Inspection on 17/01/06 for Hibbert Lodge

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hibbert Lodge 19/05/08

Hibbert Lodge 25/05/07

Hibbert Lodge 01/06/05

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 Announced Inspection 17th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000022977.V267013.R01.S.doc Version 5.0 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 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) 01753 885278 Manager.hibbertlodge@fremantletrust.org 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 DS0000022977.V267013.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-seven residents, including up to 9 residents with dementia Date of last inspection 01/06/05 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 DS0000022977.V267013.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a summary of the annual announced inspection visit carried out on 17th January 2006 by Nicky Cahill (lead inspector) and Gill Gentles (inspector). The inspection consisted of assessing compliance against requirements made of the home in June 2005, an assessment of how the home are meeting a selection of the core standards, a tour of the home and discussions with service users and staff. A full feedback of inspection findings was presented to the manager, Lynnette Evans and three members of the senior care team. What the service does well: A comprehensive service users guide and statement of purpose are in place. This allows service users to access information regarding the services provided and to make an informed choice. The routines of daily living are flexible and service users are able to express their own preferences and choices. The home has a satisfactory complaints system ensuring that service users and/or their representatives are listened to and concerns acted upon. The location and layout of the home are suited to its stated purpose; it is accessible, safe and reasonably well maintained. The environment meets the individual needs of the current service user group. In most parts the home is clean and free from offensive odours, providing a control from the spread of infection and diseases. Vetting and recruitment practices of the home are adequate, ensuring the safety of service users. Staff have received appropriate training, ensuring that the ongoing needs of service users are met. Effective quality assurance systems are in place to ensure that the home is run in the best interests of service users. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 6 Personal allowances are kept by the home for a number of service users. Safeguards are in place to ensure that the interests of the service users are protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 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 the following standard(s): 1 A comprehensive service users guide and statement of purpose are in place. This allows service users to access information regarding the services provided and to make an informed choice. EVIDENCE: A copy of the homes revised statement of purpose and service users guide were forwarded to the Commission prior to the inspection visit. Both documents were found to be comprehensive and informative and were available in the front entrance of the home. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7, 8 Care plans were in place and reflected the current and ongoing needs of the service users and the intervention by other health care professionals. This information ensures that the needs of the service users are appropriately met. EVIDENCE: Four care plans were viewed, these were chosen at random. During the inspection visit in June 2005 it had been disappointing to note that care plans were not being reviewed appropriately and did not reflect the current and ongoing needs of the service users. It was clear during this visit that much work had been carried out to ensure that all documentation was detailed, that current and ongoing needs had been noted and that regular reviews had been carried out. Care plans evidenced that service users were receiving visits from external healthcare professionals, thus ensuring that they were receiving all NHS services for which they are entitled. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12, 14 The routines of daily living are flexible and service users are able to express their own preferences and choices. EVIDENCE: The home offers a wide range of social activities to all service users, which were advertised throughout the home. It was pleasing to see photographs of such activities displayed in the main corridors. Service users care plans evidenced that they are consulted regarding day-to-day choices. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 11 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 the following 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 policy, ‘The Listening Ear’ was displayed in the front entrance of the home. A record of complaints and concerns is maintained, this was viewed during the inspection visit. One complaint had been received since the last inspection visit. Documentation would indicate that this complaint was investigated appropriately and action taken. The home has a record of all compliments from service users and relatives who have been highly complimentary of the service delivered. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19, 26 The location and layout of the home are suited to its stated purpose; it is accessible, safe and reasonably well maintained. The environment meets the individual needs of the current service user group. In most parts the home is clean and free from offensive odours, proving a control from the spread of infection and diseases. EVIDENCE: During the inspection visits in January and June 2005 requirements were made regarding the general upkeep of the home. During a tour of the premises at this inspection it was noted that much work had been carried out to ensure that the décor and general presentation of the home had improved. Decoration had been carried out in some areas, new carpeting had been laid throughout the home over a twelve-month period and new bathroom suites had been fitted in some areas of the home. Some bedrooms had been fitted with new hand wash sinks and taps and vanity units had been rebuilt. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 13 A new kitchenette had been fitted to the dementia care unit the day before the inspection visit. With the exception of a few bedroom areas the home was clean, hygienic and free from offensive odours. The manager had noted problematic areas and action was being taken to rectify any issues. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 Vetting and recruitment practices of the home are adequate, ensuring the safety of service users. Staff have received appropriate training, ensuring that the ongoing needs of service users are met. EVIDENCE: 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. Training files were viewed for a number of staff. Documentary evidence confirmed the following; • 15 staff had received POVA training in the last twelve-month period. • 28 had received dementia care training • 24 had received fire awareness training • 11 had received food hygiene training • 7 had received first aid training • 23 had received manual handling training • 6 had received training in the safe handling of medications. All new staff had received a thorough induction to the home and current care practices. Records had been signed appropriately. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 Effective quality assurance systems are in place to ensure that the home is run in the best interests of service users. Personal allowances are kept by the home for a number of service users. Safeguards are in place to ensure that the interests of the service users are protected. EVIDENCE: The home has an advocate who visits regularly and will chair service users meetings. Details regarding contact for this advocate are displayed on the homes notice board. The minutes of such meetings were also displayed. The organisation carries out unannounced visits, in accordance with The Care Homes Regulations 2001, Regulation 26. Copies of visit reports are forwarded to The Commission. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 16 The homes manager completes service monitoring forms, which include, service details, referrals received, complaints, service users meetings, staffing information, visits from other authorities and training issues. Staff meeting minutes were viewed, these are carried out six-weekly. Service users personal allowances are kept by the home for a number of service users. Records of transactions made on behalf of two service users were viewed during the inspection and appeared to be in order. Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 17 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hibbert Lodge DS0000022977.V267013.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury 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 DS0000022977.V267013.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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