Inspection on 08/11/05 for Hilgay

This inspection was carried out on 8th November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hilgay 15/05/07

Hilgay 14/11/06

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 J Hough Unannounced Inspection 10.30 8 November 2005 th 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.V258927.R01.S.doc Version 5.0 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.V258927.R01.S.doc Version 5.0 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@higaycare.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.V258927.R01.S.doc Version 5.0 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 9th June 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.V258927.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 4 hours and the registered manager Judith Shearn was present at the inspection, and provided the information required. A tour of the premises took place and some of the resident’s rooms were seen. Records were examined with regard to the resident’s care plans and assessments, staff files, maintenance of equipment and systems, complaints and accident logs. Fourteen residents and three members of staff were spoken with to find out what it was like living and working in the home. Not all of the standards were assessed as part of this inspection. The last inspection carried out in June 2005 found that those standards were fully met by the home. What the service does well: What has improved since the last inspection? No medication is stored in the refrigerator situated in the cellar. The necessary medication is stored appropriately in a separate refrigerator. All food was stored, labelled and dated appropriately. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 6 One patio area had been cleaned of moss following the last inspection. 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. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 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.V258927.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 All the residents receive a statement of terms and conditions of the home. The staff are experienced and trained to provide a high standard of care to the residents. The home invites new residents to visit the home prior to moving in. EVIDENCE: Each resident has a statement of terms and conditions for living in the home that is signed and agreed on admission. The contract provides the resident with all the information about the home in relation to the fees, any extra costs, period of notice, care and services provided, and the rights and obligations of the home and the resident. The staff training records and a programme of specialist training for 2005 show that the staff have individually and collectively the skills and experience to provide a high standard of care to the residents. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 9 All residents thinking of coming to stay in the home are encouraged to visit the home and meet with the staff and other residents, and to view the environment, prior to making any decision to move in on a long or short-term basis. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 11 The health, personal and social care needs of the residents are fully met. A review of the method used for administering medication is needed. Wherever possible the home continues to provide care for the resident who is dying. EVIDENCE: Four of the resident’s care plans and assessments were examined and showed that a full assessment is carried out and a care plan completed which identifies the level of care and assistance the resident requires. The care plans seen were signed and agreed by the resident and reviewed on a regular basis. Nutritional and risk assessments were completed as necessary and the residents weight was regularly monitored. The residents said that the staff were very kind and caring and attended to all their needs allowing them to make choices on how things were done. The medication records were examined and the lunchtime medicine round was Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 11 observed. The medication records were completed on the computer in the home, taken from the resident’s prescription and signed by the member of staff giving out the medication. The method used for administration of medicines involves the medicines being re-dispensed from the original containers from the pharmacist and put into separate medicine pots with lids for each resident. Although the home has not experienced any errors using this method, the Royal Pharmaceutical Society guidelines state that medication should never be secondary dispensed for someone else to administer at a later time or date. A review of the administration of medication should therefore take place. The home endeavours to care for the resident who is declining in health and dying, unless there are strong medical reasons that prevent this. The home has a policy for death and dying, which is read and understood by all members of staff. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14 Visitors are welcome in the home. The residents are given every opportunity to make choices and maintain their independence as long as able. EVIDENCE: The home has a visiting policy that states that visitors are welcome at any time but to avoid mealtimes where possible. However, visitors are welcome to have a meal having given prior notice. The residents spoken with said that visitors were always made very welcome by the staff and they could entertain their visitors in the communal areas or in the privacy of their own rooms if they preferred. The home supports and encourages those residents who wish, or are able to deal with their own financial affairs to continue to do so. The home has a policy not to get involved with the financial affairs of the residents and for those residents who have no relatives information is available in the home on advocacy services. Some of the resident’s rooms were furnished with their own personal possessions and small pieces of furniture making their rooms individual to their requirements. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home has a clear complaints procedure. EVIDENCE: The home has a clear complaints procedure that explains the process for making a complaint and the timescales in which it will be responded to. The complaints procedure is displayed in the home and included in the Service User Guide. Not all the residents spoken with were fully aware of the procedure, but all said they would not hesitate to speak with the registered manager or a senior member of staff on any matters of concern. However, none of the residents spoken with had felt the need to complain, as they were all very happy with all aspects of the home. The complaints log was seen and no complaints had been recorded for some considerable time. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21,22,23,25 & 26 The home is clean, pleasant and comfortable for the residents. EVIDENCE: Some of the bedrooms offer en-suite facilities and there were a sufficient number of communal toilets and bathrooms to meet the needs of the residents. The home is adapted to suit the needs of the present residents with assisted bathrooms and grab rails situated in appropriate areas. The home does not have a hoist, as the dependency levels of the residents does not make this necessary at present. None of the washbasins had pre-set valves fitted but risk assessments were completed and the appropriate warning signs were displayed. All the baths had pre-set valves fitted and water temperatures were monitored and recorded daily. The home was clean and fresh in all areas and the laundry facilities appropriate for the needs of the home. The home has an Infection Control Policy that is discussed during induction training and the staff were seen wearing plastic aprons and gloves as needed. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 15 Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 29 There were appropriate numbers of staff on duty to provide the residents with the care they need. The recruitment procedure is not followed in all cases. EVIDENCE: The residents spoken with felt the staffing numbers were generally good and their calls for assistance were responded to within acceptable times. Staff spoken with said there was sufficient numbers of staff on duty to care for the residents, and at the busiest times the registered manager was available to give assistance when needed. The staff rota’s showed the level of staffing was maintained and the home did not employ any agency staff. The home encourages and supports the care staff to undertake NVQ training and six members of the care staff are qualified in NVQ level 2 in care and others are in the process of working towards the qualification. Domestic staff work daily and the cook covers 5 hours a day to prepare, plan and cook the meals. The evening meal for the residents is prepared by the cook and the care staff are responsible for heating and serving the food. Staff files showed that two members of staff working in the home are still awaiting the results of their Criminal Records Bureau check, due to one disclosure having been sent back and forth for amendments, and one member of staff reaching the age of 18. The registered manager is aware that any Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 17 future new members of staff should not commence work prior to having received a satisfactory CRB/POVA check. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36,37 & 38 As far as practicable the home protects the residents and staff from harm. The residents are given every opportunity to express their views about the home. The home is run with an open style of management. The staff are supported and trained for their jobs. EVIDENCE: The residents and staff said that the registered manager was very approachable and they would be happy to talk with her on any matter. The staff said that she often worked alongside them and included them in any decision making for the home. A quality review is given to the residents each year to find out their views on the services the home offers. Daily contact with the residents also gives them the opportunity to discuss any matters and a suggestion box is also made available. Insurance cover is in place against the loss or damage to the assets of the home and the valid insurance certificate is displayed in the entrance hall. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 19 The policy of the home is not to get involved with the financial affairs of the residents and this responsibility is placed with the relatives or an advocate where appropriate. Small amounts of spending money are handled for some of the residents and accurate records are maintained for all transactions. All the care staff receive formal staff supervision that includes the registered manager working alongside them together with one- to- one meetings. The resident’s care plans were stored on shelves in the office and all personal files for the residents and staff were securely kept in a locked filing cabinet. The maintenance records showed that all equipment and systems in the home were serviced and maintained within the appropriate timescales. All accidents, incidents and injuries were recorded and reported to the appropriate authorities. Staff training records and the training programme show that all staff are updated in fire safety, manual handling, and food hygiene. Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X 3 3 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 3 3 3 3 3 3 Hilgay DS0000014566.V258927.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP29 Regulation 19 Requirement Timescale for action 30/11/05 2 OP9 13(2) CRB/POVA checks are to be undertaken for all staff prior to commencing employment. (Previous timescale 9th August 2005) The registered person shall make 31/12/05 arrangements for the safe administration of medicines in the care home. 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.V258927.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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.V258927.R01.S.doc Version 5.0 Page 23 - 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!