Inspection on 14/11/06 for Hilgay

This inspection was carried out on 14th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hilgay 15/05/07

Hilgay 08/11/05

Hilgay 09/06/05

Hilgay 03/02/05

Hilgay 18/10/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Hilgay Keymer Road Burgess Hill West Sussex RH15 0AL Lead Inspector Mrs V Gay Unannounced Inspection 14th November 2006 09:00 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 Hilgay DS0000014566.V320258.R02.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. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilgay Address Keymer Road Burgess Hill West Sussex RH15 0AL 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) 01444 244756 judi@hilgaycare.co.uk Mrs Judith Hilary Shearn Dr Christopher Anthony Shearn Mrs Judith Hilary Shearn Care Home 36 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (35) of places Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 35 persons in the category OP and 1 named person in the category LD who has not reached the age of 65 8th November 2005 Date of last inspection Brief Description of the Service: Hilgay is a large detached house on the southern fringes of Burgess Hill within walking distance of the railway station, local shops and a church. Accommodation is provided over three floors with 28 single bedrooms and four double bedrooms 15 of which offer en-suite facilities. A passenger lift provides access to all floors. Facilities include two lounges, two dining rooms and a conservatory. There is a garden with patio together with parking facilities. The residents are able to stay for long term, short term and holiday stays. The owners of Hilgay are Dr. Christopher Shearn and Mrs Judith Shearn. The Registered Manager is Mrs Judith Shearn who is responsible for the day-to-day running of the home. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key Inspection, which took place on 14 November 2006 between 9am and 1-30pm. Prior to the Inspection, the previous inspection report was reviewed along with any correspondence received since the last inspection. Where there have been no changes the report remains the same. During the inspection the Inspector spoke with residents, and staff. Records in relation to care planning, meals, quality assurance, accidents, health and safety issues were reviewed. Relatives were present, and a visiting professional, all spoke highly of the home. Six residents were case tracked to ensure their needs were being met. These included new admissions and short stay residents. Six files for new staff members were examined as part of the inspection process. Residents praised the home in every respect. Comments included the following “ You couldn’t fault the care…staff are so good …it is so clean and fresh…and the food is of a good quality”. No requirements were made during this inspection. What the service does well: What has improved since the last inspection? Since the previous inspection a monitored dosage system has been implemented following advice from the Commission for Social Care Inspection Pharmacist. This will improve the safe handling, storage, recording and disposal of prescribed medication. A separate refrigerator is now used to store liquid medication, as advised by the pharmacist. All cooked food is now stored correctly, labelled and dated before being refrigerated. The surface of the patio area has been treated to ensure the safety of the residents. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 6 All staff have been issued with a handbook, in respect of the health and Safety policy which has recently been revised. 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. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prior to moving into Hilgay people are given sufficient information about what the home offers, to enable them to make a choice as to whether or not they want to live there. In addition before moving into the home, people are assessed, by a member of staff, in their own home or hospital whenever possible, to make sure they are suitable, and invited for a trial period. People know exactly what they can expect from Hilgay and what is expected from them. Hilgay does not provide intermediate care. EVIDENCE: Records showed a thorough assessment was undertaken prior to admission to ensure the home could meet individual needs. A relative told the inspector that prior to her Mother being admitted she had visited the home and spent time with the manager to ensure it was the right home for her mother. Another resident said, “ Staff are wonderfully kind…I couldn’t fault the care in any way…I have made a lot of new friends”. Residents said that their families Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 9 had received a Statement of Purpose and Service Users Guide giving full details about the home and facilities available. Staff members spoken with were able to demonstrate a clear understanding of each resident’s needs and special preferences. They were observed to go about their duties in a calm warm professional manner, which was appreciated by the residents. It was clear from discussion with the residents and observations made during the inspection that they enjoyed a good relationship with the staff. Records inspected were up to date and care plans had been agreed and signed by the residents. Each resident receives a written contract and terms and conditions of residency indicating what is included in the fees. A monthly newsletter is distributed to ensure residents know what is happening in the home. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social cares needs are recorded in an individual plan of care. Medication was being safely stored and suitably recorded. Residents said staff members treat them with respect at all times. EVIDENCE: Six care plans of residents admitted since the previous inspection were examined as part of the case tracking process. The inspector noted that entries made and information recorded complied with what the residents told the inspector during discussion. A dependency assessment tool and physical needs chart gave a clear indication of what assistance was needed and what residents could do for themselves. Residents were encouraged to remain as independent as possible within their own physical ability. One resident said “ The staff assist me in the morning, and put my clothes out to enable me to dress at my own pace, they really praise me and encourage me”. Another resident said no restrictions were imposed on him and that he was free to spend his time as he wished. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 11 Residents spoke highly of the attention given to them by the staff. One resident said, “ The night staff are so kind they answer my call bell promptly and are always kind and helpful”. “ My carer is wonderful she takes me to the dentist and opticians when necessary”. “The staff are wonderful, I dreaded having to come into a place like this, but it is fine”. “You can do what you want there are no hard and fast rules”. Care plans, report any changes in the resident’s health and well being. Equipment is in place to promote independence and assist residents with their daily tasks of living. Medication was securely stored and suitably recorded. The medication record was up to date and the senior member of staff had duly completed and signed for the early morning drugs round. Residents who choose to manage their own medication would be encouraged to do so following a risk assessment. No resident currently manages his/her own prescribed medication. Staff were seen to knock on residents doors and to wait before entering. Residents care plans showed that GP’s visited by request and other health related services were provided. Three visitors said the home was good and the staff were very willing. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Hilgay are able to make the day-to-day decisions about how they want to live their life. There are activities for those who wish to participate, and residents are encouraged to maintain contact with all their old friends and family wherever possible. The food is of a good standard, and offers a choice of menu. EVIDENCE: A newsletter informs residents of forthcoming events, together with weekly programmes which are displayed on the notice boards. Good practice was observed, that staff also remind residents daily of what’s on in the home. On the day of this unannounced inspection residents were having their hair done in the homes hairdressing salon. There was plenty of laughter with residents putting the world to rights. Residents said they could furnish and personalise their rooms. Residents have the opportunity to join in exercise classes, bingo: art and craft classes. Residents said they are encouraged to maintain contact with their old friends and family wherever possible. A visitor’s book showed that the home had several visitors. Outings are not available, but residents able to go out unescorted do so. A resident recently admitted to the home said she found it very comfortable and everyone was kind and accommodating. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 13 Meal times are served in the dining room or in the residents own room. The main meal served during the inspection offered a choice between minted lamb and tomato roulade served with swede, broccoli and sautéed potatoes. The servings were generous and the meal appeared appetising. One resident said although food was not a priority to her they “ did their best and meals were varied and generally plentiful”. The inspector noted that residents are offered extra servings if they wish. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents said the management team listens to them. Training sessions for staff, a complaints book, plus policies and procedures regarding abuse, ensure that, as far as is possible, the people who live at Hilgay are protected from bad practice. EVIDENCE: There is a complaints procedure included in the Statement of Purpose and Service Users Guide. Residents spoken with said they knew who to complain to should the need ever arise. Residents meetings and Quality Assurance surveys encourage residents and their families to comment on the standard of service. Examples seen showed that if a concern was raised then action was promptly taken. Staff members had received training in Protection Of Vulnerable Adults as part of the National Vocational Qualification level 2 and 3, or it is covered during inhouse training sessions. The Registered Manager confirmed that any incident or allegations of abuse would be dealt with following the correct procedure. No complaints have been received and no adult protection issues are pending. All staff have Criminal Records Bureau enhanced checks done before working in the home to ensure they are safe to work with vulnerable people. It was noted that two references were missing from files examined, and the administrator confirmed that she had telephoned the referees, who would re issue them. Until such time the staff members are working under supervision. Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 15 Hilgay DS0000014566.V320258.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. There are no locks on bedroom doors. Standards of hygiene and cleanliness are high throughout the home. EVIDENCE: The home was extremely clean, welcoming and comfortably furnished. Residents spoken to commented on the cleanliness of the premises. The home has two lounges, a conservatory, two dining rooms and an attractive garden for residents to enjoy. Bedrooms were noticeably clean, well decorated and furnished. Bedrooms do not have locks, but all residents or their representatives have signed to say they do not wish to have locks on their doors. However, when a new resident enters the home they should be offered the choice of being able to lock their bedroom door, not only to safe guard their personal belongings but to promote privacy. All residents have lockable drawers in their rooms in which to store personal Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 17 items, although residents are discouraged from bringing items of value into the home. When asked about her bedroom, one resident said, “I am very comfortable…. I have a private bathroom.” Another resident said, “It’s a friendly place.” Residents spoke highly of the homes facilities. One resident said, “she had lived at the home for a year and she was fully satisfied. Another resident said, “ I just could not be better cared for”. One gentleman said he preferred his own company, and the staff respected this. One resident said she would like to change her room and the manager had agreed that when one became available, she would have the opportunity to move. The Fire Service last visited the home in September 2003 and assessed that the fire safety measures were being satisfactorily maintained. The manager confirmed that regular training is provided, in what action staff must take in the event of a fire. Hilgay DS0000014566.V320258.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hilgay is adequately staffed with employees who appear competent to care for older people. National Vocational Qualification is on going and further development training is expected. All training is recorded on staff member’s files. EVIDENCE: Recruitment was an area that was found to be in need of improvement at the previous inspection. The manager confirmed that procedures had been reviewed, and all staff have Criminal Bureau Record checks to ensure they are suitable to work with vulnerable people. Staff files examined supported this. The inspector saw the duty board and asked residents if there were sufficient staff for the help and support they needed. Residents confirmed that staff were always available and willing to help. The home was sufficiently staffed on the day of the inspection. Records and discussion with residents and staff showed that there was a nucleus of long serving staff that knew the residents needs and wishes very well. Six new staff had been employed since the previous inspection and these files were examined. They were found , apart from the two references previously mentioned to comply with Schedule 4 regulation 17 (2) of the Care Regulations 2000. The duty rota confirmed who was on duty and showed where cover had been arranged. The staffing arrangements of the home were discussed with the residents and a visiting relative. Comments received included the following: Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 19 They are wonderful…nothing is too much trouble…they are very kind to me during the night…always answer call bells promptly in a respectful manner” A relative made a special point of praising the home, and staff team. A visiting professional said the “staff had a good attitude”. New staff members receive induction training and have the opportunity to attend training in all mandatory subjects after a probationary period of employment. A staff meeting was being held on the morning of the inspection and minutes were taken. 14 the staff have obtained National Vocational Qualification level 2 or 3 and others are undergoing training. Five members of staff are training to become registered nurses. A programme of staff training and regular supervision has been planned for this year. Hilgay DS0000014566.V320258.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced, well qualified and professional manager. Records needed for the safe running of a care home are kept up to date. Policies and procedures are available for staff members to refer to, to ensure the safety of the people who live and work at Hilgay. EVIDENCE: Mrs Shearn is an experienced nurse and has worked for seventeen years as registered provider / manager of Hilgay. In 2004, she obtained the National Vocational Qualification Level 4 in Management. Mrs Shearn was present throughout the inspection. The home has no dealings with the resident’s finances; this is usually dealt with by a family member or solicitor acting on their behalf. Residents and staff said they found the manager approachable and sensitive to their needs. Comments from staff on duty included the following: Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 21 “Nice place to work…training is available in relevant topics…the manager is always available and is approachable.” Record keeping in general is of a good standard, although the following issues need to be addressed. References must be received for all new staff prior to them commencing work and any incident affecting the well being of a resident must be recorded to ensure their protection. The manager informed the inspector that fire safety and health and safety procedures are being reviewed to take into account the recent changes in legislation. Hilgay DS0000014566.V320258.R02.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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 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 X X 3 Hilgay DS0000014566.V320258.R02.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hilgay DS0000014566.V320258.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Hilgay DS0000014566.V320258.R02.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!