Inspection on 25/05/07 for Hibbert Lodge

This inspection was carried out on 25th May 2007.

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 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 17/01/06

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 Barbara Mulligan Unannounced Inspection 10:30 25th May 2007 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.V333320.R01.S.doc Version 5.2 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.V333320.R01.S.doc Version 5.2 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 01753 891491 manager.hibbertlodge@fremantletrust.org Manager.ladyelizabeth@fremantletrust.org The Fremantle Trust Mrs Lynette Evans Care Home 37 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (37) of places Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 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. Fees range from £381.78 per week to £550 per week Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on Friday May 25th 2007 at 10.30 am. The visit consisted of discussions with the registered manager, staff team and service users, a tour of the premises and an examination of the homes records, policies and procedures. The inspection officer was Barbara Mulligan. The registered manager is Lynette Evans Twenty-six of the National Minimum Standards for Older People were assessed during this visit to the home. Six of these are almost met and twenty have been fully met. Standard six has been assessed as not applicable. As a result of the inspection the home has received six requirements. The inspector would like to thank the registered manager, the staff team, service users and visiting relatives for their cooperation and assistance during this visit. Service users and relatives/representatives, both those interviewed and those who responded to the survey expressed a high level of satisfaction with the care received from support staff. Positive comments made about the service include, “ they genuinely care for the residents, my mother could not be in better hands and “my father is well care for at all times”. Two comments raised concerns about information available to them before choosing a home, “a nightmare getting information before choosing a home, there should be more detailed information, prices, type of room, whether the staff have experience of caring for people with dementia” and “I felt pressured to make a decision before I knew any thing about the home”. The evidence seen and comments received, indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the service users, the staff team and the registered manager for their cooperation and help during the inspection. What the service does well: Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 6 Meals are of a good standard and presented in an appealing way. Comments made from people who use the service include, “ the food is always very nice ” and “there is always plenty of food and snacks in between meals”. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “nothing is too much trouble “. Comments received from relatives include “My mother is cared for as an individual and this is what the staff do so well, caring” and “my father is treated as an individual and with respect, the staff understand dementia”. Communication between service users and visitors was observed to be positive and open. One comment received from a relative states, “the staff are very sensitive in the way they speak to my father”. A further comment received by a relative records “could have a little improvement in English speaking and literacy of some staff”. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. Comments received from relatives include” the training shows and care staff are confident in their duties”. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, including an annual service satisfaction survey and a monthly news letter which is to be commended. Health and safety policies and procedures are clear and informative. Training for dementia care is completed by all staff and this is to be commended. What has improved since the last inspection? The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home and liked the fact that the home is small and they know all the staff. Ongoing improvements are made to environment ensuring a safe and comfortable home for people to live in. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 8 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.V333320.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is adequate. Overall the assessment tool is adequate, however this needs to be fully completed for all service users to ensure that staff are prepared for admission and have a clear understanding of the service users requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pathways to admission is either direct contact with the home for someone who is self-funding or through social services care management arrangements via a ‘central resource team’. Either pathway will lead to an assessment of the prospective service user’s needs. It is the responsibility of the registered manager or a senior staff member to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 10 The inspector observed the assessment documentation for four service users, including those most recently admitted to the home. The admission tool covers personal details, medical history, medication, mobility, allergies, pressure area care, nutritional status, personal hygiene needs, continence needs and mental health needs. The admission documentation seen contains limited and conflicting information. For example, in one assessment of need under “communication” it records “good”. However, in the care plan it records that the service user “speaks Polish and does not speak English very well”. In another assessment under “dressing and personal grooming” it records “all”. The sections for date of birth, preferred term of address, religion and ethnic origin have not been completed for two assessments looked at. The assessment tool needs to contain as much information as possible, about the individual, to ensure the home can assess if they are able to meet the needs of a potential service user. This will be a requirement of the report. Comments received from relatives are positive and include “after having inspected six other care home before selecting Hibbert Lodge I feel my mothers needs are well met”. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. The care planning system does not always adequately provide staff with the information they need to satisfactorily meet service users needs. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. However Waterlow risk assessments do not contain correct information as per the care plan and this could potentially put service users at risk. The medication policies and procedures are clear and informative, but there is no consistent implementation of the policies, that could result in unsafe working practices. Service users feel that they are treated with respect and dignity and that their right to privacy is upheld ensuring personal care is delivered appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four service users was case tracked and their care plans were examined. The overall standard of the care plans is variable and depends on who has completed the care plan. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 12 Care plans include a pen picture, likes and dislikes, preferred daily routines, a summary care plan, a night care plan, a moving and handling plan and daily reports. Overall the care plans are informative. However, numerous entries in the care plans examined are vague and would benefit from further detail. An example of this includes “ legs to be creamed” but does not include the name of the cream to be applied or how often this must be applied. Another entry under “mental health” records “Mrs X can say what she wants” and the action plan for this entry records “all carers to ask”. This is confusing and does not explain what is expected of staff. Another entry in a care plan records that a service user “does not speak English very well” but the plan of care fails to mention how the service user will be understood so his needs can be met, and how appropriate communication will occur. A further entry in a care plan states that the service user “is very hard of hearing but does not possess a hearing aid”. The action plan informs staff that they must speak clearly and at a suitable volume” but does not mention anything about the individual having a hearing assessment or whether they are suitable for a hearing aid. These statements require more detail to ensure that all aspects of the health, personal and social care needs of the service users are met. It will be a requirement of the report that care plans provide specific details on how the needs of service users needs are met and monitored. One care plan for a service user admitted five days previously had not yet been completed. The care plans are hand written and several entries were difficult to read. It is strongly recommended that all hand written entries in the care plans are legible. There are risk assessments in place for pressure area care, prevention of falls and nutrition. However, information contained within the care plans and within several risk assessments looked at is inconsistent. For example, recorded in a Waterlow assessment it states that the service user is fully mobile. In the care plan for the same service user it states that the service user requires a frame and the support of one carer to walk. This conflicting information affects the scoring of the Waterlow assessment making it incorrect and potentially putting the service user at risk. In another Waterlow assessment it records the service user as being “occasionally incontinent” but the care plan records the same service user as “doubly incontinent”. Again this affects the scoring of the Waterlow assessment making it incorrect. The overall standard of the risk assessments is again variable. Several risk assessments were incomplete, not dated or signed by the author. Others were fully completed, detailed and very informative. It is a requirement of the report that all risk assessment documentation is reviewed in line with service users current needs and changes made as necessary. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 13 Service users at the home are registered with three local surgeries. The registered manager stated that service users can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. At the time of the inspection there are two service users who require pressure area care and there is evidence that the district nurse is attending to these. A domiciliary optical service visits the home on an annual basis. Referrals for a hearing test go through the service users G.P. or the district nurse. The home is able to gain advice from the dietician and nutritional risk assessments are in the care plans of service users. Weight monitoring is undertaken monthly and recorded in care plans. Chiropody services visit the home on a six weekly basis. Dental services are accessed on a needs only basis and there a domiciliary service visits that visits the home. Records of all medication received and returned are completed and recorded by the registered or senior staff. Medication storage and medication records were checked. Arrangements for the storage of medicines is satisfactory with medication being kept in four lockable trolleys, one for each lounge area, and one large metal cupboard in the staff office for extra storage. The home uses controlled drugs, and the controlled drugs register was looked at. There are two entries, one for April and one for May where two signatures have not been obtained. All controlled drugs are stored in a metal cupboard, which complies with the Misuse of Drugs Regulations 1973. Photographs of service users, on medication charts, are used for identification. Medication records were examined for each lounge area. In Sunrise lounge and Rose Cottage the records show several entries that have the code “G”. On the back of the MAR sheet it is recorded that this means “not signed for”. It was explained to the inspector that the night staff check the MARS sheets daily. If they observe any omissions they will insert the code “G” and record on the back of the MAR sheet that it has not been signed for. This practice does not improve practice or help to reduce the number of omissions or errors. The recording practices for the administration of controlled medicines and other prescribed medicines needs to be improved and the registered manager is required to address this. A requirement has been made for improvement in this area. Service users receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Individuals are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans show routines of daily living and include bathing, rising and retiring times. As part of the admission process, the home ask service users and/or their families to complete a pen picture of their life to give staff information about previous leisure pursuits, hobbies and other interests. On the day of the visit the activities time-table indicated that there should be either a coffee morning or nail care in Sunrise lounge. The inspector sat in this lounge throughout the morning and no activities were observed taking place. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 15 However, service users spoken to said they do enjoy activities in the home and especially enjoy the afternoon trips out on Wednesdays. Examples given to the inspector of in-house activities include a weekly church service, manicure sessions, crosswords, armchair exercises, a visiting shop, bingo, a quiz, music and hairdressing. On a notice board in the home are activities advertising outside entertainers to the home and other activities taking place in the home. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, various visiting entertainers and a monthly church service. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “nothing is too much trouble “. Comments received from relatives include “My mother is cared for as an individual and this is what the staff do so well, caring” and “my father is treated as an individual and with respect, the staff understand dementia”. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the inspector was informed that this could be facilitated if it was requested. Service users are offered three meals a day. The menus cover a four weekly rotating system. A choice of main meal is available. The inspector had the opportunity to observe lunch in Sun Rise lounge. This was relaxed, unrushed and well organised. All meals seen were attractively presented and plentiful. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. Comments made from people who use the service include, “ the food is always very nice ” and “there is always plenty of food and snacks in between meals”. The inspector was told that service users can take their meals in their rooms if they wish and this was the choice of several individuals on the day of inspection. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 16 The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. Hibbert Lodge DS0000022977.V333320.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. There are systems in place that enable service users, staff and stakeholders to make comments about the quality of the service in a non-judgemental manner. Policies and procedures to protect service users from abuse are in place, which protect service users from abuse and ensures their human rights are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure. This includes timescales for responding to complaints. However the complaints procedure still refers to the National Care Standards Commission and needs to be updated to the Commission for Social Care Inspection. The home has received four complaints since the previous inspection. These are well recorded and responded to within timescales. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. There have been no complaints reported to the Commission for Social Care Inspection. The registered manager is aware of the POVA register and would submit staff for inclusion if it became necessary. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 18 The home uses the Bucks Multi Agency POVA policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this forms part of their induction. The registered manager does not act as appointee for any service users. There are systems in place to look after small amounts of personal allowance or for the safekeeping of service users valuables. Hibbert Lodge DS0000022977.V333320.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 and 26. Quality in this outcome area is adequate. The standard of the environment within the home is adequate, providing service users with a homely place to live. However, there are several areas of the home that have offensive odours and this needs to addressed. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hibbert Lodge is a care home that is registered to provide care and accommodation to thirty-seven older people. The home is run and managed by The Fremantle Trust. 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. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 20 The home is divided into four lounge areas, two on the upper floor and two on the lower floor. The largest of these is Sunrise lounge. The internal decoration of the home is generally in good repair, however Sunrise lounge is tatty and would benefit from redecoration. The carpet in this lounge has a strong offensive smell and this needs to be addressed immediately. A requirement has been made for improvement in this area. The kitchen is clean, spacious and well looked after. However, the kitchen would benefit from new cupboards, drawers and work tops and this is strongly recommended. The home has a large garden that is well-maintained and accessible to service users. There are no CCTV cameras in use within the home at the time of the inspection. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. There are quiet areas around the home where service users can meet visitors in private. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. All radiators have low temperature surface covers and are thermostatically controlled. Emergency lighting is provided throughout the home. Hot water control valves are fitted to all hot water outlets accessible to service users. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. Hibbert Lodge DS0000022977.V333320.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. Staffing numbers are adequate to ensure that the assessed needs of the service users are met. There are effective recruitment procedures in place to ensure service users are protected from harm. It is unclear due to poor training records if care staff and ancillary staff are unto date with mandatory and specialist training, making it difficult to assess if staff are competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the needs of the service users are always met. This includes sufficient numbers of ancillary staff. The registered manager is extra to these numbers. Vacancies at the home is the assistant manager post which has recently become vacant, two posts for night work and twelve hours which is to be used for an activities co-ordinator. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 22 The home continues to support staff on NVQ training and at the time of this inspection twenty four care staff had NVQ level 2 or above. This means that the home has achieved 72 of care staff who have achieved NVQ training. A random selection of staff files were made available for inspection purposes, including those most newly recruited. All files looked at contain the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB checks had been obtained. The home employs two volunteers. There is an induction programme that staff are required to complete within their probationary period. Mandatory training forms part of this induction. Training records are not well organised and have not been updated. It is difficult to assess if staff are up to date with their mandatory training. This includes, fire training, manual handling, basic food hygiene, first aid and infection control. It is strongly recommended that the training records are well maintained and kept to date. Comments received from relatives include” the training shows and care staff are confident in their duties”. All staff receive a minimum of three paid days training per year. Hibbert Lodge DS0000022977.V333320.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. The manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of the service users. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. Protocols and systems are in place to ensure service users financial interests are safeguarded. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. This judgement has been made using available evidence including a visit to this service. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 24 EVIDENCE: Hibbert Lodge is owned and managed by Freemantle. There is a registered manager and she has completed the Registered Managers Award. She has been the registered manager at Hibbert Lodge for three and a half years. Examples of further training undertaken by the manager include effective communication, management and leadership training, dementia mapping and mandatory training. The registered manager is an NVQ assessor. The manager is not responsible for any other registered establishment. There is an equal opportunities policy in place and this was looked at during the inspection. The registered manager stated that service users satisfaction questionnaires are sent out to service users and their relative or representative on an annual basis. The results of the last annual quality control questionnaire demonstrate that service users are overall happy and satisfied with the service provided. Accident and pressure sores and complaints are monitored on a regular basis. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. The manager does not undertake the role of appointee for any service users. She said that most families look after their relative’s money and only a small number of individuals require the home to look after personal money. Relatives will bring in small amounts of personal money and written records are maintained of all transactions. Secure facilities are available for the safekeeping of valuables if required. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually. Evidence of mandatory health and safety training is unclear due to poor organisation of training records. That several care staff have not received basic food hygiene training. A requirement has been made for improvement in this area. Service reports are in place for the maintenance of the stair lift, Gas boiler 29/11/06 and Pat testing 04/01/07. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. The homes incident and accident book is completed legibly. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP3 Regulation 14 Requirement The registered manager is required to ensure that the initial assessment is fully completed and contains as much information as possible. The registered manager is required to ensure that care plans provide specific details on how the needs of service users are met and monitored. The registered manager is required to ensure that all risk assessment documentation is reviewed in line with service users current needs and changes made as necessary. The registered manager is required to ensure that staff adhere to procedures for the recording of medicines administered. The registered manager is required to ensure that all carpets in the home are free from offensive odours. The registered manager is required to ensure that all care staff complete the required mandatory training. DS0000022977.V333320.R01.S.doc Timescale for action 07/06/07 2 OP7 15 30/07/07 3 OP8 13(4) 30/06/07 4 OP9 13(2) 07/06/07 5 OP26 23(2) 14/07/07 6 OP38 18(1) 14/06/07 Hibbert Lodge Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP19 OP30 Good Practice Recommendations It is strongly recommended that all hand written entries in the care plans are legible. It is recommended that the kitchen cupboards, drawers and work tops are replaced. It is strongly recommended that training records are well maintained and kept up to date. Hibbert Lodge DS0000022977.V333320.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V333320.R01.S.doc Version 5.2 Page 29 - 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. 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