Key inspection report CARE HOMES FOR OLDER PEOPLE
Hickling House Town Street Hickling Norwich Norfolk NR12 0AY Lead Inspector
Dragan Cvejic Key Unannounced Inspection 19th August 2009 09:00
DS0000027434.V377412.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 2 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hickling House Address Town Street Hickling Norwich Norfolk NR12 0AY 01692 598372 P/F01692 598372 info@hicklinghouse.fsnet.co.uk info@glendonhouse.fsnet.co.uk Mr Rhoderick Smart Mrs Frances Smart Angela Marlow Care Home 29 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) Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (28) of places Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Up to twenty-eight (28) service users, over 65 years of age with dementia may be accommodated. One (1) adult with dementia may be accommodated The total number not to exceed twenty-nine (29). Date of last inspection 17th March 2009 Brief Description of the Service: Hickling House is a care home providing personal care and accommodation for 29 older people with dementia. The home is situated on the outskirts of the village of Hickling, close to Hickling Broad and less than 5 miles from the Norfolk Coast. Originally a Victorian Inn, the premises has been extended and modernised to provide residential accommodation on two floors. There is a choice of communal areas to suit the various needs of people living in the home. There are 25 single rooms, 24 of which have en suite facilities, and 2 double rooms, both with en suite facilities. A shaft lift and separate stair lift provide access to the upper floor and there are two outside fire escapes. The weekly fees for care and accommodation are between £404 and £500 a week. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
We used the home’s AQAA - a self assessment, and regular reports of the events that affected residents made to us to plan the site visit and inform this report. We carried out a site visit and spoke to 7 residents, checked 4 residents’ files, 3 staff files, spoke to two staff and the owner. The owner was currently managing the home as the previous registered manager had just left to progress elsewhere. We observed some care practices at breakfast time and afterwards. We observed the medication administering process and checked medication policy, procedure, storage and records. The manager-owner showed us around the home, providing information about the environment. We checked all areas addressed in previous requirements and found that all of them were now, met. What the service does well:
The home provided good information about the service in their statement of purpose, user’s guide and the home’s brochure, enabling residents and their families to make an informed choice when they choose the home. The home organised and conducted a pre-admission assessment, ensuring that the assessed needs would be met if a potential resident decides to move into this home. They also consulted other professionals, such as prospective residents’ GP’s, during the initial assessment to complete a life history for each individual and organise the best way to meet the assessed needs. The previous manager and, recently the owner reviewed the format and content of the care plans and risk assessments and, by improving these, ensured better care and protection of residents. One of the residents commented: “The home is good, they could do with few more staff, but they are good. I feel safe here, I am happy that staff help me with my medication, I would not be able to do it myself. The home is clean and fresh. They take us out, organise quiz games, they help me when I want to go to sit in the garden. There is no need for anything to be addressed in your report.” Another resident who recently moved into the home commented on health and personal care: “A chiropodist comes here, hairdresser too. I had my hair done
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 6 3 times. They (staff) are good to us, they come when I call them. I usually do not need to wait too long for them. I do feel safe here.” Care plans, risk assessments and other documentation helped staff to focus on the assessed and recorded needs and offer care that was discussed and agreed with residents. All residents spoken to stated that they were happy with the activities the home organised and offered to all of them. Three new activity co-ordinators, were covering the whole weekly programme. Keeping records of the activities undertaken by each individual, coordinators could ensure that all residents had something appropriate for their interests and abilities. Observing breakfast showed us that the food was appropriate, meal times were organised in an unhurried way and those that needed support were provided with that in a dignified way, while independence was very much encouraged. One of the residents took part in gardening and hanging washing out for drying, as she wanted to remain independent and useful for as long as possible. A cook was exceptionally good with a resident who needed help eating. Patiently and with full respect for her choice, she helped the resident have her breakfast. New legislation on Deprivation of Liberty was promoted throughout the home’s procedures and written information about it was provided and displayed both for staff and residents. What has improved since the last inspection? What they could do better:
Although in the majority of observed procedures the residents’ needs were met, it was observed how a resident was left struggling to drink with shaky hands and only at medication administration time did staff helped her. Staff did try to promote her independence, but due to shaky hands she was not able to
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 7 drink without support, even with the special beaker that was given to her when her tremor was noticed on the morning of the site visit. The home would need to consider another smoking area, as the current one could cause smoke to enter a bedroom behind it if the wind direction was towards it. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hickling House DS0000027434.V377412.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 Hickling House DS0000027434.V377412.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their relatives could choose the home based on information provided prior to admission and on properly conducted initial assessments as an indicator that the assessed needs would be met. EVIDENCE: The home provided appropriate information about the service in their information pack, enabling potential residents and their relatives to make an informed choice of home. The owner, who was currently managing the home, stated that she was just working on revising the Service users’ guide. Initial assessments were checked in 4 checked files and were appropriate. The manager explained that they also collected information about potential residents from their GP.
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 10 Observing the care process and checking residents’ daily records showed that the home was able to meet the residents’ needs. Seven residents spoken to confirmed that their needs were met. One comment included: “Here is OK, they could do with few more extra staff, but they do come when we need them.” Hickling House DS0000027434.V377412.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were protected by appropriate and organised health care and prompt involvement of external medical professionals when the need arose. However, staff would need to be aware that, when a resident is unwell, they might need extra support and help. EVIDENCE: The owner, who also managed the home at this time, stated that they have introduced new format for recording care plans. Four checked files showed that the new plans, whereby each assessed need was addressed on one page, making it more detailed and allowing reviews to properly address changes in needs. Staff actions to meet the assessed needs were appropriately recorded. The care plan format contained a section to indicate changes in risk assessments. The risk assessment included all areas of risk, including risk of falls, sensitive skin conditions, dietary monitoring, continence related issues
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 12 and the ability to make decisions regarding any relevant areas of their lives. Additional, so called ‘personal risk assessment’ addressed issues such as potential aggression as a result of residents’ conditions and was addressed with clear instructions for staff on what to do. Thus, health protection for users of the service was ensured. Medication process was improved. A staff member was observed administering medication, safely, patiently and appropriately. She explained to a resident what the medication was for, when asked. She followed hygienic procedure, used gloves and individual pots and seperate glasses for each resident. Four records were checked and all were appropriate. A new audit system, introduced by the owner-manager, ensured appropriate procedure was followed. Privacy and dignity were respected. Staff talking to residents were gentle, kind and patient. Breakfast was served to each table at a time, thus promoting dignity and allowing residents to eat independently. However, a resident that had become extremely shaky on that morning did not manage to drink her chosen juice by herself. A staff member, rightly, tried to encourage independence by transferring the juice to a special covered beaker. Shaky hands still prevented the resident from drinking by herself. Only after 10 minutes, when the staff administering medication came to give her her tablets, did she get support to drink her juice. Staff did not react appropriately to the changed needs and left the resident waiting to have her drink. When, finally she was helped, she stated: “I was so thirsty.” Her cardigan was brought in when she asked for it, but was left on her wheelchair handles and only later, staff put it around her. Staff would need to address deterioration of the conditions of residents straight away to show full respect and preserve residents’ dignity in the changed circumstances. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ activities were improved and their contribution increased by engaging 3 staff members to provide organised, structured and stimulating activities. EVIDENCE: The owner-manager reported that 3 staff were given responsibility to organise and conduct residents’ activities. This way, preferences and interests of individuals could be accommodated. Good records of activities in each checked file confirmed that residents were taking part in these activities. One of the residents spoken to stated: “They take us out. When I want to go to the garden, staff comes with me. They organise quizzes and other activities.” Initial assessments in checked files contained preferences, likes and dislikes and helped staff structure residents’ time as residents wanted. Another resident was quite pleased and proud that she had her “hair done 3 times”.
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 14 The records of preferences were detailed as seen in one file: “likes TV and soaps: Songs of Praise.” Breakfast time was observed. A choice was given to all residents. Eleven people present in the dining room were asked what they wanted. The cook was exceptionally good with residents; patient, helpful and respectful. The menu was written on the board in large writing. A printed version was also displayed. The manager explained that they were planning to laminate menus and display them on each table. However, the best example of choice was observed when the cook offered a plate with toast or bowl of cereals, showing the actual appearance to residents who might have been confused. The cook stated that she does the same at lunch time. She also recorded who had what, ensuring that good records of dietary intake were recorded, allowing the monitoring process to address any potential problem regarding nutrition. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were protected by a clear complaints procedure and by an open atmosphere that ensured both practical and procedural protection of people who used the service. EVIDENCE: The manager stated that there was a complaint from a relative of a user. This complaint was responded to by the complainant to her satisfaction. There was one referral to the Protection of Vulnerable Adults (POVA) scheme, but not directly related to the care practices or detriment to residents. Six users of the service spoken to stated that they did not have any reason to complain. The staff were aware of the whistle blowing procedure and were prepared to report any potential malpractice. The staff attended training both on protection and safeguarding, and deprivation of liberty and the Mental Health Capacity Act. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offered a comfortable and nice environment where residents were deciding on decoration and furnishing, thus expressing themselves freely. EVIDENCE: The location of the home was appropriate for residents’ conditions. Safe, in a small local community, it allowed more freedom than would be offered in a busier, urban area. The garden was divided into a paved and grassed area, again offering better choice to residents. Resident spoken to confirmed that the majority of residents could use the garden either completely independently, or with staff supervision.
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 17 The designated smoking area reduced exposure to smoke for non-smokers, without depriving smokers of enjoying the garden at the same time whilst smoking. However, one bedroom window could be exposed to smoke with a specific wind direction and the staff, residents and the manager-owner would need to reconsider how to ensure that this did not happen. A shed outside was used for storage and helped keep the internal area of the home cleaner. The washing drying line outside the home also helped, making washing fresh. The owner explained that they were considering plans for relocating the laundry room, to free a bathroom that currently was used to access laundry room. A regular maintenance and renewal programme was done in consultation with residents and ensured respect for their wishes and suggestions. Current topic of quality assurance review was the environment and the owner hoped to get other suggestions from staff, from regular visitors and from residents on how to further improve the environment for residents. Three of seven residents spoken to were asked about cleanliness and all stated that the home was clean and odour free. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate staffing level, checks on new staff aid working practices ensured that residents were cared for by good staff in an organised and protective manner. EVIDENCE: Staffing rota was checked for the last 4 weeks. It showed appropriate staff deployment, in shifts organised according to the assessed needs and plans how to meet them. Thus the home had 5 carers in the morning and 4 in the afternoon. Three staff members were responsible for organising and conducting residents’ activities that resulted in well structured and stimulating time throughout the day. The very good, knowledgeable and skilled assistant manager ensured that stability was maintained even after the previous registered manager had recently left. The owner stepped in to ensure that the temporary unfilled manager’s position did not affect the day to day operation of the home. This arrangement also helped improve some areas of the work of the home, such as care plans, risk assessments and some others. Staff training was given necessary emphasis and provided good opportunity for individual staff development. The current training plan included renewed
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 19 training on POVA (Protection of Vulnerable Adults) for all staff who attended training more than 2 years ago. New subjects were also emphasised: Deprivation of Liberty and Palliative care. Recruitment procedure was respected and all new staff went through rigorous checks before starting work with residents. They attended mandatory and other training during their initial working time and before a full CRB (Criminal Records Disclosure) was received in respect of each new staff member. Three staff files checked showed that all necessary documentation was collected before staff were engaged to work with residents. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were protected by well organised and managed processes of care that were backed up by safe working practices, policies and a good recording system. EVIDENCE: Regular staff training after initial induction ensured that safe working practices and principles were respected and followed. Stability of the management, even when the previous manager left, by cover provided by the owner, ensured continuity of care for residents.
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DS0000027434.V377412.R01.S.doc Version 5.2 Page 21 Questionnaires for the quality assurance review were just distributed to residents and their families. This circle, as the manager explained, would concentrate on the environment. The owner-manager stated that the action plan would be designed when the results of the surveys were analysed. Residents spoken to about their money stated that they were happy with the current arrangement. The owner explained that no staff were signatories or controlled anyone’s financial matters. Social workers were involved in money management solutions for residents, thus ensuring good financial protection. The new supervision grid showed that supervision restarted again and showed the regularity of these supporting sessions. Safe working practices and appropriate policies ensured a good and safe place for residents to live in. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 22 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 X X X X X X 3 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 3 X 3 Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 23 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 OP10 Regulation 12 Requirement Residents’ dignity must be respected even when their health conditions deteriorate and reduce their ability to retain their independence. Timescale for action 30/10/09 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 OP19 Good Practice Recommendations The home should consider relocating smoking area so that nearby bedroom windows were not exposed to smoke. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 24 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk
We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Hickling House DS0000027434.V377412.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
