Inspection on 01/06/05 for Hibbert Lodge

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hibbert Lodge 19/05/08

Hibbert Lodge 25/05/07

Hibbert Lodge 17/01/06

Hibbert Lodge 04/01/05

Hibbert Lodge 10/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hibbert Lodge Gold Hill East Chalfont St Peter Bucks SL9 8DL Lead Inspector Nichola Cahill Gill Gentles Unannounced 1st June 2005 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hibbert Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Hibbert Lodge Address Gold Hill East, Chalfont St Peter, Bucks, SL9 8DL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01753 885278 The Fremantle Trust Mrs Lynette Evans Care Home 37 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (37) of places Hibbert Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 4th January 2005 Brief Description of the Service: Hibbert Lodge is a residential care home providing 24-hour care and support for up to thirty-seven older service users, nine of whom have dementia care needs. Hibbert Lodge is a Fremantle home, which is managed by Lynette Evans.The home is situated in the village of Chalfont St Peter and whilst situated close to shops, pubs and other local amenities the home is located at the top of a steep hill. Accommodation is provided on two floors of a purpose built home, which is divided into four small separate units, each with its own lounge and dining areas. All bedrooms are single, none of which offer en-suite facilities. However, bathing and toileting facilities are in close proximity to all bedrooms and communal areas. A passenger lift is provided for access to the second floor of the home.The home has access to services from the local GP practice; support is also given from the district nurse team and other healthcare professionals. Hibbert Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Hibbert Lodge took place on 1st June 2005 between, 11.20am and 3.45pm. The lead inspector was Nicky Cahill who was accompanied by Gill Gentles (inspector). The homes manager, Lynnette Evans, met the inspectors. The inspection consisted of meeting with service users, visitors and staff. The inspectors viewed the care plans for individual service users, contracts and terms and conditions of residency, staff personnel and training files and other information pertinent to the day-to-day running of the home. The inspectors toured the building selecting bedrooms, communal areas and bathing and toileting facilities to view. Before leaving the home the inspectors fed back all findings to the homes manager. The home has one partially not met requirement from the inspection in January 2005. This requirement is with regard to some issues within the environment, which should be addressed by 30th June 2005. What the service does well: All service users have signed contracts and terms and conditions of residency. The home has an admissions procedure, which includes meeting potential service users and / or their representatives prior to admission. A four-week trial visit is offered to ensure that the service user makes the right choice of placement. The home ensures a safe approach to the safe handling, storage and administration of medications. Staff treat service users with dignity and respect. The home offers open visiting and service users are encouraged to maintain links with all family, friends and with the local community. The dietary needs of service users appeared adequately catered for with a balanced and varied selection of food and drinks available that meets the service users tastes and choices. A copy of the organisations complaints procedure, ‘The listening ear’, was displayed in the front entrance and around the home. Staffing levels appear sufficient and appropriate training is in place and therefore meets the current and ongoing needs of the service users. Vetting and recruitment practices of the home are adequate, ensuring the safety of service users. Hibbert Lodge Version 1.10 Page 6 Systems are in place to ensure that fire equipment and systems are maintained, with appropriate records kept. This provides safety for service users, staff and other visitors to the home in the event of a fire. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hibbert Lodge Version 1.10 Page 7 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 Standards Statutory Requirements Identified During the Inspection Hibbert Lodge Version 1.10 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 5. The service user or a representative has signed a contract and terms and conditions of residency, thus ensuring that they are aware of the service that will be offered. The admissions procedure appears to allow the home to make an informed decision as to whether they can meet the service users needs. It would appear that service users are all placed appropriately. Service users and / or representatives are invited to the home prior to admission and are then afforded the opportunity to have a four-week trial stay. This will ensure that service users are familiar with surroundings, have met the homes staff and can make an informed decision whether to take permanent residency. EVIDENCE: Signed contracts and terms and conditions of residency were viewed during the inspection and appeared to be complete and contained the relevant information. Service users purchasing their care through a funding authority Hibbert Lodge Version 1.10 Page 9 had a Care Service Order in place detailing contributions to be paid by the service users and the authority. The home has an admissions procedure, which includes meeting potential service users and / or their representatives prior to admission. The records for the most recently admitted service users were viewed and appeared to be complete and contained detailed information. It was evident within documentation viewed that service users had made visits to the home prior to admission. The statement of purpose clearly states that a four week trial stay is offered. Hibbert Lodge Version 1.10 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10. Care plans did not accurately reflect the current and ongoing needs of service users. This does not ensure that service users needs are known to staff and does not enable them to deliver appropriate care. Documentation viewed only evidenced visits from GP’s and district nurses, it was unclear whether service users have regular access to all NHS services for which they are entitled. The home cannot ensure that all health care needs are being met. Medication appears to be received, stored, administered and disposed of in a satisfactory manner and service users appear to receive their medication as prescribed. All staff respect service users rights to privacy and dignity. EVIDENCE: Individual care plans were available for inspection, and five were viewed. The inspectors were disappointed to note that no progress had been made in updating and reviewing care plans since the inspection visit in January 2005. Two of the five care plans included a very detailed account of the care needs, however, they had not been reviewed. Three care plans did not provide Hibbert Lodge Version 1.10 Page 11 adequate information to ensure that all of the service users needs had been identified. Examples of shortfalls were: • No signature of the service users and / or the representative to agree on a plan of care. • No overall objectives outlined. • Care plan update ‘tick chart’ indicated that the care plan had not been updated since December 2004. • No clear review dates were identified. It is a requirement that all care plans accurately reflect the current and ongoing needs of service users and are regularly reviewed. All reviews and amendments made should be in consultation with the service users and / or a representative. The inspectors viewed documentation relating to ‘medical intervention’. It was clear that service users had been seen by their GP and district nurses as appropriate. However, there was no indication that service users were able to access dental and optical services. There was no clear evidence that service users had been appropriately assessed for products used in the promotion of continence. It is a requirement that all service users are provided with information regarding their entitlements to NHS services and assistance is given to access such services. All health care needs must be identified within service users care plans. The inspectors viewed the medication storage and administration records in ‘Rose Cottage’. MAR sheets appear to have been appropriately signed at the time of administration. All medication appeared to be appropriately stored in a lockable facility. A policy was in place with regard to the administration of PRN medication, however, it is recommended that this be revised to include how or who decides when medications should be administered where a service user may not be able to communicate effectively. ‘Refused’ or ‘wasted’ medication was stored in accordance with the guidance of the pharmacy supplying the homes medications and had been appropriately signed out of the home. The medication cabinet was ‘sticky’ and spilt medication had clearly not been wiped away. It is recommended that the home is more vigilant with regard to the cleanliness of all medication cabinets. From observations made during the inspection and discussions with service users it would appear that privacy and dignity are respected at all times. Hibbert Lodge Version 1.10 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 15 The home offers opening visiting and service users are encouraged to maintain links with all family, friends and with the local community. The dietary needs of service users appeared adequately catered for with a balanced and varied selection of food and drinks available that meets the service users tastes and choices. EVIDENCE: The home has open visiting. This was observed throughout the inspection visit, and confirmed through discussions with service users. The lunch served appeared adequate and a choice of main meal was being offered. Service users were able to eat meals within one of the dining areas or within their own bedrooms should they wish. Staff were seen to assist service users discreetly were appropriate. Hibbert Lodge Version 1.10 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints system ensuring that service users and/ or their representatives are listened to and concerns acted upon. EVIDENCE: A copy of the organisations complaints procedure, ‘The listening ear’, was displayed in the front entrance and around the home. A record of complaints and concerns is maintained and this was viewed. Some service users spoken to were positive that any concerns or complaints would be addressed appropriately. The home were unaware of any complaints made since the last inspection visit. Hibbert Lodge Version 1.10 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24, 25, 26 The home has sufficient communal areas and the appropriate number of toileting and bathing facilities throughout the home. The environment is presently not well maintained and the health and safety and privacy and dignity of service users are compromised. In most parts the home is clean and free from offensive odours, providing a control from the spread of infection and diseases. EVIDENCE: During the announced inspection in January 2005 a requirement was made with regard to the décor, general presentation and maintenance of the home. The home was given until 31st June 2005 to address all areas of concern. Some areas identified were: • No locks, or doors that did not shut completely, to some of the bathing and toilet facilities. • Yellow stained and cracked ceilings. • Water stained hand wash basins and broken and damaged vanity units. Hibbert Lodge Version 1.10 Page 15 • • Bathroom areas needing complete refurbishment and redecoration. Window frames, which needed repainting and new draft seal in some places. During this inspection visit it was noted that some areas had been addressed, however, the inspectors were concerned that there were still both minor and major works to be carried out and the requirement would not be met. One toilet had no seat and the cistern was missing, no call bell leads in some bedrooms, trailing telephone leads were found in the hairdressing room. (This list is not exhaustive). The Commission are aware that there are financial implications for the home when redecorating and refurbishing areas such as bathing and toileting facilities. However, smaller areas such as repainting walls where plaster repair work had not been carried out and the fitment of appropriate locks on doors etc must be completed by the given timescale. The Commission has received copies of quotes for major work and is presently satisfied that this is being addressed. However, it is a requirement that this work is completed by 31st August 2005. A further requirement is made that the manager address all other areas of maintenance required around the home to ensure the health and safety, privacy and dignity of service users at all times. The manager is reminded that failure to comply with requirements will lead to enforcement action. In most parts the home was clean and free from offensive odours. The manager had addressed most cleanliness issues raised during the last inspection visit. However, there were still areas around the home that presented with a strong and unpleasant odour. It is a requirement that the manager ensure that all areas of the home are clean and free from offensive odours at all times. Hibbert Lodge Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29. Staffing levels appear sufficient and appropriate training is in place and therefore meets the current and ongoing needs of the service users. Vetting and recruitment practices of the home are adequate, ensuring the safety of service users. EVIDENCE: During the inspection visit in January 2005 it was recommended that staffing be reviewed for one unit in the home. The manager confirmed that the member of staff in this area now receives extra assistance at busier times of the day. Staffing hours have been increased by five hours per day. One concern raised during two discussions was that some staff were inclined to sit and chat or read the news paper at times when service users would benefit from extra assistance and activities. It was also discussed that there had been times were a member of staff was not immediately available to assist a service users in need. It is a requirement that the manager ensures that staff are available at all times to ensure that service users needs are met. The inspectors viewed the training files for staff. It would appear that mandatory training is up to date at present. However, it was discussed that some areas of training would be due to be updated before the next inspection visit. Hibbert Lodge Version 1.10 Page 17 Four recruitment files were viewed. All documentation required under The Care Homes Regulations 2001 was present and appeared to be in order. All staff working in the home had received a CRB and POVA disclosure. Hibbert Lodge Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38 The management of the home appears to promote service user focused care, which ensures that service users are cared for by appropriately trained and competent staff. Systems are in place to ensure that fire equipment and systems are maintained, with appropriate records kept. This provides safety for service users, staff and other visitors to the home in the event of a fire. EVIDENCE: The manager, Lynnette Evans, has extensive experience in the care of older people. Lynnette is in the process of completing her Registered Managers Award and was visited by her assessor during the inspection visit. A weekly fire alarm test is carried out, all staff have been trained in fire awareness and fire alarm systems are tested at appropriate intervals. Documentary evidence was seen to support this. Hibbert Lodge Version 1.10 Page 19 Hibbert Lodge Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 x x x 2 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x x x 3 Hibbert Lodge Version 1.10 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Timescale for action 31.07.05 2. 8 12 3. 19 13 4. 26 16 It is a requirement that all care plans accurately reflect the current and ongoing needs of service users and are regularly reviewed. All reviews and amendments made should be in consultation with the service users and / or a representative. It is a requirement that all 31.07.05 service users are provided with information regarding their entitlements to NHS services and assistance is given to access such services. All health care needs must be identified within service users care plans. It is requirement that the 31.06.05 manager must address all areas of concern regarding health and safety and redecoration and refurbishment of the envirnment identified in January 2005. Confirmation of completion must be forwarded to The Commission. It is a requirement that the 02.06.04 manager ensure that all areas of the home are clean and free from offensive odours at all times. Hibbert Lodge Version 1.10 Page 22 5. 29 18 It is a requirement that the manager ensures that staff are available at all times to ensure that service users needs are met. 02.06.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that the policy on PRN medication be revised to include how or who decides when medications should be administered were a service users may not be able to communicate effectively. It is recommended that the home is more vigilant with regard to the cleanliness of all medication cabinets. 2. 9 Hibbert Lodge Version 1.10 Page 23 Commission for Social Care Inspection Cambridge House, Smeaton Close 8 Bell Business Park, Aylesbury Buckinghamshire HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hibbert Lodge Version 1.10 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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