Care Home: Hyde Nursing Home

What the care home does well From the evidence we have available to us, and from direct conversations with people living in the home and their families, visiting professionals and staff, this is a well run home with a strong management team. There is a focus on involving people in the day to day running of the home, and on listening to Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 their views. The promotion of a person centred approach ensures that people are supported to express their views on how they want to receive care and support. This approach is used in developing the Gold Standard Framework which is a method used by staff who work closely with the PCT in supporting people to choose how they would like to plan their care for end of life in cases of terminal illness. The care plans are informative and provide staff with information to staff to support them in assisting people in the home to maintain their preferred lifestyle. Evidence in care plans showed that people in the home were supported to participate in care planning and reviews and that they were consulted on all aspects of care and support where possible. The home offers a wide range of activities for people to select and choose from. The staff make sure that families and visitors are welcome so that people in the home are supported to maintain contact and participate in community life. The manager regularly uses monitoring systems to make sure that key policies and procedures and good practice are followed by staff. Visiting professionals spoke highly of a supportive management team with an open management style. There was evidence that the staff team and management had worked hard to create a relaxed, welcoming and positive atmosphere for people living in the home and for their family and friends. There were numerous positive comments about staff and these included the following: “This is an excellent home and they provide excellent care. People are treated with respect”. “”You get a lot of information, the carers are good, anything you want they do it straight away. They keep me up to date”.“I congratulate the organisation on excellent care and the standards”.“It’s very good here. The staff make me feel at home”. What has improved since the last inspection? The service continues to develop the training and development opportunities for staff and the percentage of staff with National Vocational Qualifications has increased. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 There have been improved opportunities to access a wide range of activities and additional services such as regular visits from a qualified aromatherapist. Financial record keeping have been improved with new IT systems. Improvements in the fabric of the building and refurbishment is ongoing in this organisations which means good standards are maintained so that people in the home can enjoy good facilities. What the care home could do better: No requirements or recommendations have been made as a result of this inspection visit. Key inspection report CARE HOMES FOR OLDER PEOPLE Hyde Nursing Home Grange Road South Gee Cross Hyde Tameside SK14 5NY Lead Inspector Ann Connolly Key Unannounced Inspection 26th August 2009 08:30 DS0000025436.V376828.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. Hyde Nursing Home DS0000025436.V376828.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 Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyde Nursing Home Address Grange Road South Gee Cross Hyde Tameside SK14 5NY 0161 367 9467 0161 368 7707 hnhadmin@meridiancare.co.uk 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) Meridian Healthcare Ltd Mrs Helen Audrey Hubbert Care Home 100 Category(ies) of Dementia (25), Physical disability (75) registration, with number of places Hyde Nursing Home DS0000025436.V376828.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: Dementia - Code DE (maximum number of places: 25). Physical disability - Code PD (maximum number of places: 75). The maximum number of service users who can be accommodated is: 100 22nd February 2008 Date of last inspection Brief Description of the Service: Hyde Nursing Home is a purpose built home, owned and operated by Meridian Healthcare Ltd providing accommodation for up to 100 service users requiring nursing care. Fees for accommodation and care at the home range from £559.66 to £611.72 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Details of the facilities provided by the home are contained in the service user guide, which is displayed in the reception area of the home. The home is a two-storey building, divided into four separate courts: Newton, Flowery Field, Godley and Werneth. Each court has a maximum of 25 beds, 15 on one floor and ten on the other. The courts link into a central area known as The Pavilion. Godley, Newton and Flowery Field Courts provide accommodation for service users who require general nursing care. Werneth Court provides accommodation for 25 service users with dementia who require specialised nursing care. All bedrooms are single with en-suite facilities. Each of the four courts has two dining rooms, two quiet rooms, two lounges and four bathrooms. Passenger and wheelchair lifts provide access to both floors. The Pavilion overlooks the Mary Secole gardens and is the central core of the home, serving as the social and recreational focal point, equipped with a hairdressing salon and shop. The home is built on the site of Hyde Hospital. Public transport is within easy access, providing links to all towns within Tameside. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 5 Fees for this home range from £559.66 to £611.72 per week. Hyde Nursing Home DS0000025436.V376828.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 3 star. This means that the people who use this service experience excellent quality outcomes. This was a key inspection that included a visit to the home which lasted eight hours. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. The inspection looked at all the key standards and included a review of all available information received by the Commission about the service provided by the home since the last inspection. During the visit to the home a selection of records, care plans, policies and procedures were looked at. Discussions took place with the manager, staff working in the home and some relatives and visitors. People living in the home were spoken to in order to find out about what they thought about the home and what they felt about the way in which staff supported them. A tour of the building took place and people living there were asked for their views and comments about the environment. Before the inspection we asked the manager of the service to complete a form called the Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This is one of the ways we get information from the manager about the service and about how they feel they are meeting the needs of the people who live there. The information provided on this occasion was detailed and comprehensive and showed us that this was an organisation committed to the ongoing development of the service so that people living there receive support in a way that meets their individual lifestyle preferences. Surveys consulting people were sent to the home and there was a good response. Since the last inspection of the service which took place on 26th September 2007, the Commission have not received any recent complaints about the service. There was evidence during this visit that the manager was handling complaints well and that she followed correct policies and procedures for managing complaints and safeguarding issues. What the service does well: From the evidence we have available to us, and from direct conversations with people living in the home and their families, visiting professionals and staff, this is a well run home with a strong management team. There is a focus on involving people in the day to day running of the home, and on listening to Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 7 their views. The promotion of a person centred approach ensures that people are supported to express their views on how they want to receive care and support. This approach is used in developing the Gold Standard Framework which is a method used by staff who work closely with the PCT in supporting people to choose how they would like to plan their care for end of life in cases of terminal illness. The care plans are informative and provide staff with information to staff to support them in assisting people in the home to maintain their preferred lifestyle. Evidence in care plans showed that people in the home were supported to participate in care planning and reviews and that they were consulted on all aspects of care and support where possible. The home offers a wide range of activities for people to select and choose from. The staff make sure that families and visitors are welcome so that people in the home are supported to maintain contact and participate in community life. The manager regularly uses monitoring systems to make sure that key policies and procedures and good practice are followed by staff. Visiting professionals spoke highly of a supportive management team with an open management style. There was evidence that the staff team and management had worked hard to create a relaxed, welcoming and positive atmosphere for people living in the home and for their family and friends. There were numerous positive comments about staff and these included the following: “This is an excellent home and they provide excellent care. People are treated with respect”. “”You get a lot of information, the carers are good, anything you want they do it straight away. They keep me up to date”. “I congratulate the organisation on excellent care and the standards”. “It’s very good here. The staff make me feel at home”. What has improved since the last inspection? The service continues to develop the training and development opportunities for staff and the percentage of staff with National Vocational Qualifications has increased. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 8 There have been improved opportunities to access a wide range of activities and additional services such as regular visits from a qualified aromatherapist. Financial record keeping have been improved with new IT systems. Improvements in the fabric of the building and refurbishment is ongoing in this organisations which means good standards are maintained so that people in the home can enjoy good facilities. What they could do better: 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. Hyde Nursing Home DS0000025436.V376828.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 Hyde Nursing Home DS0000025436.V376828.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): 1,3 and 6 People using 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. People moving into the home are given information about the service and have their care needs assessed so they will know if their needs can be met there. EVIDENCE: A comprehensive admission policy was in place which provided information about opportunities for people to visit the home on a trial basis, stay for a meal and talk to people who live in the home. Information in the Annual Quality Assurance Assessment (AQAA) stated that people were encouraged to visit the home without making an appointment. During this visit, two people turned up unannounced to visit the home. They were greeted by the manager and given a tour of the home. These people told us that the reception they had Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 11 received was helpful and informative. They told us that they had been given a brochure. The information given to people making an enquiry was looked at. This was detailed and comprehensive. The service user guide included information about the admission criteria and details about the services and facilities available to people living in the home. The information helps people to make an informed decision about their future care and support arrangements and to decide if this home is suitable for them. Hyde Nursing Home offers care and support to people at the end of their lives. This is known as the Gold Standard Framework and aims to achieve the best quality of life for residents, particularly towards the end of their life. An information leaflet explaining this service is included in the information pack. We looked at the files of two people who were recently admitted into the home and saw evidence that care needs and nursing assessments had been completed. Both files were detailed and comprehensive and the information in the assessment was used to develop the care plan. Information included personal details, information on personal care, past history and medical information. Intermediate care is not provided at Hyde Nursing Home. Hyde Nursing Home DS0000025436.V376828.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): 7,8,9 and 10 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. Care plans were in place that detailed the needs of the individual person and supporting policies and procedures were in place to ensure the safe handling and administration of medication in the home. EVIDENCE: A selection of care plans were looked at during this visit. Each person living in the home had an individual care plan that had been drawn up by using the information in the pre- admission assessment and from information obtained in discussion with the individual person and their relative or representative. The recordings in the care plans demonstrated that there was an emphasis on involving the individuals in developing the care plan. Recordings showed that Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 13 consultations took place so that the views of individuals were taken into account and their preferences on how they wanted to be supported were written into care plans. There was evidence to show that regular reviews were held to look at changes in care needs. One visiting professional told us that the service prioritised the review process and tried to involve family members where possible so that it was clear to everyone what the care and support needs were, and what staff were required to do to meet these needs. From observations made during this visit, and from recordings made in care plans, there was evidence to show that visits were taking place by other healthcare professionals such as district nurses and General Practitioners. People who were spoken to during this visit, expressed satisfaction about the way healthcare needs were being met. One visitor told us that he felt he was kept up to date with any changes in care needs. One person said, “I congratulate the organisation on the standards and quality of care, in my opinion, this is an excellent home providing excellent care. My relative is treated with respect and her dignity is maintained”. One visiting professional told us that staff respond quickly to changes in care needs and that they are good in following guidance from professionals. A member of staff told us they received good training to help them in providing care and support in a professional way. It was evident that staff had a good understanding of person centred approach. One comment from staff was, “We work well with individuals and their families. We listen to their individual preferences”. Medication was looked at in two of the units in the home. Medication was stored appropriately in a locked room. The medication file contained all the appropriate documentation including a photograph of the person receiving the medication and sample signatures of staff members responsible for the administration of medication. Medication Administration Records (MAR) were in place to record the receipt and disposal of medication. The records reflected the stock levels and the MAR sheets that were looked at were up to date with all recordings made appropriately. The manager told us that regular audits were made of medication practices in the home. Documentation was looked at of a recent audit that took place on 28.07/09. In this audit a number of issues were identified as requiring action. The findings had been included in the manager/lead clinician’s action plan. This included the requirement to improve practices in the disposal of medication and in the recording in the administration of medication. The audit carried out Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 14 by the service and the action plans demonstrated to us that the service was pro- active in developing and applying systems which promoted improvements in the safe handling of medication. Hyde Nursing Home DS0000025436.V376828.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): 12,13,14 and 15 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 had choice and support to meet their expectations and preferences regarding their daily lifestyle. The quality and choice of meals were praised and people’s special dietary needs were met. EVIDENCE: Various activities are available for people to participate in and these are advertised throughout the home. There is a full time activities co-ordinator who is responsible for organising activities in the home. The activities organiser told us that weekly meetings were held in rotation on each unit and these were used as an opportunity to consult with individual about their preferences. Some activities were group sessions, whilst others were organised on a one to one basis, depending on individual needs. People in the home told us that Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 16 there was always plenty going on. One relative told us that quite often activities were arranged on a one to one basis so that the individual person was given the correct amount of support to assist them in participating. Activities on offer included armchair aerobics, services from a qualified aromatherapist, carpet bowls, games and outings. During our visit we saw many visitors coming to the home. People living in the home told us that they enjoyed visits from family and friends. Mealtimes were seen as an important part of the day and as such, people living in the home were encouraged to make choices about what they would like. Some relatives told us that they were invited to have a meal, one relative said, “The meals are very good here, and I should know as I have had plenty”. The cook told us that regular meetings took place with people in the home and their families, she said, “We work with people and their families and listen to their individual preferences”. She was able to provide numerous examples of a creative approach to meeting individual needs and told us that she had specific shopping lists for some people, quoting the example of an Italian menu. The menu provided evidence of people being offered a choice of meals. The meals offered during this visit was a choice between lamb or steak pudding with fresh vegetables, bread and butter pudding or lemon meringue. One relative said, “ When mum refuses dinner, the staff immediately find an alternative”. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 17 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): 16 and 18 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. Policies, procedures and training was in place for staff to support people to raise any issues of concern and to protect people from neglect and abuse. EVIDENCE: There was a detailed complaints procedure in place which was readily available and was included in the service user guide and information booklet. Since the last inspection visit in September 2007 the home had received 25 complaints. Clear details about each complaint had been recorded on the complaints file, which included letters of response to the complainant, any action taken and the outcome. All complaints, no matter how small were responded to , demonstrating a commitment to take all complaints seriously. The manager had systems in place to monitor complaints which took note of the type of complains, and picked up any patterns The manager told us that all complaints were looked at in detail as part of the monitoring and auditing of systems and processes in the home. All of the people we spoke to told us that they felt confident in raising issues of concern. One person said. “I have never had a concern, but if I had I would Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 18 talk to the manager or a member of staff, the staff listen to me and they are polite”. There was written evidence to show that safeguarding referrals had been managed appropriately, and thorough investigations had taken place by the relevant authority. All staff had received training in safeguarding. Staff who were spoken to had a clear understanding of what to do in the event of any allegations of abuse, and were aware of the correct policies and procedures. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 19 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): 19 and 26 People using 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. A safe comfortable environment is provided for people living in the home, which includes numerous areas for relaxation and meeting with family and friends. EVIDENCE: The home is decorated and fitted to a high standard. During this visit we received many positive comments on the standards in the home. Comments included: “We like all aspects of this home and the ambiance is lovely”. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 20 “The rooms are always very clean”. “The standards are very high, the rooms are lovely, look at this room ( the function/reception) it’s lovely”. The environment provided many areas which could be used for different purposes, for example, a hairdressing and beauty salon, quiet sitting rooms, large lounges. The large reception area called ‘The Pavillion’ was set out in small group sitting areas, and provided an ideal place for entertaining visitors. This was seen to be well used during the course of this visit. Large television screens and sound equipment were available and enhanced the environment further. The grounds were well maintained and provided plenty of benches and tables so that people could enjoy the outdoor space in the warmer weather. Bedrooms were personalised to reflect individual tastes and preferences. The standard of cleanliness during this visit was high, and this finding has been consistent during the last few inspection visits to this service. The housekeeper told us that staff took pride in keeping the home clean and maintaining good standards. The housekeeper told us about quality checks that were made on all parts of the building, and about how staff were accountable for ensuring that high standards were maintained by having responsibility for certain areas throughout the building. Information in the AQAA confirmed that regular safety checks were carried out throughout the building. There is 24hrs support including out of hours for weekend and emergency repairs, and contractors visit the home to service equipment on an annual or bi annual basis or as necessary. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 21 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): 27,28,29 and 30 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 people who live at the home are supported by well trained, effective staff who have gone through a thorough recruitment process, so their needs are met and they are safe from possible harm or poor practice. EVIDENCE: The information in the AQAA provided evidence of a structured staff team led by senior staff who had been given specific responsibilities, for example, a clinical lead nurse supernumery to the rota, and head of care, also supernumery. The findings during this visit, reflected the information in the AQAA as there appeared sufficient staff on duty to meet the needs of the people living in the home. Comments made by people in the home and their relatives were consistently positive about the staff team. Comments included: “”Staff listen to me, they are polite”. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 22 “The staff are polite, they make me feel welcome and are always around to have a chat”. “I think care needs are met as staff work very hard. They are caring and considerate and aware of individual needs. People are treated as individuals”. “I’m very happy with the staff, care needs are being met and I know my relative is happy here”. A visiting professional spoke highly of the staff team. She told us that staff were good at following guidance from professional leads, and were very honest and open. She said that any issues highlighted in a review were addressed immediately and resolved promptly by staff. One comment about staff was, “The care staff are respectful and well trained”. During this visit there were numerous examples of good practice where staff were seen engaging in positive and meaningful exchanges with people in the home and their family members. There was a staff training and development plan in place which showed us that staff had good training and development opportunities. Staff who were spoken to told us confirmed that they had access to ongoing training and refresher courses. Information in the AQAA confirmed that 81 of staff had achieved National vocational qualifications (NVQ) level 2 or above. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 23 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): 31,33,35 and 38 People using 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. The people in the home benefit from having the support of and experienced manager and management team who have developed and implemented quality monitoring systems to ensure that their health, safety and well being is promoted. EVIDENCE: The manager holds appropriate qualifications and has the management experience to ensure that the health, safety and well being of people living in Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 24 the home is promoted. The manager was able to demonstrate to us that she has continued with her ongoing professional development to keep up to date with current practices. The employment of a clinical lead ensures that staff receive support and guidance with any clinical and nursing issues. The manager told us that she regularly meets with other managers and representatives from continuing health care to discuss good practice issues and issues raised by guest speakers. Information in the AQAA confirmed that the service does not hold any personal money for anyone living in the home. A system is in place to invoice people and their families at the end of every month. We were told that improvements had been made to managing financial records which provided up to date calculations of any expenditure. The information in the AQAA states that all financial transactions are monitored by the company finance department to promote the safeguarding of people living in the home. Good systems were in place to audit and monitor all aspects of working practice including health and safety. We looked at the audit summary dated 28/07/09 and there was evidence to show that a random selection of care plan files had been looked at. The audit was detailed and comprehensive and included checks of the pre-admission assessment which focused on mental capacity and deprivation of liberty. Some shortfalls had been identified in the audit and we were told by the manager that the audit was used as a tool to improve key areas of practice and identify training issues. The findings were linked to an improvement and action plan. This audit provided evidence that the service was pro-active in using monitoring to improve practice, and there was an open and transparent approach to identifying weaknesses and addressing shortfalls. A quality assurance and monitoring resident/relative survey was undertaken by the service in June 2009. This shows us that the service takes consultation with people using the service seriously, and makes every effort to seek the views of people living in the home. It was confirmed in written information provided by the manager prior to this taking place (in the AQAA), that all routine maintenance and servicing of equipment used in the home had been carried out to ensure the health and safety of people in the home. Some visiting professionals spoke highly of the management style in the home. One person told us, “Well run home with excellent management. The manager is in touch with what goes on”. One person told us that this service follows procedures and is open and honest when concerns are raised. Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 25 The staff spoke highly of the management style and said they felt they could approach the manager or senior staff with any concerns. One comment from a relative stated, “I congratulate the organisation on the standards and quality of care”. One person described the care in the home as ‘excellent’. Hyde Nursing Home DS0000025436.V376828.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 4 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 4 X X X X X X 4 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 4 X 4 X 3 X X 3 Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 27 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. 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. Refer to Standard Good Practice Recommendations Hyde Nursing Home DS0000025436.V376828.R01.S.doc Version 5.2 Page 28 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. 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