Care Home: Hascot House

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What the care home does well Comprehensive assessments took place, and detailed information was recorded from these assessments. Visits to the service user and the service user visiting the home also occurred. Through comprehensive documentation, visits and the recording of information the service and each member of staff will be aware of the service users needs prior to admission. The care plans were up to date and recorded the service user`s needs and there was a daily entry, in most cases. The service users, who were spoken with, had limited ability to express themselves, however it was established that they were satisfied with their care. The service users` quality of life will be enhanced because of the availability of activities and outings and the participation within their selection and preparation of meals. The service users commented that they were satisfied with the food. The majority of the time, members of staff who had received training give out medications. Service users were able to express their concerns and these were acted upon. On touring the building it was observed that the rooms had been personalised by pictures, posters and included items, which would be in a younger persons room i.e. stereos etc. The home was clean and well decorated and odour free. This would reflect the programme of redecoration that had just occurred. The atmosphere within the service was warm friendly and relaxed. The robust staff recruitment process regarding the checking of staff will contribute toward the protection of service users. What has improved since the last inspection? The service has complied with one of the two requirements, and at the time of the visit the manager was actively completing her registration form to start the process of registration, which would achieve compliance on the second requirement. What the care home could do better: The daily entry within the care plans had omissions. Staff should record information on the day, not have spaces left for completion on another day. Staff who had not received adequate training give out medications, this could place the service users at risk, as they would not be aware of how to recognise and deal with problems. The environment, monitored at this inspection, had been maintained to the required standard to provide a well-maintained environment for services users, except for the locks, which could restrict emergency access to the rooms. CARE HOME ADULTS 18-65 Hascot House 243 Gleadless Road Sheffield South Yorkshire S2 3AL Lead Inspector Ivan Barker Unannounced Inspection 6th September 2007 10:30 Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 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 Hascot House DS0000002970.V347198.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 Adults 18-65. 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. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hascot House Address 243 Gleadless Road Sheffield South Yorkshire S2 3AL 0114 258 8895 0114 258 8895 dh@valeoltd.com 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) VALEO Limited Post Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: Hascot House is a large detached domestic, two-storey style building. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries etc). It has single rooms, communal bathrooms and toilets and a large lounge and dining room. The gardens are landscaped and it has a car park. The service provides care for nine adults. The fees are variable as they are set on assessment of an individual’s needs for care and service provision. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. Within this site visit, which occurred over a six hour period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare, care plans and other records; by talking to the service users themselves; viewing their personal accommodation as well as communal living areas), and spoke with other service users, and 3 staff and examined assessments, care plans, risk assessments, menus, complaint files, staff files and quality monitoring documents. The history of the service was examined prior to the site visit. This included the Self-assessment document, telephone contacts, letters, notifications etc. What the service does well: Comprehensive assessments took place, and detailed information was recorded from these assessments. Visits to the service user and the service user visiting the home also occurred. Through comprehensive documentation, visits and the recording of information the service and each member of staff will be aware of the service users needs prior to admission. The care plans were up to date and recorded the service user’s needs and there was a daily entry, in most cases. The service users, who were spoken with, had limited ability to express themselves, however it was established that they were satisfied with their care. The service users’ quality of life will be enhanced because of the availability of activities and outings and the participation within their selection and preparation of meals. The service users commented that they were satisfied with the food. The majority of the time, members of staff who had received training give out medications. Service users were able to express their concerns and these were acted upon. On touring the building it was observed that the rooms had been personalised by pictures, posters and included items, which would be in a younger persons room i.e. stereos etc. The home was clean and well decorated and odour free. This would reflect the programme of redecoration that had just occurred. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 6 The atmosphere within the service was warm friendly and relaxed. The robust staff recruitment process regarding the checking of staff will contribute toward the protection of service users. What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through comprehensive documentation, visits and the recording of information the service and each member of staff will be aware of the service users needs prior to admission. EVIDENCE: The manager advised that the prospective service user’s assessment from the care managers were sent to the director of care for the company. On receipt of the assessment the director would then contact one of the services within the company to establish a placement. The manager and another member of staff would then visit the service user and undertake an assessment. On completion of this assessment, additional visits would be organised. The next visit would be with the member of staff who would be supporting the service user. The service user would visit the service for lunch or tea and then an over night stay. These visits would carry on until there was a full assessment that the service could meet the needs and that the service user appeared settled and the service user was ‘happy’ with the placement, an the contracting department wished to confirm the placement. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 9 The documentation provided by the manager was examined and found to be quite extensive. Each assessment, which identified the service users needs, was converted into a specific contract for that individual. Because of the comprehensive assessment process and the extensive assessment documentation, this section was awarded an excellent and a score of 4. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users will benefit from up to date comprehensive care plans. However omissions of information, by some individuals will not provided accurate information for the review. EVIDENCE: On examination of the care plans the inspector found that the care plans were extensive and details all aspects of the care needs of the individual. These included the required social, mental and physical interventions. The plans were up to date, however there was no evidence of previous reviews. The files had a named folder (Reviews), which should have contained the old reviews, but these folders were empty. The manager advised that the reviews should have been kept in the folder and she would discuss this matter with the staff. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 11 The daily entries were recorded within a hard backed book. Some of the entries were very detailed and contained a lot of information, which would be useful for a review of the care. However there were numerous blank spaces within the book. On discussing this with the staff it was advised that some of the spaces had been left for staff to complete the information at a later date, as the entry had not been written that day. Completing records a day or more later is poor practice. There should not be gaps left in documentation for staff to complete retrospectively. On discussing when the records were completed, the staff advised that they completed the record at the end of the shift and were ‘often pushed for time’. It was discussed that the entry did not need to be at the end of the shift, but may be recorded at an earlier time, and any significant changes, added as necessary. Despite the omissions it was found that the care plans did reflect the care to be delivered and details information regarding the daily care and observation of the service user. The omissions would appear to be the fault of one or two members of staff. The manager identified that she would speak with these individual member of staff. The service users, who were spoken with, had limited ability to express themselves, however it was established that they were satisfied with their care. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users’ quality of life will be enhanced because of the availability of activities and outings and the participation within their selection and preparation of meals. EVIDENCE: There was evidence recorded of activities for service users, within their own daily entry within their care plan. This showed that service users attended day care services and took trips to the countryside, Meadowhall shopping centre and the Winter Gardens in Sheffield City Centre. Also some service users followed their own interesting in attending church, theatre and a music club. It was discussed that a weekly activities / outings planner displayed in the office may would be useful. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 13 The service users commented that they went out to places as they wished and reiterated some of the list of places stated above. Regarding the meals, the manager advised that a menu for the week was drawn up in consultation with each service user and then staff and service users would shop for the items. Service users who were able were also involved within the kitchen and helped to cook and to prepare the meals. The service users commented that they were satisfied with the food. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The majority of the time, members of staff who had received training give out medications, however on a few occasions staff who had not received adequate training give out medications, this could place the service users at risk, as they would not be aware of how to recognise and deal with problems. EVIDENCE: The service users had the opportunity to access the primary care facilities, which included GP and dental services etc. The medications were stored within metal cupboards within the office. The office could be locked when the room was left unattended. The administration of medication was through the ‘Boots’ system. The medication administration records were pre printed and all the administration boxes were signed. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 15 On discussing the care staff training on the administration of medications, the manager advised that the senior care staff received training from the Boots Pharmacist and then the senior care staff trained the care staff. However it was mainly the senior care staff who gave out medication and there was very few occasions when the care staff gave out the medication. The manager was informed that only staff, who had received the necessary structured training, should administer medications. The manager accepted this comment and advised that she would look at the care staff attending the training from the Boots Pharmacy. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users were able to express their concerns and these were acted upon. EVIDENCE: The complaints procedure was printed within the service user guide. A copy of the guide was available to the service users and visitors. On discussing complaints with the manager, she identified that the service had not received any complaints. There had been no complaints received by the Commission for Social Care Inspection, regarding the service. However it was observed that any ‘views’ expressed by the service users were recorded within the daily entry of the care plan, with later records to show if it had been acted upon. The service had policies and procedures regarding Safeguarding Adults. The training records of the staff were examined and it was established that staff had attended training on Safeguarding Adults. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment, monitored at this inspection, had been maintained to the required standard to provide a well-maintained environment for services users, except for the locks, which could restrict emergency access to the rooms. EVIDENCE: On touring the building it was observed that the rooms had been personalised by pictures, posters and included items, which would be in a younger persons room i.e. stereos etc. The home was clean and well decorated and odour free. This would reflect the programme of redecoration that had just occurred. The atmosphere within the service was warm friendly and relaxed. It was observed that on three of the room doors, there was ‘Yale’ locks, which were not the type to allow access in an emergency. The manager identified Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 18 that she thought that the locks had received attention to allow emergency access. However she accepted that the locks required attention, and informed the maintenance man, who advised her that he would sort the locks the next day. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The robust staff recruitment process regarding the checking of staff will contribute toward the protection of service users. EVIDENCE: On examination of the staff on duty and the rota it was established that the staffing was as follows: A.M. P.M. N. 4 care staff 4 care staff 2 care staff The manager was supernumerary to these figures. There was also a senior member of staff on call, during the night. Caring for 8 service users. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 20 The manager identified that 2 new staff had just been interviewed and were currently being offered posts subject to the necessary checks. She advised that a service user had been included on the interview panel to follow the recommendations from the last inspection. On examination of the staff training records, the staff had received training in fire, moving and handling and other clinical training. This included the agency staff regarding fire training, as stated as a requirement at the last inspection. On examination of 3 staff files, the inspector established that the files contained all the information required within Schedule 2, except that of one member of staff. It was established that no references could be found in the file. On discussing this with the manager and the member of staff, and further examining the file, it was established that the member of staff had been employed for some considerable number of years and that they ‘transferred’ into the current company from another employer, rather than being a ‘new employee’. The manager identified that she would discuss this issue with her manager and the member of staff, and explore ways of correcting this minor shortfall. As the omission was a considerable number of years ago, and had only been found at this stage and the manager was to act on the matter, no requirement has been made. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the service is operating with a manager, who is new in post and yet to register. Extensive quality assurance systems were in place that should assist the manager and owners to measure the home against expected outcomes EVIDENCE: On arrival at the service, on this unannounced inspection, the manager was observed to be completing the application to be the registered manager for the service. She advised that she was to submit the form on receipt of her Criminal Records Bureau check undertaken by CSCI. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 22 She advised that her previous experience was as a deputy manager and had 5 years experience in care and 18 months as a manager. Regarding Quality Assurance, the manager and her manager undertake the quality monitoring of the service. The systems include the monitoring of the environment and Health and Safety Audits. It was discussed that more robust systems could be introduced that would measure the service provision and outcomes for service users. Regulation 26 documentations, which are a record of the registered person’s monthly visits, was complied on a monthly basis, evidence of this was seen at the visit. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; have been received by CSCI (Commission for Social Care Inspection). Within the last inspection report it was raised as a recommendation that the manager was to have a separate office to conduct private and confidential business. On discussing this with the manager she identified that it had been difficult when interviewing or holding case reviews etc not to encroach into service users’ areas of the home, for example the communal areas. Also the joint staff office and her office had created issues relating to confidentiality during staff supervision etc. The limitation of the current building was recognised but several suggestions were discussed with the manager including the reorganising the office or the use of external buildings, all of which could have cost implications. Therefore as clearly there are still problems within the service the recommendation remains. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 24 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 YA37 Regulation 8 Requirement The recently recruited manager should continue to register with the Commission for Social Care Inspection. (Previous timescale 01/01/07) Staff giving out medication should receive appropriate training. The rooms should be accessible in the event of an emergency Timescale for action 01/11/07 2 3 YA20 YA24 19 13 06/10/07 06/10/07 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 YA37 Good Practice Recommendations The plan for the manager to have a separate office to conduct private and confidential business should continue. Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hascot House DS0000002970.V347198.R01.S.doc Version 5.2 Page 26 - 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. 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