Inspection Report - Care Quality Commission · |Inspection Report | Hall Steads Residential and...

| Inspection Report | Hall Steads Residential and Nursing Home | February 2014 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Hall Steads Residential and Nursing Home

Stacey Crescent, Grimethorpe, Barnsley, S72 7DP

Tel: 01226781525

Date of Inspection: 03 February 2014 Date of Publication: February 2014

We inspected the following standards as part of a routine inspection. This is what we found:

Care and welfare of people who use services Met this standard

Safeguarding people who use services from abuse

Met this standard

Management of medicines Met this standard

Staffing Met this standard

Complaints Met this standard


Details about this location

Registered Provider Bupa Care Homes (CFHCare) Limited

Overview of the service

Hall Steads Nursing and Residential Home is situated in thevillage of Grimethorpe in Barnsley. The home is registered toprovide accommodation for up to 90 older people. Currently, care is provided on three units. Ladywood provides nursing and/or personal care for people, Willowgarth, personal care and Mile View, personal care for people who have a diagnosis of dementia. Each unit has a communal lounge and dining area.

Type of service Care home service with nursing

Regulated activities Accommodation for persons who require nursing or personalcare

Diagnostic and screening procedures

Treatment of disease, disorder or injury


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

More information about the provider 5

Our judgements for each standard inspected:

Care and welfare of people who use services 6

Safeguarding people who use services from abuse 8

Management of medicines 10

Staffing 12

Complaints 14

About CQC Inspections 16

How we define our judgements 17

Glossary of terms we use in this report 19

Contact us 21


Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 3 February 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information sent to us by commissioners of services.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific wayof observing care to help us understand the experience of people who could not talk with us.

What people told us and what we found

People received appropriate care that met their needs. Family members we spoke with told us they were satisfied with the care their family member received. They commented, "It's a good home, we've no problems. Staff are always cheerful and helpful. They're loving. They let us know [my family member's] needs and/or when they see a doctor. Everything's personal to [my family member]. There's always something happening, functions arranged. When we come they've people up singing and dancing" and "My mum's settled. She's always clean and has a clean bedroom. She eats well. I can go homeand give my mind a rest that she's being looked after."

The service had taken reasonable steps to protect people from abuse. People expressed no concerns about their safety and family members also felt their family members were safe.

People were given the medicines they needed, when they needed them and in a safe way.One person said, "I take my medication. They know I know more about it than them. They also bring me my other medication, that I don't take every day, when I need it."

Overall, enough members of staff were available to meet people's needs and keep them safe.

There was an effective complaints system available. Complaints were acknowledged, investigated and the findings provided to the complainant.

You can see our judgements on the front page of this report.


More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was meeting this standard.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

We looked at the systems in place to check people received appropriate care that met their needs. To check this information we spoke with five people who used the service, fivefamily members, observed staff practice, spoke with the manager, five members of staff and reviewed records.

Family members we spoke with were satisfied with the care their family member received. They commented, "It's a good home, we've no problems. Staff are always cheerful and helpful. They're loving. They let us know [my family member's] needs and/or when they see a doctor. Everything's personal to [my family member]. There's always something happening, functions arranged. When we come they've people up singing and dancing," "My mum's settled. She's always clean and has a clean bedroom. She eats well. I can go home and give my mind a rest that she's being looked after," "We come at different times and it's always good. Staff are great and they can't do enough for them [residents]" and "I think it's brilliant. Carers are ever so nice, brilliant with me, very friendly. They look after [my family member] well. They have activities like painting nails, games and dominoes. They let me know any concerns, anything wrong with meeting his needs, for example, if heneeds a doctor. They're very good with him. I'd advise anyone to come here."

During our observations throughout the day we evidenced some positive interactions between staff and people who lived at the home. People were given assistance where theyneeded it. On Mile View (the unit for people with dementia) we saw an activities co-ordinator spending one to one time with people. This included engaging one person in discussion and an activity that involved recalling numbers and colours and for another person initiating discussion by showing the person pictures. In the afternoon a quiz took place on Willowgarth, with one person from Mile View being asked if they wanted to join in,which they did.

We also saw staff redirecting people to become involved with an activity or task when they became unsettled.


Staff demonstrated patience and a variety of techniques with people where they were unable to assist the person in understanding an 'instruction', for example, asking the person in different ways and using different staff members to do this.

The provider may wish to note, on Ladywood there were nine people in the lounge/dining area during the morning and there was no, or little, stimulation provided for those people by staff. When we spoke with staff they explained they had time to meet people's needs, but didn't always have the opportunity to spend quality time speaking with people, particularly during the morning shift.

People on Ladywood said, "Staff come and bring my tablets and that's it, they're gone again. The entertainment staff come now and again. It's short of human interaction," "It's all ok, but there's no activities. We have our nails painted now and again, but I'd like to go out" and "The staff are alright. I have everything I want, if not, you just ask."

The provider may wish to note, having two televisions playing different programmes in the same lounge was not conducive to people watching either. We observed one person moving to turn up the volume on one television because they couldn't hear it due to the noise from the other television.

We saw the activities displayed that were taking place in the next three months. On Ladywood these included a trip to Cannon Hall to see small animals and on Mile View a church service, Valentine sing-a-long, pancake afternoon, St Patrick's afternoon and an Easter sing-a-long.

The manager provided the customer satisfaction survey for January 2014. Thirty one questionnaires were dispatched and 27 returned. Everyone who responded said they werehappy and content living in the home and that their health and wellbeing was the best it could be. 96% of people who responded were satisfied overall with activities.

We saw that people spent their time as they chose, moving around the units as they wished, where they were able or remaining in their rooms.

When we spoke with staff they were knowledgeable about people's needs and each person's individual preferences.

We reviewed five care files of people who lived at the home. These contained care plans covering a variety of areas including communication, skin integrity, personal safety, mentalstate and eating and drinking. We saw that these had been reviewed at regular periods. We saw that the information we had obtained through observing people, speaking with people who used the service, family members, staff and the manager that relevant information was reflected in people's care plans and people were cared for in line with these.

We also saw involvement with other professionals recorded in people's files. This meant people were receiving input from health professionals when required to meet their needs.


Safeguarding people who use services from abuse Met this standard

People should be protected from abuse and staff should respect their human rights

Our judgement


People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.


We looked at the systems in place to ensure people were protected from abuse. To check this information we spoke with five people who used the service, five family members, observed staff practice, spoke with the manager, five members of staff and reviewed records.

People we spoke with who lived at the service did not express any concerns for their safety.

Family members we spoke with also said they felt their family members were safe at the service.

The manager provided the customer satisfaction survey for January 2014. Thirty one questionnaires were dispatched and 27 returned. All respondents said they felt safe and secure at the home.

The provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening. This was evidenced because the home had a current safeguarding policy in place. This was available for staff and informed them of what constituted abuse and what to do if they suspected a person was being abused or an allegation of abuse was made. The policy/procedure included the reporting of the incident to the local safeguardingauthority and CQC.

We noted from our records held about the service that the manager had notified us of past incidents that had also been referred to the local authority safeguarding team. In addition, if necessary, plans were put in place to protect people and discipline staff in order that people were better protected in future.

We saw a training matrix that confirmed staff had received safeguarding training. This meant staff members when we spoke with them were able to explain what constituted abuse and what action they would take if they suspected abuse or an allegation was madeto them.


We inspected the financial records of three people who used the service where the servicehad identified they were the appointee for the safeguarding of these. We found documentation in place to confirm the status that the service were appointees. The provider may wish to note, there was no supporting documentation for people that lacked capacity that this had been agreed as part of best interest discussions.

We found that when we looked at people's financial records there were records of amountspaid into their accounts. The amount paid for the person's fees corresponded with the breakdown of the amount payable identified by the placing authority. For other monies there were records of amounts withdrawn and deposited to their accounts. Receipts were in place to verify items that had been purchased on behalf of the person. The provider maywish to note, there were not always two signatures to verify the exchange of the amounts between staff and/or the person.


Management of medicines Met this standard

People should be given the medicines they need when they need them, and in a safe way

Our judgement


People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.


We looked at the systems in place to check appropriate arrangements were in place to manage medicines. To check this information we spoke with five people who used the service, five family members, observed staff practice, spoke with the manager, five members of staff and reviewed records.

When we spoke with people about their medication they indicated they received their medication that they needed. One person said, "I take my medication. They know I know more about it than them. They also bring me my other medication, that I don't take every day, when I need it."

We observed people being administered their medication on Ladywood and Mile View. Wesaw that the medication trolley was locked at times when the trolley was unsupervised andmedication was prepared individually and then taken to each person in medication 'pots', together with a drink for the person. The members of staff waited until they could be confident the person had taken their medication before returning to the medication trolley and completing the medication administration record to evidence that the person had beenadministered their medication. This demonstrated medication was dealt with safely, to minimise the risk of people being given the wrong medication. The provider may wish to note, staff members did not wear gloves when removing tablets from their storage, in accordance with good hygiene practice to reduce the risk of medication being handled accidently by a member of staff.

We found that medication was administered in accordance with the written prescribed dose.

We found that medication records contained a photograph of the person and detailed clearly the name of the person, the prescribed medication and dose and the time to be/actually administered, a record of the receipt of medication, the medication administered and the medication to be returned.

People's medication was stored safely. The provider may wish to note, the 'room' where the medication was stored on Mile View was not a sufficiently clean area for the storage of


medicines. The floor area was carpeted and had visible debris on it, the plaster walls had plaster peeling away from it and was marked, wooden rails that had been used for shelving were lined with dust and the 'room' was being used for the storage of other items.

When we spoke with staff they were clear of their responsibilities in the management of medicines. They confirmed a medication policy/procedure was in place they could refer to should they need to and that they had received training. They also explained the checks inplace to minimise the risks of any errors occurring that may place people at risk.


Staffing Met this standard

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement


There were enough qualified, skilled and experienced staff to meet people's needs.


We checked there were sufficient numbers of suitably qualified, skilled and experienced staff on duty to safeguard the health, safety and welfare of people who used the service. To do this we spoke with the manager, five members of staff, five people who used the service, five family members and reviewed records.

We discussed how staffing levels were determined with the home manager. They told us that each unit had a designated number of staff on each shift. On Ladywood this was one nurse at all times, plus four care assistants on a morning, three care assistants on an afternoon and one care assistant at night. On Willowgarth and Mile View there was a senior care assistant on duty at all times, two care assistants on a morning and afternoon shift and one care assistant at night.

The manager said staffing levels were mainly number based, but they would increase staffing numbers if necessary dependent on the needs of people using the service.

In addition to care staff there were house-keepers, cooks, administration and managementstaff on duty.

Discussions with the manager and staff on Ladywood identified the number of people they provided care to was currently limited to 20 people, so that appropriate nursing care could be provided for people. This was because the service had been unable to recruit suitable nursing staff in sufficient numbers to meet people's needs. At the time of the inspection, Ladywood was providing care for 17 people, with 16 of those people requiring nursing care.

At the time of the inspection on Willowgarth, the unit for people who required personal careneeds, there were 15 people.

At the time of the inspection on Mile View, the unit for people who had a diagnosis of dementia there were 11 people.

The manager provided a sample of staff rotas to confirm the staffing numbers on each unit, so we could verify the numbers of staff on duty according to what she and staff had


told us were usually on duty. We looked at the staffing rotas for the period from 3 January 2014 until 30 January 2014. These confirmed the numbers of staff on duty was that described by the manager and confirmed by staff.

The manager provided the customer satisfaction survey for January 2014. Thirty one questionnaires were dispatched and 27 returned. 89% said they were satisfied with the numbers of staff in the home.

Overall, when we spoke with people and their family members they spoke highly of staff and said generally they felt there were enough staff on duty.

The provider may wish to note we observed that the lounge/dining area on Ladywood was unsupervised for at least 15 minutes on one occasion. This meant there was a risk sufficient numbers of staff were not available at times to meet people's needs, which may place them at risk of harm. One family member had to assist a person who used the service to move, because of this risk. They said to another visitor, "I don't think they shouldleave the floor unoccupied for all this time." When we spoke with staff, it identified there was no formal system in place to determine whose responsibility it was to supervise the communal area.


Complaints Met this standard

People should have their complaints listened to and acted on properly

Our judgement


There was an effective complaints system available.


We looked at the systems in place to check people had their complaints listened to and acted on properly. To do this we spoke with the manager, five members of staff, five people who used the service, five family members and reviewed records.

When we spoke with people using the service they told us they had no complaints, if they had, they would tell staff. One person said, "They'd [staff] tell me to fill a form in."

Family members also told us they had no complaints and if they had they would raise themwith staff.

A current complaint's policy/procedure was in place for staff to refer to should they need to if a complaint was made and they were unsure of the action to take.

We also saw a complaints procedure displayed in areas throughout the home for people and other stakeholders to refer to if necessary. The provider may wish to note that the information included referring complaints to the CQC if the complainant remained dissatisfied with the outcome of the complaint from the provider. However, the CQC does not have the authority to investigate individual complaints from people, therefore the complainant may not see this action as a way forward to resolve their complaint.

We spoke with the manager who confirmed that any formal complaints would be passed toher to deal with. We saw a current complaints policy was in place and this stipulated time limits by which certain actions should have been taken, such as sending acknowledgment letters.

The manager provided a computerised print out of a complaint that had been made since she commenced employment. The print out recorded the date the complaint was received,the summary of the complaint, the action taken, whether the complaint was upheld and thedate a response letter was sent to the complainant. This told us the service listened to complaints and acted on them properly. The provider may wish to note, the manager did not have access to complaints that had been made prior to her appointment. As we were aware of one complaint, we could confirm the complaint was investigated and the complaint responded to, but an absence of the record for the manager meant full and accurate information about complaints were not readily available.


We spoke with staff who told us that if they received any complaints that they were unable to deal with themselves, they would pass on to a senior staff member or the manager. Onecare worker told us, "If it was something I could deal with myself, something minor I would do so, would make a note of it." This showed that staff attempted to deal with complaints ata local level where appropriate.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

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