Inspection on 15/05/07 for Hilgay

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 14/11/06

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 Ms B Tye Unannounced Inspection 10:00 15th May 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hilgay DS0000014566.V336081.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. Hilgay DS0000014566.V336081.R01.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.V336081.R01.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 14th November 2006 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.V336081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined. This included a completed pre-inspection questionnaire by the manager, a staff list, rotas and training schedules, menus and notifications of significant incidents within the home. Eleven feedback forms were received by the inspector, which included comments from current residents, their relatives and two health professionals. During the course of the inspection the inspector spoke to some of the people living in the home, interviewed staff and spoke at length to the manager. A tour of the premises was undertaken. The inspector observed lunch being served and staff interaction with residents. Five care plans and staff personnel files were examined alongside the homes records including, staff training, complaints, fire, incident and accident reports and all records relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter What the service does well: What has improved since the last inspection? At the last inspection a recommendation was made to ensure two references are received in respect of new employees. Personnel files were examined and this standard has now been met in full. Records demonstrated that any incident affecting the well being of residents is now recorded in the accident book in full. This has now been implemented and records were up to date and relevant. Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 6 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.V336081.R01.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.V336081.R01.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): Quality in this outcome area is good. To ensure residents’ needs can be met appropriately by the home, the manager carries out a full assessment prior to admission. Each resident is provided with a written contract of terms and conditions, which is signed by all involved parties, so residents are clear about their rights within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A pre-admission assessment is carried out for all residents. Relevant correspondence from involved professionals was seen on care files. Five residents were case tracked during the inspection. Those spoken to confirmed they had received relevant information and either they or a representative had visited the home prior to admission. This enabled them to make an informed decision about what the home has to offer them. One resident stated ‘the home was recommended by my granddaughter and we looked round before I came’. All residents confirmed that in addition to a visit they were sent a Statement of Purpose and Service users Guide detailing Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 9 what was on offer at the home. One said ‘‘I visited but they also sent me information which was enough to help me decide’. The manager completes pre-admission assessments. This outlines relevant areas of need including; diet, communication, health, social and cultural needs. Additional information and correspondence by community based professionals is collated to form the basis of an on going care plan. This information is kept in resident’s files in a locked cabinet only accessible by care staff to ensure confidentiality. Each resident receives a contract of terms and conditions indicating what is included in the fees. Residents have a signed copy of their contract held on file. All records seen in respect of admissions are up to date and in good order. The home does not offer intermediate care. Hilgay DS0000014566.V336081.R01.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): Quality in this outcome area is excellent. All residents have a comprehensive care plan, which is reviewed and updated on a regular basis. Medication procedures are in place and staff receive medication training. This promotes good practice when dealing with medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans of residents were examined as part of the case tracking process. Case tracking and discussion with the residents confirmed good practice is upheld in the home. One resident said ‘We are looked after very well by the staff’. Another said ‘ all the staff are nice and polite, I am very well looked after here’. Each care plan contains relevant details relating to the residents health and social well-being. Information was up to date and easily accessible. The residents do not currently sign their care plans or monthly reviews. It was recommended that this practice would demonstrate the residents were involved in the planning of their care. The manager proposes to implement this at the earliest opportunity. Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 11 Staff are assigned key worker roles for each resident. Those spoken to were aware of individual needs and details of care plans. This demonstrates residents can be confident the staff have a good knowledge of their care needs. Comments from surveys returned by health professionals linked to the home stated ‘this is an excellent care service which maintains high standards of care’ and ‘staff are very helpful and efficient’. Residents are encouraged to maintain their independence where possible. Individual risk assessments held on care files support this. In relation to health and personal care needs, observation and feedback from residents reflected that they are treated with respect by staff, and their privacy and dignity is upheld. Any specialist health needs are referred to communitybased professionals via the GP’s. Correspondence held in individual files supported this. A Chiropodist visits the home on a six weekly basis. Staff receive medication training from a local chemist, who audits the homes medicines on an annual basis. The home has an up to date policy, procedure and code of practice relating to dispensing medication. Medication charts and storage of medicines within the home was examined. These were all completed correctly, demonstrating the staff adhered to the procedures within the home. Hilgay DS0000014566.V336081.R01.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): Quality in this outcome area is good. A range of activities is offered within the home. The meals are nutritionally balanced and varied according to dietary requirements and preference. Residents are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s visitors are welcomed to the home and feedback from residents confirmed that contact with family and friends are encouraged. A visitor’s policy is in place to support this. Activities are organised at the home on a regular basis, offering stimulation to those residents who are less able to explore interests outside the home. Group outings are not available but residents often go out with visitors or unescorted if they are able to do so. Forthcoming activities and events are displayed on the community pin boards in the home and advertised in the monthly newsletter. Of the five residents spoken to about activities, four stated there was enough to do and one said she did not have much interest in what was on offer. When discussing this with the manager, she stated that questionnaires are often sent out with the newsletter encouraging residents to state their preferences for Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 13 future activities. Planning would then include ideas and suggestions made. The home does not have an activities log, but staff use a daily diary to record which residents participate. Staff escort residents to community events and appointments as required. The menu offered at Hilgay offers a wide range of balanced, home cooked food. The home has recently employed an experienced chef and all feedback from residents stated the food ‘is really excellent’ and ‘the meals are super here’. The inspector observed residents taking the time following lunch to praise the chef. Specialist diet for diabetics and vegetarians are catered for and detailed in care plans. The chef speaks with the residents on a daily basis to offer a choice from the set menu and gain feedback about the meals provided. This promotes choice for the residents and provides an opportunity for them to eat what they prefer. Staff were observed knocking on rooms before entering and those seen speaking to residents demonstrated relaxed but respectful interactions. Resident’s feedback about the staff confirmed this. One relative stated ‘ staff really make sure peoples dignity is preserved’. Hilgay DS0000014566.V336081.R01.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): Quality in this outcome area is good. The home has provided residents with information in respect of complaints. Residents spoken to were aware of their rights and how to complain. Staff have received abuse training, and those spoken to were clear about appropriate action if they suspected abuse within the home. This judgement has been made using available evidence including a visit to this service. 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 and felt confident to do so to should the need ever arise. Regular questionnaires and Quality Assurance surveys encourage residents and their families to comment on the standard of service. The Commission has received no complaints since the previous inspection. The home holds a complaints log and six entries had been made since the last inspection. All were minor issues, which were dealt with promptly by management in line with the homes policy. All staff have undertaken a full induction and Adult Protection training to ensure they respond appropriately to suspected abuse in the home. A copy of the West Sussex County Council Multi Disciplinary Adult protection Policy is kept in the office for reference. The procedures for the recruitment of staff are robust and provide the necessary safeguards to offer protection to the residents living in the home. A Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 15 previous requirement has now been met to ensure all new staff have two written references prior to employment. All care staff have undertaken a Criminal Records Bureau enhanced check to ensure they are suitable to work with vulnerable people. Staff spoken to during the visit demonstrated a sound knowledge of how to act should an incident of suspected abuse arise. All stated they felt the management at the home was ‘supportive and approachable’ if there was an issue of concern they needed to discuss. Hilgay DS0000014566.V336081.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The communal areas of the home and residents bedrooms were clean and homely providing the residents with a pleasant and hygienic living environment. Specialist equipment is provided to maximise the independence of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following a tour of the premises and examination of the homes records it is evident the home provides a homely, well-maintained and safe environment. Standards of hygiene and cleanliness are very good throughout the home. There is a passenger lift for residents with limited mobility to access all floors of the house. Two of the resident’s surveys reported ‘the lift is unreliable’. The inspector spoke to the manager about this and examined maintenance records. It was reported that during the month of April the lift had broken down on a few Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 17 occasions due to a faulty part. However this has been fixed and the problem is now resolved. Records showed all fire, health and safety checks are regularly undertaken and up to date. All equipment is regularly serviced and certificates held on file. Staff and residents were spoken to, to gain an insight into what it was like to live in the home. It was evident that residents felt the environment was comfortable and clean. All expressed they like their rooms and were able to personalise them with pictures and items of furniture to achieve a sense of ownership. Provision of a bath grab rails and raised seating in toilets provide individuals with limited mobility more independence. All hot water outlets in the home are regulated. A call bell is provided in every room so staff are aware and can attend an emergency situation should it arise. Health and safety signs are posted throughout the home. Staff were seen wearing gloves and aprons and there was liquid soap available at each shared sink. The manager confirmed the staff undertake infection control training as part of their induction although this was not recorded. It was recommended that the training should be recorded on training records to demonstrate staff are knowledgeable in this area and their practice limits the spread of infection within the home. Hilgay DS0000014566.V336081.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The staff numbers are sufficient to meet the assessed needs of residents. An induction and training programme for staff is provided, to ensure resident’s needs are met in full. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments from surveys, feedback from residents, relatives and involved health professionals all highlighted the good practice undertaken by staff in the home. One resident said ‘they are wonderful and really look after us’. A relative stated ‘they should be praised for their friendliness and consideration’. Staff spoken to demonstrated commitment to delivering high standards of care and have the skills and experience to deliver this. The home is sufficiently staffed. There are two weekend vacancies for care staff, which have been advertised and are currently being covered by the team The majority of staff have been at the home for a number of years and during interview reflected a good knowledge of the residents care needs. Since the last inspection recruitment records have been updated and each staff member has two written references on file in addition to CRB checks and relevant documentation. The previous recommendation has now been met. Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 19 Recruitment policies and procedures are in place and records show they are adhered to. Staff files showed the staff attend an induction at the start of employment, followed by a range of courses specific to the care needs of the resident group. Fewer than 50 of the staff have attained the National Vocational qualification at present. Staff attend meetings every six weeks to discuss issues relating to practice and performance. These meetings are minuted and staff said ‘they are helpful and give us the opportunity to talk about important things to do with the home’. Hilgay DS0000014566.V336081.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Resident’s benefit from a well run home and are safe guarded by the homes policies, procedures and record keeping. The management of the home is competent and committed to the best interests and welfare of the people who live and work there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents live in a home that is run and managed by a person, who is experienced and able to discharge, her responsibilities fully. The manager has obtained the National Vocational qualification Level 4 in Management. Residents and staff spoken to fed back that they were confident in the manager and felt she was ‘very approachable and supportive’ enabling them to seek guidance, to ensure resident’s needs were met appropriately. Hilgay DS0000014566.V336081.R01.S.doc Version 5.2 Page 21 The home has comprehensive policies and procedures in place in line with current legislation to safeguard the interests and rights of the residents and staff. The homes insurance is up to date and the last inspection report from the Commission was displayed in an area accessible to residents and parties involved in the home. All care records are kept in a locked office to maintain confidentiality. The inspector examined all health and safety records including fire checks, accident book, maintenance checks, water temperatures, regulation 37 reports and risk assessments. All were found to be up to date and in good order. The Registered Manager confirmed that the home has no dealing with the resident’s finances. An annual development plan and quality assurance system is in place, which includes contributions from residents and their families. In addition questionnaires are sent out with newsletters to gain feedback from residents about aspects of the home. Use of consultation with residents, staff and their families ensure those providing and receiving care have an input into how the home is run. Hilgay DS0000014566.V336081.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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 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 3 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 X 3 4 Hilgay DS0000014566.V336081.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. 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. 1 2 Refer to Standard OP26 OP7 Good Practice Recommendations To record the staff training in the area of infection control For residents to sign their care plans and reviews to demonstrate their involvement in the process. Hilgay DS0000014566.V336081.R01.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.V336081.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. 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