Care Home: Hawksyard Priory Care Home

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What the care home does well Detailed assessments are in place, people can be assured when moving into Hawksyard Priory that a thorough assessment has been carried out and the home can meet their needs. Peoples relatives we talked to spoke highly of the home, and the care provided by the staff to support and care for the people using the service. Relatives and people using the service said that health care needs are promptly met, and every one is kept informed. Three complaints have been made to the service, two were resolved within 28 days, and one remains ongoing. Two safe guarding referrals have been made and dealt with. What has improved since the last inspection? All requirements and recommendations of the previous inspection have been dealt with. A central enclosed garden area has been developed and provides flower beds, pathways and seating with shaded areas, for people using the service and their visitors. The home continues to provide activities on a daily basis. Three diversional therapists are employed and provide activities on a one to one basis, for people with a short concentration span. Staff records have been reviewed along with training records. Nutritional assessments are taking place for people using the service. What the care home could do better: Quality assurance system would benefit from being more formalised as this is currently fragmented with information in various forms. The service is working on this. Signage on toilet and bathroom doors to indicate when in use would ensure privacy for people using this facility.Hawksyard Priory Care HomeDS0000022334.V376093.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Hawksyard Priory Care Home Armitage Lane Armitage Rugeley Staffordshire WS15 1PT Lead Inspector Kathryn Marks Key Unannounced Inspection 16th July 2009 09:30 DS0000022334.V376093.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawksyard Priory Care Home Address Armitage Lane Armitage Rugeley Staffordshire WS15 1PT 01543 490112 01543 492546 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) Hawksyard Priory Nursing Home Limited Mrs Susan Haskett Care Home 106 Category(ies) of Dementia (106), Old age, not falling within any registration, with number other category (106), Physical disability (6) of places Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 (OP) 106 Dementia (DE) 106 Physical Disability (PD) 6 The maximum number of service users to be accommodated is 106. 2. Date of last inspection 5th August 2008 Brief Description of the Service: Hawksyard Priory is a privately owned care home situated on the outskirts of the Staffordshire village of Armitage. The home is a former Dominican Priory and is set in extensive and pleasant grounds. The maximum number of service users to be accommodated is 106. The home provides both nursing and personal care, including mental health care, for up to a total of 106 elderly people. Access to the home is via a long driveway. A regular bus service stops at the end of the drive and all shops and community facilities are available in the village. Bedrooms are on all three floors. The ground floor accommodates 34 people and the first floor 36 people, offering accommodation for people with general personal care and nursing care needs. The top floor accommodates 36 people, and offers accommodation for people with mental healthcare needs. Separate lounge and dining facilities are provided on each floor. Hairdressing and smoking facilities are also provided. A large church is also part of the buildings. Laundry and kitchen facilities are provided on site. The service user’s guide identified fees on an individual basis as these varied according to assessed needs of the person using the service. People wishing to use the service should contact the home for information regarding fees. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 5 Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced Key Inspection was carried out on Thursday 16th July 2009 by three inspectors who used the National Minimum Standard for Older People as the basis for the inspection. The last key inspection on this service was completed on the 5th August 2008. On arrival for this inspection the Care Manager who is a trained nurse plus three trained nurses, seventeen care staff, 10 housekeeping staff and one laundry person were on duty. They were supported by one chef, two kitchen assistants, six maintenance persons, three diversional therapists and two administration staff. The Care Manager provided written information regarding staffing, staff training, menu and dietary provisions that were observed to be in place at the home. We discussed with the Care Manager arrangements for the day, and ascertained the situation in the home to avoid disruption to people using the service, staff, and routines in the home. We spoke to the people using the service and their relatives who were visiting them. We checked the financial records of six people using the service. Seven peoples care records were checked, and the records of three staff, including recruitment and training records. We discussed the food with people living in the home, observed lunch being served, and talked to the staff and relatives in the dining areas at lunchtime. We also looked at the Annual Quality Assurance Assessment (AQAA) this is a self assessment tool, and had been well completed with a lot of detail, and sent to us prior to the key inspection. Completion of the AQAA is a legal requirement and it enables the service to undertake a self assessment, which focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 7 What the service does well: Detailed assessments are in place, people can be assured when moving into Hawksyard Priory that a thorough assessment has been carried out and the home can meet their needs. Peoples relatives we talked to spoke highly of the home, and the care provided by the staff to support and care for the people using the service. Relatives and people using the service said that health care needs are promptly met, and every one is kept informed. Three complaints have been made to the service, two were resolved within 28 days, and one remains ongoing. Two safe guarding referrals have been made and dealt with. What has improved since the last inspection? What they could do better: Quality assurance system would benefit from being more formalised as this is currently fragmented with information in various forms. The service is working on this. Signage on toilet and bathroom doors to indicate when in use would ensure privacy for people using this facility. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 9 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 Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. People who wish to use the service have the information they need to make an informed choice about living at the home. EVIDENCE: The AQAA we received prior to the Key Inspection told us that “The service provide a good, comfortable home, the staff are well trained and the standard of nursing care is good. General Practitioner is supportive and will see people using the service and family on request. More staff now have National Vocational Qualification, better teams and more objectives set”. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 11 The previous key inspection report told us that “People coming to live at Hawksyard Priory for long term care have an assessment of their needs undertaken by the Manager before they come to live at the service. We looked at these assessments and found them to be detailed and informative. A copy of the Social Workers assessment was also included in peoples care records to assist staff in planning peoples care”. We saw that admissions to the home only take place if the unit manager is confident that her staff have the skills, ability and qualifications to meet the assessed needs of the prospective new admission. The management team consider the application before an agreement is given to families or social workers. We saw that people considering moving in to the home are given the opportunity to spend time in the home to help them see how the home is run and the facilities and services available. We saw the homes Statement of Purpose and Service Users Guide that have been updated and provide detailed information for people who may wish to use the service. The Service Users Guide identifies fees applicable to the individual based on their assessed needs. We saw records that told us peoples relatives had visited the home prior to admission. We talked to peoples relatives who were visiting the home, they confirmed this to us. We spoke to the son of one person who was very positive about the home, the staff, and how they care for his mother. The service does not provide intermediate care. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 health and personal care needs of people using the service are met. Personal care is delivered in a way the individual wishes. EVIDENCE: The AQAA we received prior to the inspection told us that “The service provide a good standard of personal and nursing care, for people using the service, our staff are empathic to their needs and follow their individual care plans, staff strive to act in the best interest of the people at all times. We are also part of the Supportive Care Register (Gold Standards)”. We saw through case tracking several people, that they do receive personal and healthcare support using a person centred approach. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 13 One relative told us that dignity and respect are considered at all times. He went on to say “The care here is excellent and the staffs are very respectful to protect my wife’s privacy and dignity. Nothing is too much trouble for the staff, they are marvellous.” We saw that the care records had individually recorded personal healthcare needs including specialist health, nursing and dietary requirements. We saw that the care records identified individual needs and preferences of people using the service. There was evidence that individual’s mental capacity was documented and discussed at admission. Family and professional involvement is included in the process. We saw that the delivery of personal care is individual, flexible and person centred with choices being given where there was some basic capacity. Privacy and dignity was promoted at all times. We saw that people are supported and helped to be independent and can take responsibility for their personal care needs. Staffs were seen to listen to individuals and give choices. The health care needs of persons unable to leave the home are managed by visits from local health care services. We saw that people do have the aids and equipment they need and these are well maintained to support them and staff in daily living. Staffs have access to training in Health Care matters and are encouraged and given time to attend courses on specialist areas of work. One member of staff spoken to told us “I love going on training courses I have done lots, such as dementia care, first aid, nutrition, food hygiene, health and safety, abuse”. There was evidence that the managers observe care practices to ensure the staff understand the importance of treating people as individuals with respect and dignity. The home has an efficient medication policy supported by procedures and practice guidance. All medication is handled by trained nurses only. We saw that medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are made to monitor compliance. People are given the support they need to manage their medication and if individuals prefer or where they lack capacity, the trained staff manages Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 14 medication on their behalf. Storage of medication is in line with the regulations and safe storage and disposal is carried out following guidelines within the homes policy and procedures. The staff support individuals regarding any refusal to take medication. The manager told us they do continue to encourage people to take medicines that have been refused. If refusal continues a review is carried out by the attending doctor. We saw that the home has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. The deputy manager observes staff to ensure each individual is competent to handle, record and administer medication appropriately. A full pharmacy audit was carried out in July 2008 with very good outcomes. The managers audit the medication monthly to assess storage and administration. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. People who live at the service have the opportunity to live the life they choose. They can take part in a range of group and individual activities of their choice. Meals are varied and people always have a choice. EVIDENCE: The AQAA we received prior to the inspection told us that “Hawksyard Priory provide good care,in a homely environment and respect the individuals right to live as they wish, and to include and encourage family involvment in daily life and activities. The service encourage people and their relatives to access diverse and enjoyable activities on a daily basis, the home employ 3 Diversional Therapists who run joint sessions and also work on a one to one basis. People using the service and their families are happy, some families join in with daily activities, some assist with these activities on a voluntary basis. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 16 The homes three activity coordinators who enjoy their work are always willing to help in other ways. We saw that a daily activities programme is in place mainly in the afternoons; this involves and provides for the social needs of people living in the home. Activities were recorded in peoples care plans that we looked at. We saw people sitting in the garden and walking around the grounds, some with relatives. There is monthly Holy Communion at the home and one couple go to church. We saw people are involved in watching films, bingo, visits to the garden centre. The activities person will take people shopping. Records kept for each person show that the main activity is on a one to one basis for example playing cards and dominoes, sitting chatting, writing letters or doing nails. We saw that the Dementia Care Unit has its own full time activities person, who does activities on a daily basis. This is sometimes in a group but she tries to see all people on a daily basis and does one to one with them. There are different textures and objects for people to feel, reminiscence cards, and do some crafts. People are taken outside for walks. We saw the Dementia Care Unit has its own hairdresser. Further plans for this unit are environmental in that they will have themed lounges, appropriate décor and pictures. People we spoke to said that the service had newspapers delivered and that the County Library provided books. The service also has a range of its own books and DVDs that are available for people to use. We looked at a sample of people’s finances and this shows that the service has addressed the requirements made at the last inspection. Full records are being kept, with expenditure recorded and receipts kept to support expenditure. A system for monthly checks is now in place. We saw the menu displayed on boards outside the dining room with a choice of meals available. There is a choice of two main dishes plus salads, omelette, jacket potato, choice of desserts, one hot, plus ice cream, yoghurts, and fruit. Tea was a selection of different sandwiches, cakes, soups, salad, jacket potato, curry. We observed mealtimes in all dining rooms where each person is served individually from a hot trolley. Portions were of a good size, and people also tell us they can ask for something else if they do not want the meal on offer. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 17 The menus confirm that a varied diet is provided. The service is able to offer specialist diets including a soft diet and a diabetic menu. The service provides drinks and snacks between meals and in the evening. We saw people being assisted to have their meal this was done discreetly and sensitively by staff. We also saw that people are provided with specialist equipment to enable them to eat their meals as independently as possible. We talked to people after lunch and they told us that they had enjoyed their meal, that the food was nice, and that they always had enough to eat. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. People who use the service are able to make complaints and are safeguarded by the homes procedures. EVIDENCE: The AQAA we received prior to the key inspection told us that “The service keep complaints to a minimum and, investigate any complaint immediately, and communicate all findings with all concerned. The service tells us they learn from each complaint and strive to improve upon their service. The service has made it mandatory for all staff to have additional training in the Protection of Vulnerable Adults. The service have encouraged an honest and open approach towards service users and relatives and other staff members, the service activly promotes No Secrets”. We saw a complaints procedure in place this is displayed in the home and contained in peoples personal files. We talked to staff who told us they were aware of the complaints procedure and how to report and make a complaint. Two staff said they had recently completed training; staffs were aware of safeguarding and had completed Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 19 safeguarding training in the last 6 months. Staff said if I had any concerns I would go to the nurse on duty or the matron. We talked to relatives who told us that management were approachable and that they would not hesitate to talk to Matron if they were unhappy about something. We looked at the outcomes of two complaints that had been made since the last inspection, reports of the investigations were on file and both complaints had been fully investigated, appropriately recorded with the outcomes. We talked to people using the service who told us they would talk to a member of staff, their relatives or matron if they were not happy about something. One person on the first floor said staff very nice but will tell them if not happy. Also said her daughter would tell matron if she felt something was wrong. We looked at a sample of people’s finances and cash balanced with records kept. We saw staff training records that identified that staff have received Equality and Diversity training. The service have improved staff training so that choice and diversity are an integral part of their training. The service has a mixed workforce with team members coming from various backgrounds. We saw on staff files that Criminal Records Bureau and Protection of Vulnerable Adults checks are carried out, and two written references are taken up prior to employment. This means people using the service are being cared for by a staff team who have been appropriately recruited and trained. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 physical design and layout of the home enables people to live in a safe, clean, well-maintained and comfortable environment. EVIDENCE: The AQAA we received prior to the key inspection told us that “The service keep the home clean, and odours to a minimum. Re-decoration is ongoing and some areas of the home have been refurbished. The AQAA tells us they have recently completed a 30 bed extention and are now offering a much improved service, all new rooms have a flat screen television and telephone. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 21 The enviroment and peoples accomodation has improved with the opening of the extention. We now have more lounges, storage areas, wet rooms and a general refurbishment of existing areas. New carpeting to the Ground and First Floor corridors, new accustic flooring to corridors and all rooms on the Second Floor”. The AQAA said “We have received positive comments regarding the Homes environment and on the standards of cleanliness, people using the service are content”. We saw that the physical design and layout of the home meets the needs of the people using the service. The communal areas are comfortable and homely, people were relaxed in their surroundings. We observed there to be no unpleasant odours on the dementia care unit; it was a credit to the staff and the domestics. We saw that the bedrooms on all floors were tidy, personalized and very well presented. Double bedrooms have privacy screening. People with wheelchairs on the ground floor had space to move around their bedrooms unaided. We observed that bathrooms and toilet doors are lockable but need a sign to say if occupied. We saw that Health and Safety checks are carried out and records are maintained. We saw good infection control practices in place, staff spoken to say they had received training in infection control, that there was always plenty of equipment, gloves and aprons. The home was very clean and fresh. We saw training records that identifies staff have received training in infection control. Policies and procedures were in place for the control of infection. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. A well trained and consistent staff team support the people using the service. EVIDENCE: The AQAA we received prior to the key inspection told us that “The service provide good staff, who are pleasant and polite and are willing to train, to improve themselves and maintain a good standard of care”. The AQAA tells us “they provide excellent mentorship and have regular placements for Student Nurses, satisfy the expectations of Stafford University, who annualy audit the home. The service train staff to comply with all New Legislation for instance The Mental Capcity Act, and Deprivation of Liberties. We have good staff ,with training records that show varied training has been received, good staff morale and good outcomes for people using the service. Student Nurses provide good feedback to the home and the university, we often employ student nurses as bank workers” We saw on arrival at the service today the following staffs were on duty: Ground floor 6 carers and 1 trained nurse. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 23 First floor 5 carers plus 1 trained nurse. Second floor 6 carers plus 1 trained nurse. Housekeeping staff 10 plus 1 laundry person. Kitchen, 1 chef supported by 2 kitchen assistants. Matron Maintenance there are 6 persons. Office there are 2 administrators. 3 Diversional therapists in the afternoon We saw the staff records of the last three people employed by the home. Records told us that staff have received appropriate pre-employment checks prior to commencing employment at the home. We saw staff training records in staff files that told us regular training takes place. Fire Training, Manual Handling, Food Hygiene, nominated First Aiders, Appointed Persons First Aid, Health and Safety, COSHH, all mandatory training is completed. Training has also taken place in managing challenging behaviour, the Mental Capacity Act and Deprivation of Liberties. We saw staffs have access to training in health care matters and are encouraged and given time to attend courses on specialist areas of work. We saw staff have completed and passed an appropriate medication course including, some senior care staff that are responsible for applying creams and lotions. One member of staff spoken to told us “I love going on training courses I have done lots, such as dementia care, first aid, nutrition, food hygiene, health and safety, abuse and I have supervision.” We saw records that told us thirty six care workers are trained to National Vocational Qualification Levels 2, and 3. We talked to members of staff who told us they received regular training opportunities, and that training is scheduled into the rota. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. People using the service are safeguarded by competent management systems. EVIDENCE: The AQAA we received prior to the key inspection told us that “The service run an efficient and friendly office, providing advice and support for relatives and staff. All matters are treated confidentialy and all information is held in the appropriate locked files. Only designated key holders have acess to files. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 25 All policy documents are in place and updated by the manager, the offices have an open door policy and welcome queries, and efficiently deal with any concerns the service users or families may have. We saw that the home is managed by Matron who is a trained nurse with 35 years experience. Matron continues to update her training the same as trained nurses and care staff in the home. Matron is committed to running a home where people feel cared for and staff said they feel supported. We saw that good leadership was in place, the job of staff management was well carried out, and staff knew what was expected of them. We saw that the relationship between management, staff, people using the service and their relatives generates a happy atmosphere. Relatives we spoke to confirmed this. We saw good quality monitoring systems in place, with quality assurance being monitored by staff completing questionnaires, relatives and people using the service also completing questionnaires. There are relevant policies and procedures in place. Health and safety audits are carried out by maintenance. There is an in house quality assurance system in place in various formats that the administrator is formalising into one system. A sample of people’s finances was checked and this shows that the service has addressed the requirements made at the last inspection. Full records are being kept, with expenditure recorded and receipts kept to support expenditure. A system for monthly checks is now in place. We observed safe working practices to be in place, staff records show that health and safety training have been completed along with other mandatory training. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 26 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 3 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 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP10 OP33 Signage on toilet and bathroom doors to indicate when in use would ensure privacy for people using this facility. As discussed the service bring together their quality assurance system and audits into one format. This will enable standards to be monitored to. Hawksyard Priory Care Home DS0000022334.V376093.R01.S.doc Version 5.2 Page 28 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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