Care Home: Hall Steads

Annual service review Name of Service: Hall Steads The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Jayne White Date of this annual service review: 1 3 1 1 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: Stacey Crescent Grimethorpe Barnsley South Yorkshire S72 7DP 01226781525 01226781308 firthj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 90 0 0 90 The maximum number of service users who can be accommodated is: 90 The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Hall Steads is a purpose built care home that accommodates up to 90 older people. The home is divided into 3 units, each accommodating up to 30 people. The Willowgarth unit provides personal care, Ladywood nursing care and Ferrymoor care for people with a mental disorder or dementia. Annual Service Review Page 2 of 7 BUPA Care Homes (CFHCare) Limited owns the home. The home is situated on the outskirts of Barnsley. It is a short distance from public transport, shops, the post office and local amenities. Extensive gardens surround the home. The home is single storey. All bedrooms are single. Each unit has its own lounge and dining area, plus a smoking room for people that live there. A kitchen is available on each unit, but a commercial kitchen provides the meals for each of the units. A commercial laundry carries out all the laundry for the units. Sufficient bathing facilities are available on each unit. There is a large car park. Information about the home is available from the reception and in welcome packs for new people. Inspection reports produced by CQC are displayed on each unit. On 11 November 2009 the manager stated the fees at the home currently range between £356.77 and £606.30. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last annual service review. This included: 1 The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. 2 A survey returned to us by someone using the service, a survey by a relative and four surveys from members of staff. 3 What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. 4 The previous key inspection and annual service review. What has this told us about the service? The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. We looked at the information in the AQAA. This told us they used the QUEST assessment and personal care plan programme to focus on personalised care and increased opportunities for people. To ensure the views of people are incorporated into what they do they do an annual customer satisfaction survey, respond to complaints and compliments, hold resident/relative meetings and the provider visits monthly, holding discussions with residents and relatives. As a result of this changes to the service have included regular communication and newsletters to keep people and their representatives up to date with choices and developments in the home, amendments to menus and a new bench in the general grounds. The AQAA told us the resident customer satisfaction survey illustrated overall residents were very happy with the home. The relative survey also had high scores. One person living at the home returned their survey. It told us they had received enough information about the home to help them decide if it was the right place for them before they moved in and that they received a contract. They said they always received the care and medical support they needed. Staff they said were always available when they needed them and usually listened and acted on what they said. They told us the home usually had activities they could take part in and that they always liked their meals. If they werent happy they knew how to complain and there was someone they could talk to if they werent happy. They said the home was always fresh and clean. A relative who returned their survey told us they received enough information from the service to help them make decisions and were kept up to date about important issues affecting their relative. They stated the service always met the needs of their relative and always gave the care to their relative they expected. They stated the staff always had the right skills and experience to look after people properly. They knew how to make a complaint and stated the service always responded appropriately if they had Annual Service Review Page 4 of 7 raised any concerns. They commented, they provide what my mother needs very well in her condition. We are very happy with their service. Four staff returned their surveys. It told us that generally they were given up to date information about the needs of people they cared for. They were appropriately recruited and received an induction. Their subsequent training they stated was relevant to their role and kept them up to date with new ways of working. They knew what to do if someone had concerns about the home. However, only one member of staff said they were regularly supported by their manager, who met with them to discuss how they were working, the other three said sometimes. When staff were asked what they thought the home did well they commented, our residents all receive individual care. The home is friendly. All nurses and carers are fully trained. We are all pleasant and treat people as if it is their own home. Residents and relatives are always respected and we give good care, but a lot of the time we have not enough staff to give the level of care we would like to give. On Ladywood it is not taken into account the high dependency of the residents and we work mainly to staff ratios set down by you. It must be noted that CQC dont lay down staff to resident ratios. We determine that staffing levels are sufficient by looking at the dependency of people and that they receive the care they need in a timely way and that they receive a good quality of life. The residential staffing forum is what we would use as a guide and this takes into account the dependency of people. However, this information conflicts with what the person living at the home and relative told us in their surveys. We acknowledge this is a small percentage of peoples views. However, we have taken into consideration that no information has been received about concerns with staffing levels. Despite this, the service need to speak with staff about their concerns and identify what their concerns are because all staff have made comments about the inadequacy of staffing levels. They include, most staff feel they are a number and undervalued, has gone from being the best paid to the worst in the area - not good for morale, I go home feeling mentally and physically exhausted - the cause being staffing levels. We are a 30 bed unit, but the needs of our clients are such that I really feel for them because of the amount of time they have to wait for cares, even a basic one of reaching the toilet, our staffing levels do not reflect the needs of our residents, my main concern is for night staff - 2 to 30 residents, when 18 need 2 staff for all transfers, 6 are at high risk of falling and we have unhappy clients who get fed up of waiting to be put to bed. The manager, operations manager and BUPA Quality Assurance are aware, who keep saying its under review and personally, I do not spend enough time with the residents. We have too much paperwork. Quest was supposed to lesson paperwork, instead it has increased it. We asked the manager to submit information about staffing levels. Although they do not include the dependency needs of residents, they do indicate sufficient staff on each unit. However, the service need to do this within a dependency framework such as the Residential Staffing Forum. In addition, they need to consider on Willowgarth Unit, whether there is sufficient staff on duty in the evening. This is because the night staff start work at eight oclock with two members of staff, when a number of people may still be up and require two staff to assist them to bed, which would leave some residents without supervision. Staff also commented, funding is not always readily available for items of equipment i.e. bed rail extensions, BUPA is too concerned about the cost of equipment etc. They Annual Service Review Page 5 of 7 refuse to pay for bed rail extensions and bumpers that fit some of our beds. When air wave mattress, for example, is needed, which are too high for bed rails, management aware but wont pay for extensions, therefore, its dangerous and always short of pillows. Again, this is a concern, so the manager was asked to submit further information. There were 21 people who had specialist equipment whom this might affect. Nineteen of these complied with risk assessments for their use. The other two highlighted shortfalls in complying with the risks associated with their use. The manager stated this equipment had been ordered. The home continues to let us know about things that have happened since our last key inspection and they show that they manage issues well. There are a significant number of incidents at the service, which could be as a consequence of staffing levels, given the comments by staff. This needs to be analysed along with staffing levels. The number of incidents has also been highlighted by social services as a concern and a meeting took place in respect of four people who lived at the service. There was agreement between social services and the service that there are no safeguarding concerns that need addressing further. Hall Steads are managing care appropriately and all incidents are documented and logged. People are appropriately placed and Hall Steads do review ways in which peoples behaviour can be managed. They hold activities for people. The manager stated that currently people with certain types of behaviour are not being admitted to the service because they already have sufficient numbers of people with those types of behaviours to care for. The service work well with us and other agencies, but need to address the comments made by staff, to demonstrate their service continues to provide good outcomes for the people who use it. What are we going to do as a result of this annual service review? We are not going to change our inspection plan and will do a key inspection by 19 August 2010. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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