Inspection on 16/07/08 for Hilcote Hall

This inspection was carried out on 16th July 2008.

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

Hilcote Hall 02/07/09

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

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Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Hilcote Hall Stone Road Eccleshall Stafford Staffordshire ST21 6JX Lead Inspector Rachel Davis Unannounced Inspection 16th July 2008 09:45 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 Hilcote Hall DS0000070843.V368179.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. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilcote Hall Address Stone Road Eccleshall Stafford Staffordshire ST21 6JX 01785 851 296 01785 851 853 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) Select Health Care (2006) Limited Mrs Lorraine Osbourne Care Home 44 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (44), Physical disability (2) of places Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Older People (OP) 44 Dementia (DE) 18 Physical Disability (PD) 2 The maximum number of service users to be registered is 44 2. Date of last inspection Not applicable Brief Description of the Service: Hilcote Hall is a care home registered to provide residential care for 44 older people; there were 37 people in residence on the day of inspection. The needs of the people who may wish to live at Hilcote Hall range from old age to dementia or a physical disability. The home can accommodate 18 people with dementia and 2 with a physical disability and staff are trained in these areas of need. The registered provider is Select Healthcare Ltd. who has overall responsibility for the home; the registered manager is Lorraine Osbourne. Information about the fees for this service were not available as needed, fees must be recorded in the service user guide but presently people will need to enquire directly to the home to obtain this information. The home provides accommodation on three floors in a mixture of single and shared rooms. Communal areas are sited on the ground floor; there is one dining room and a Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 5 number of lounge areas. Suitable facilities are available for people who use the service to sit outside and enjoy the surrounding countryside. The home lies just over a mile from the local shops and services of the town of Eccleshall. A reduced bus service passes the home, and the nearest railway station is Norton Bridge, about two and a half miles away. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people who use this service experience adequate outcomes. This unannounced inspection took place over 7.5 hours; it was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This was a ‘Key’ inspection; during a ‘Key’ all the core standards are assessed. Another inspector came to the home for approximately 2.5 hrs and completed a Short Observational Framework Inspection (SOFI). SOFI is designed to give us an opportunity to record our observations during the inspection of care homes where people have dementia or severe learning disabilities. It can enable us to look closely at practice issues and observations; it is used illustratively alongside other evidence. SOFI offers first hand experience of sitting alongside people who use the service for a couple of hours in a communal space within the care home. It gives an insight into their general well being during this time, and also into the staff interaction with the people who use the service. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent, good, adequate or poor based on findings of the inspection. Prior to visiting the home on this inspection, survey information was completed and returned to us by people who use the service and their relatives but disappointingly no questionnaires were returned by the staff group. During this ‘Key’ inspection we looked at the life people are able to lead and whether their health and personal care needs are being met. We also looked around the home to see the standard of the accommodation. We looked to see whether people who use the service are being protected and the arrangements the service has for listening to what people think about Hilcote Hall. During the visit we met and spoke to a number of people living in the home and members of staff. There were no visitors during our time there. Observations were made of staff and resident interaction around non-personal care tasks, at lunchtime and during the Short Observational Framework Inspection (SOFI.) Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 7 Our inspection reports can be obtained directly from the provider or are available on our website at www.csci.org.uk What the service does well: What has improved since the last inspection? Due to a change of registered provider this service is considered a new service and therefore this ‘Key’ inspection is their first under the new registration details. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 8 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. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 9 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 Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 10 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): 1 and 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. More written information is needed to ensure people who use the service and prospective residents can make an informed choice about the home. Prospective people who use services have a needs assessment carried out before they are admitted to the home. EVIDENCE: The service has a statement of purpose and service user guide, which set out the aims and objectives of the home, and include information about the service. The Service User Guide needs to be reviewed and include the fees payable. There was evidence to verify that the Service User Guide was made available to people who use the service. When asked in questionnaires: Did you get enough info regarding home before moving in? Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 11 1said yes and 1 said no. Hilcote Hall should consider developing their statement of purpose and service user’s guide specific to the resident group and consider the different styles of accommodation, support, treatment, philosophies and specialist services required to meet the needs of people who use the service. The information should be in a format suitable for them and their families’ needs, using, for example, appropriate language, pictures or Braille. The home should be as open and transparent as possible and offer diverse information to prospective people about gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. They should also be clear of what is or is not available, offering such information then enables prospective users the opportunity of making an informed choice as to whether they would be happy with these arrangements. The care records for a number of people who use the service were checked and contained the needs assessment as required, pre admission documentation is sound and offers appropriate opportunities for the manager to assess whether Hilcote Hall can meet the needs of the prospective user. Hilcote Hall is developing a key worker system, having a named worker will help individuals feel comfortable in their new surroundings, and enables people who use the service to ask any questions about life in the home. It should also encourage and help the staff to develop a person centred approach to care. Standard 6 is not relevant to this home and therefore not assessed. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. Plans of care record information on how to give support and keep people who use the service safe. Medication systems and administration practices identify that people cannot be confident they will receive the proper medication in a safe manner. EVIDENCE: We looked at three plans of care and spoke to these people (and others); a plan of care had been developed and reviewed for all. There was evidence to confirm one individual had been involved with the development of their new care plan. The manager confirmed this will be the new format for all the people who use the service and they are presently working hard to achieve this goal. New plans will contain succinct information around areas of need such as personal care, recreation, nutrition, spiritual needs, sexuality, life skills, hobbies etc. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 13 The plans of care include an assessment of risk for moving and handling and any other identified area of need. The information on how to manage this risk is then recorded on the plan of care and subsequent reviews where necessary. On the whole people feel the delivery of personal care is flexible, consistent and reliable. They verified the staff and the manager are approachable and they could talk to them at any time. As part of the inspection process we examined the medication storage areas, the records kept and had discussions with the care staff and people who use the service. We found that on the whole the recording the receipt of medicines into the home was occurring. However, the audit sampling process showed that some people were not receiving their medication as prescribed by their doctor. The audit process showed that one Medicine Administration Record (MAR) chart had only recorded a medicine 3 times a day when it was required 4 times a day. We also found other poor practice issues with the MAR charts and these included some gaps where staff had not signed to say whether or not the medication had been administered, where variable doses have been prescribed the records did not always show what quantity had been given. We also found that creams and eye drops stored in the fridge and prescribed to individuals were not recorded on the Medication Administration Records, this means there is no audit trail to evidence whether or not the creams or eye drops have been applied. Staff were seen recording ‘not required’ on the Medication Administration Record chart when the person requiring the medication was not asked. This means decisions and judgements are being made by the staff members administering medicines without consulting the people who use the service. We found that appropriate risk assessments and care plans were not in place to ensure that medication was administered safely and correctly, for example, there was still little or no information available to ensure that medication prescribed as “when required” was given correctly and safely. Plans of care are lacking information about medicines that have been prescribed on an as when required basis. The home needs to ensure they have been offered clear guidelines on the amount of medication required, and under what circumstances when the prescription reads: “ take one or two tablets as and when required”, this should then be suitably recorded. The maximum and minimum temperatures of the fridge are not being recorded on a daily basis, this needs to be undertaken to ensure medications are stored within the correct temperature range. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 14 We found that the staff who administered medication to the people who use the service had received training on the safe handling of medicines. We found the staff are not receiving recorded ongoing assessments for their competency to handle and administer medication safely. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 15 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 adequate This judgement has been made using available evidence including a visit to this service. The home needs to become more flexible in providing opportunities for interaction within the current staffing and resources. Some activities and stimulation are in place but they need to be improved upon to further stimulate people living at Hilcote Hall. EVIDENCE: The home is introducing a key worker system, which will enable closer resident staff relationships where likes, dislikes and needs can be shared and should be recorded. Hilcote Hall does not employ an activities coordinator. Presently there are no individuals in residence from the ethnic minority groups or anyone with specific religious needs. People who use the service were asked: Are there activities arranged that you can take part in? 1 said never and 1said sometimes. On speaking with the people who use the service it appeared that the television and reading were the main sources of day-to-day stimulation. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 16 Comments made included: “I do get bored yes.” “We used to have a volunteer who would take us out but we don’t have that anymore.” “The talking newspaper stopped, I don’t know why.” “ I would enjoy some more things to do.” The manager has recorded under this section on the Annual Quality Assurance Assessment (this is a legal document that must be completed by the home for the Commission for Social Care Inspection) that, “We need to look at new ways to encourage service users that are reluctant to participate in activities to take part.” It also states: “We now have the use of a minibus on a Thursday afternoon so are able to take the service users on trips out and there has been more entertainment within the home itself.” The manager told us the home does offer entertainment from an external source every week, usually at the weekend. What we consider necessary is an increase in the day-to-day interaction and stimulation for the people who use the service. As a result of the Short Observation Framework Inspection (SOFI) the subsequent evidence was available. This part of the inspection was carried out in the large lounge toward the middle of the home between 10:05 and 12:05. We continually observed 3 people during these 2 hours; no member of staff came to check the residents or supervise this area at any time. Staff only came in to complete tasks such as bringing in a cup of tea, removing breakfast dishes etc. One member of staff did remain to support a resident to drink their tea. Staff were polite and respectful but seemed in a hurry, therefore people who use the service did not get the interaction or responses they wished for. The television was on for the whole time but no one was watching it. Sometimes members of staff who did come into the lounge area did not speak, when other members did speak the 3 people observed became animated, responsive and engaged, and it was clear they enjoyed this interaction. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 17 On one occasion 2 members of staff were assisting someone into a wheelchair the resident sitting aside them made obvious attempts to talk but neither staff member responded. During this manoeuvre the person who uses the service was not moved and handled by staff in the way recorded within the plan of care, this potentially puts people who use the service at real risk. We offered immediate feedback to the manager following this two-hour observation. There is a requirement to revisit the activities and stimulation provided, especially for those with more complex needs, this is to ensure a high quality of life is offered to all the people who use the service. We also require the manager to ensure staff move and handle people as assessed. The manager reported that links with the community are forged and the home has an open door policy. We spoke to the cook and can confirm the kitchen is well maintained, it was clean and tidy, crockery and cutlery were of a suitable standard. Food supplies are plentiful and fresh fruit and vegetables are available. The cook is not recording the fridge temperatures as required but is recording the temperature probes. The home has one dining area and lunch is relaxed and informal. The people who use the service considered the food to be good: “It’s good, I like it.” “The meals are always nice.” “ I can have an alternative meal if I don’t like it.” We observed lunch being served and alternatives were seen, a record of what was on offer is usually written on the menu board. When we asked, the majority of people did not know what was for lunch. The home should consider various ways in which to advise the people who use the service on what is for dinner dependant on their level of need. Staff were seen assisting people who use the service at lunchtime in a discreet and sensitive manner. The home should consider providing aids to support people who use the service with eating for example plate guards and large handled cutlery. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 18 Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are given information about how to complain and know who to speak to. EVIDENCE: The recruitment of staff to Hilcote Hall follows the requirements and therefore people who use the service are protected from abuse in this area. Two safeguarding alerts received by us have been investigated appropriately and are now concluded. We have not received any formal complaints about the home since their registration. Hilcote Hall has received four complaints and these are recorded within the logbook, the manager has recorded the date, investigation and outcome, from the records we saw it was clear that action has been taken. The complaints procedure sited in the entrance hall offers clear information but it needs updating to refer to the Commission for Social Care Inspection and also our new address at Paradise Circus. Information within the Statement of Purpose and Service User Guide has been updated. Questionnaires revealed 1 person knew how to complain and 1 did not. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 20 When we talked to the people who use the service they confirmed they would feel comfortable in approaching the manager, should the need arise. Hilcote Hall also has an informal suggestions box and it is available by the visitors signing in book. People who use the service and their relatives are free to write their comments at any time. From the records available on the day of inspection it was clear that the majority of staff require training in the recognition of adult abuse. The manager confirmed this training was part of the mandatory programme but dates are not set, this needs to be addressed. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 21 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, 21 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some refurbishment is needed but the home does provide a physical environment that is appropriate to the specific needs of the people who live there. EVIDENCE: Overall Hilcote Hall is clean and comfortable and has a homely feel however; some communal areas, toilets and bathrooms, carpets, curtains and fittings are in need of upgrading. For example some bathrooms appear to be used as storage areas and are without blinds or curtains, some paintwork is chipped and some carpets are in need of replacement. When asked: Is the home fresh and clean? Four people who use the service responded usually and 1 said always. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 22 The lounge area for people with dementia related conditions, (this is where we undertook the Short Observational Framework Inspection (SOFI) does not have carpet, it has cushioned vinyl flooring. The room is not very homely or cheerful; seats are placed around the walls of the room with little visual stimulation apart from the television. The home has a designated laundry and this area is well organised, all clothing is individually returned to avoid misplacement. Laundry is being washed at the required temperature and dealt with correctly. We saw that red alginate bags are used and placed on a sluice cycle to ensure infection control standards are met. Other examples include: paper towels, liquid soap and personal protective clothing. One downstairs toilet contained an electric wheelchair, which made the toilet inaccessible. The shower room contained zimmers, a glideabout and walking sticks and other items such as incontinence wear and toiletries. Incontinence wear was also seen sited on the back of the toilets and this implies communal usage. Where toiletries are not locked away a risk assessment needs to be in place to ensure safety for the people who use the service. The home employs a maintenance person who carries out any required maintenance on an ongoing basis; these records were not checked on this occasion. Some bedrooms were seen during this visit and were personalised to reflect their interests, families and lifestyle, care plans included information on offering people who use the service lockable storage, extra seating, double sockets etc to ensure that they had been offered all the necessities that they may require. It became evident during the inspection process that someone required a lockable facility but did not have one; this was fed back to the manager to address. There is a large garden to the property, it is well maintained and offers stunning views of the countryside; the people who use the service with more complex needs are able to enjoy the outside within a secure and safe area. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 23 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 adequate This judgement has been made using available evidence including a visit to this service. The manager ensures Hilcote Hall is staffed at all times by a sufficient number of trained personnel but there is evidence to confirm outcomes for people who use the service need to be improved. EVIDENCE: Hilcote Hall has a recruitment procedure that meets statutory requirements and keeps people who use the service safe. Two staff files examined demonstrated that a thorough recruitment practice is in place, this includes two written references, criminal records bureau checks, application forms that cover gaps in employment history and the required identification certificates and health declaration. Male staff are recruited to the home, which promotes equality and choice. The manager confirmed staffing has been particularly difficult over the past month or so. The deputy manager, cook, some care staff and the administrator have left, but a recruitment drive has taken place and this situation should soon be resolved. There is acceptable use of any agency or temporary staff which doesn’t adversely affect the quality of the individual care and support that people receive. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 24 People who use the service are generally satisfied that the care they receive meets their needs, but there are times when they may need to wait a short time for staff support and attention. Differing information was offered to us: “They are too busy I have to wait.” “ I waited from 06:15 until 08:00 for a cup of tea.” “Everyone is nice.” “The don’t always communicate with us, for example I was just left at the lift they disappeared I had to wait for someone to come back.” “The staff are very pleasant.” “The agency people have been very helpful.” The manager is confident there are enough staff to meet the health and welfare of people using the service however the manager is aware that time is not always used as effectively as it should be and confirmed she will address this shortfall. We became aware that night staff do not make regular records and recommend they record the times of their checks and any pertinent information, this will then offer the manager a clear audit trail. The service recognises the importance of training, and tries to deliver a programme that meets any statutory requirements but the manager is aware that there are some gaps in the training programme and plans to deal with this. Overall staff receive relevant training that is focussed on delivering improved outcomes for the people who use the service. None of the staff returned our questionnaires but reported during our visit that they are supported to meet the individual needs of people who use the service. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 25 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 good. This judgement has been made using available evidence including a visit to this service. The home must continue to evidence that it is run in the best interests of the people who use the service. EVIDENCE: The manager is in the process of completing the required qualifications and has the experience necessary to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 26 The annual quality assurance assessment (AQAA) is a legal document that all services have to complete on a yearly basis. All sections of the AQAA were completed and the information gave us a reasonable picture of the situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done or how it is planning to improve. The AQAA only gave us limited detail about the areas where they still need to improve and the ways that they were planning to achieve this are only briefly explained. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. The home works to a clear health and safety policy. All staff are fully aware of the policy and are trained to put theory into practice. Regular random checks take place to ensure they are working to it; however, these are not recorded so therefore the supporting evidence is unavailable. The home has a statement of purpose that sets out the aims and objectives of the service. The manager knows she needs to improve and develop systems that monitor practice and compliance with the care plans and policies and procedures of the home. Confidential information was not always stored appropriately and was discussed with the manager. Staff files and discussions confirmed supervision is fairly regular, team meetings and residents meetings are also held. The manager is aware of the need to publish the outcomes of the homes quality assurance. People who use the service need to be made aware of this evaluation and how the service is improved following their input. Monies were checked and all records and receipts tallied, people who use the service can be confident their allowances are stored and managed suitably. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 27 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Not applicable 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 OP1 Regulation 5)(1)(bb) (bc)(c) Requirement Timescale for action 01/09/08 2 OP9 13(2) 3 OP9 13(2) 4 OP9 13(2) The fees must be included within the Service User Guide so people who use the service know the appropriate cost and what is and isn’t included. Appropriate information relating 15/08/08 to medication must be kept in risk assessments and/or care plans guaranteeing the staff know how to use and monitor all medication including “when required” and “variable dosed” medication. This will ensure all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. The records of the receipt, 15/08/08 administration and disposal of medicines for the people who use the service must be robust and accurate to demonstrate that all medication is administered as prescribed. All prescribed creams and eye 15/08/08 drops must be recorded on the Medication Administration Sheets thus evidencing when they have been applied. DS0000070843.V368179.R01.S.doc Version 5.2 Hilcote Hall Page 29 5 6 OP9 OP12 13(2) 16 (2)(n) 7 OP19 13(4)(a) 8 OP19 23(2)(l) 9 10 OP27 OP28 18(1)(a) 12(1)(a) 11 OP30 18 (1)(c)(i) 12 OP33 24 (2) Medication errors must be managed according to the homes policy. Activities and stimulation must be provided for all of the people using the service who wish to participate, including those with more complex needs to ensure a high quality of life for everyone. The manager needs to complete a risk assessment to ensure that the people who use the service are safe when toiletries are not stored in locked cupboards. Wheelchairs and walking aids must not be stored in toilets, this meant one toilet was not accessible to the people who use the service. People who use the service need to be confident their needs are met at all times. People who use the service are to be suitably handled and supervised at all times to ensure their health, safety and welfare. To ensure that people who use the service are protected, staff need to receive training and support for safeguarding adults and the agreed procedures for responding to any alert. A copy of the quality assurance report needs to be made available to people who use the service. This means they are then aware of the changes made following their contribution to this process. 15/08/08 01/09/08 15/08/08 15/08/08 15/08/08 15/08/08 15/09/08 15/09/08 Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 30 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 OP1 OP9 OP9 Good Practice Recommendations The home should develop a more user friendly Statement of Purpose and Service User Guide to assist people who use the service with diverse and/or complex needs. The handwritten Medicine Administration Record (MAR) charts should mirror the information displayed on the dispensing labels. Review and update plans relating to medication to make sure they reflect what choices people who live in the home are given about how their medicines are administered and their consent to the way in which staff administer their medicines. Where medication is administered and consent is not possible because of lacking capacity records must be made of the agreement that the way in which medicines are administered is in the best interests of that particular person. The fridge temperatures are monitored on a daily basis using a maximum and minimum thermometer to ensure that the fridge temperature is maintained at between 2 and 8°C when medication is being stored in the medication rooms’ fridge. All staff administering medication should undergo periodic assessments to ensure their ongoing competency to follow the home’s procedures correctly. To review the staffing structure so that people who use the service are provided with stimulation ensuring people have an opportunity to be involved in activities of their choice. The manager should ensure people who use the service know what is on offer at mealtime. The home should increase the variety offered over a 6week period if at all possible. Review the way in which meals are presented to offer people who use the service as much choice as possible. Consider ways to make the large lounge have a more ‘homely’ feel. Incontinence wear should not be used communally all people who use the service who require support have an individual assessment and therefore their products should be within their own room, not in a communal area. Night staff should record the times of their checks and any DS0000070843.V368179.R01.S.doc Version 5.2 Page 31 4 OP9 5 6 7 8 9 10 11 OP9 OP12 OP15 OP15 OP15 OP19 OP26 12 OP29 Hilcote Hall 13 OP37 pertinent information to offer a clear audit trail. The manager should offer more written evidence to corroborate her verbal statements. Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Hilcote Hall DS0000070843.V368179.R01.S.doc Version 5.2 Page 33 - 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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