were in response to assessed needs. The activities typically offered were external entertainers, bingo, karaoke, dominoes and music to movement. The quality audit surveys completed scored the satisfaction of activities and food as the most frequently lowest scoring items.
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 12 Some service users said they preferred to keep their own company and spent time in their room watching television, knitting or reading. Visitors to the home were observed being warmly greeted by staff and management and some jovial banter exchanged. One service user spoken said they had some meals served in their bedroom and preferred to keep their own company. Service users said there was a choice of meal available and this was evident from the board in the dining room which gave details of the choices available for that day. All service users spoken to said that there had been some changes in the catering staff and that this was reflected in the quality of the food served but that the main cook provided good quality meals. The service user and relative questionnaires completed in June also identified that service users had said the food was ‘mostly ok’. The July surveys completed rated the food higher than this. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 13 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Complaints have been handled appropriately and service users appeared to be empowered to voice their views. The Provider is in the process of taking action to ensure the safeguarding adults procedures are amended in order to ensure that procedures are in keeping with locally agreed procedures. EVIDENCE: Since the last inspection there had been two complaints received at the home. No complaints had been directed to the Commission for Social Care Inspection. A complaints procedure was available which included appropriate timescales for the resolution of complaints. Service users spoken to said if they had complaints they would let staff know about them. One service user gave an example where a complaint had been made and said that this was rectified satisfactorily. Where complaints had been documented there were recorded investigations and outcomes. It was evident that actions were taken to the complaints. The safeguarding adults procedure advocated internal investigation of complaints. There was no reference made to locally agreed statutory
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 14 procedures as must be accepted by the Provider when accepting service users funded by Local Authorities. It is also a statutory right of service users living within Derbyshire to have access to Social Services Protection of safeguarding adults procedures as implemented in response the Department of Health ‘No Secrets’ document. Discussions with the Area Manager confirmed that this policy and procedure was under review and a draft copy of a revised policy was available but this had not yet been implemented. Staff had received safeguarding adults training in the past year however if procedures change this should be redone. The Manager has recently undertaken a Protection of vulnerable adults training course facilitated by Derbyshire County Council. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There are some aspects of the environment that require work to ensure the home is well maintained and comfortable for service users. EVIDENCE: At this inspection only the key standards of 19 and 26 were assessed and a partial tour of the building conducted. The home has a large lounge with an adjacent open plan dining room. There is a conservatory available but staff spoken to said that the service users did not tend to use this very much. Since the last inspection some floorings have been replaced in toilets. Whilst generally found to be homely some of the furniture in the home was found to be dated and not appropriate for example hospital type lockers. The quality assurance audit had identified that carpets were stained at times and
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 16 the Manager said that maintaining them stain free was an ongoing task. Some replacement flooring was being considered and some had been replaced in the kitchen. A maintenance book was available and the handyman and the Manager both signed to confirm jobs had been completed. Since the last inspection new kitchen units had been fitted. This had addressed and exceeded the requirements of the last Environmental Health Officers visit. In some bedrooms there was large cracks evident which one service user said had been repaired but has reappeared. The service user described that the room was in a ‘bad way’. Discussions with the Manager revealed that a structural engineer had visited and the problem was being investigated. Some bedrooms were also in need of redecoration as the wallpaper was peeling badly. In the sample of bedrooms viewed there was evidence of personalisation with some service users having tea making facilities and a fridge in their room. Service users said they enjoyed making a drink when they felt like it and positively this promoted independence and choice for the service users. The home was found to have a homely atmosphere and appeared to be clean with no odours present. In one toilet there were chemical cleaning products openly stored. These must be securely stored to prevent accidental ingestion. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is staffed by a stable staff group who receive regular training in order to meet the needs of service users. EVIDENCE: The occupancy of the home on the day of the visit was 12 service users. There was typically two staff on duty for all shifts. This included the Manager, Deputy Manager or a Senior Carer on duty in charge of the shift. Many staff at the home were reported to be very long serving with few changes in the staff group. General discussions with staff confirmed that they were aware of service users preferences and positive interactions with service users were observed. All staff spoken to said there was a positive working relationship between staff that worked together to meet the needs of service users. There was 9 care staff employed at the home of which 2 held NVQ (National Vocational Qualification) level 2 in care qualifications. Discussions with the Acting Manager confirmed that 7 staff had begun or were due to begin NVQ (National Vocational Qualification) courses. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 18 Staff training records were available and a range of training had been completed including moving and handling, fire safety, Basic Food Hygiene, control of substances hazardous to health, first aid, administration of medications, diabetes and health and safety. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 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 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 (partial), 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. There is stable and competent management of the home with processes in place for monitoring the quality of the service given to service users. EVIDENCE: The registered Manager has worked at the home for 18 years and is in the process of completing a relevant managerial qualification. The Manager has completed a nursing qualification but is not employed at the home in a nursing capacity. All staff and service users spoken to were positive regarding the management of the home.
West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 20 The Providers Area Manager completes a monthly quality control audit. This covered a wide range of aspects. The providers also visited on a monthly basis this was documented and included a discussion with the Manager of the home on the outcome of the Quality audit. Audits undertaken by the Manager on a monthly basis included a falls analysis and medication audits. Care plans were also reviewed and audited monthly. Questionnaires were being given on a monthly basis to a sample of staff, service users and relatives. The findings of these were generally positive however the themes of food and activities were found to the most frequently occurring lower scoring items. These were marked on some questionnaires as ‘mostly ok’. Discussions with the Area Manager confirmed that these findings had not been explored further. Discussions revealed that questionnaires for visiting professionals were due to be sent out in the next month. An additional quality checking mechanism that had been used was that a ‘mystery shopper’ person had been sent to the home on the Providers behalf to test out the competency of staff in giving the right information to prospective service users and their families. No actual results from the findings of this visit were available. Meetings for staff and service users (relatives also attended some of these) were held regularly with minutes taken. A range of aspects was discussed with service user including décor, food, social activities and fund raising. A valid public liability certificate was on display. Records for establishing financial liability were not requested at this visit. Some monies for minor purchases and hairdressing are retained for safekeeping in the home. There was a system in place that stored monies securely and individually for each service user. Records were kept, double signed and audited regularly. A balance check of a sample of monies confirmed they were accurate. Receipts were retained for any purchases. Staff supervision records were examined. A supervision format was available and the content of the information included some observation of staff, consideration of training needs and opportunity for discussions with staff. The dates of the completed supervisions indicated that there was ongoing support for staff National Minimum Standard 37 was not fully assessed but it was evident that the activities records for service users were not being maintained individually as is required by data protection legislation. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 21 The records relating to the servicing of systems and appliances in the home were checked. A handyman was employed for 20 hours per week and undertook some daily and weekly routine checks including testing of the fire alarm and water temperatures. On the tour of the building it was noted that one bathroom had a radiator that was uncovered. This is a high risk area and an assessment and any associated action must be taken to limit the risk of service users getting burnt. West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 22 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 3 x 2 West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 Schedule 3 Requirement Medication administration records for each service user must record all medications administered and who administered them to provide a complete record of treatment received by the service user Systems must be established and implemented to ensure service users medications are available in the home to be administered as prescribed The home must have a procedure for the handling of allegations of abuse that respects service users statutory rights. This should refer to the Derbyshire’s Safeguarding Adults procedures which are there to protect the service users residing in Derbyshire The structural wall damage in bedrooms must be repaired All chemical cleansers must be secured safely to ensure there is no risk of accidental ingestion All required checks and documents must be completed prior to staff commencing
DS0000020119.V304923.R01.S.doc Timescale for action 30/08/06 2 OP9 13 Schedule 3 13 30/08/06 3 OP18 30/08/06 4 5 6 OP19 OP26 OP34 23 13 19 Schedules 2&4 30/09/06 30/08/06 30/08/06 West Hallam Residential Home Version 5.2 Page 24 7 OP38 13 employment at the home The radiator in the bathroom must be risk assessed and any identified action be taken to protect service users from potential burns 30/08/06 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 It is recommended that service users are routinely offered the opportunity to participate in the care planning process where they have the capacity to do so and records kept of their decision All handwritten medication administration records should be checked and verified by two staff members to ensure accuracy It is recommended that care plans in place detail how service users social needs are to be met All records in the home for individual service users should be held separately according to data protection legislation 2 3 4 OP9 OP12 OP37 West Hallam Residential Home DS0000020119.V304923.R01.S.doc Version 5.2 Page 25 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
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