Inspection on 09/06/05 for Hilgay

This inspection was carried out on 9th June 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 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 14/11/06

Hilgay 08/11/05

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 V Khan Unannounced Thursday, 9 June 2005 V229321 th 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 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 H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hilgay Address Keymer Road, Burgess Hill, West Sussex, RH15 0AL Telephone number Fax number Email 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 Dr Christopher Shearn and Mrs Judith Shearn Mrs Judith Shearn Care Home (PC) 36 Category(ies) of Old age, not falling within any other category registration, with number (OP) 35 places of places Learning disability (LD) 1 place Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 35 persons in the category OP and 1 named person in the category LD who has not reached the age of 65. Date of last inspection 3rd February 2005 Brief Description of the Service: Hilgay is a large detached house on the southern fringes of Burgess Hill. It is adjacent to a bus route and within walking distance of the railway station, local shops and a church. There is a main lounge, a quiet lounge, two dining rooms, a large conservatory, well planted gardens with patio areas and parking facilities. Accommodation is provided over three floors in single and double bedrooms, fifteen of which have en-suite facilities. A passenger lift enables residents to access the upstairs bedrooms and facilities. Residents are able to stay for long term, short term and holiday stays. The owners of Hilgay are Dr C and Mrs J Shearn. The home is managed by Mrs Shearn. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector started the unannounced inspection at 8.45 am, which lasted a total of four hours. The inspector spent time talking with residents and staff, walked around the home and garden, and read paperwork in the office. All service users spoken to during the inspection were happy with the care and services provided at Hilgay. Comments from residents included, “I’ve no complaints” and “I’d recommend anyone to come here.” The home was seen to be clean, tidy, warm and homely. What the service does well: What has improved since the last inspection? What they could do better: Ensure all medication needing refrigeration is stored in the designated refrigerator. Undertake a review on one patio area to ensure it poses no risk to residents’ safety. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 6 Review the staff recruitment procedure involving CRB/POVA checks to ensure the protection of service users. Ensure all cooked food is stored appropriately. 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 H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 A good selection of documents is available to prospective residents, their families and representatives, providing clear information about the home. Residents needs have been thoroughly assessed before moving in to the home to ensure their needs can be met at Hilgay. EVIDENCE: The Statement of Purpose and Service User Guide set out the aims, objectives and philosophy of care provided at Hilgay. Detailed information about the facilities and services on offer to residents and the terms and conditions are included. The home has also produced an attractive and informative leaflet with a photograph of the front view of the home. Records seen showed that good, comprehensive pre-admission assessments are completed. From the assessments, plans of care for daily living have been developed. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9, 10 Health, personal and social care needs of residents are taken seriously by staff. Residents’ welfare is closely monitored and their needs are well met. EVIDENCE: The records for six residents clearly described their care needs and how they were being met at the home. Care plan reviews had been undertaken regularly. Medication records were up to date. Some medication was being stored in the refrigerator in the cellar. The labels had worn away and the inspector was unable to read whom it was prescribed for. This needs to be reviewed by the manager as the home has a designated refrigerator for the storage of medication. Clear instructions were seen regarding any particular care needs that residents had, e.g. catheter care, nutritional screening, pressure sores. Care plans had assessments completed for handling, osteoporosis and mobility. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 10 Residents are able to register with a local G.P. of their choice. Residents are supported in attending hospital appointments and any other appointments in the community as necessary. Records are maintained of visits to the home by health and social care professionals. Staff were seen to be respectful of residents privacy and dignity. Any personal care is given in private and staff are sensitive to the needs of residents. One resident said, “Staff come to help me dress.” Residents preferred names are known by staff. Residents are able to use the home’s telephone, but twelve residents have chosen to install telephones in their rooms. Some bedrooms are large enough to be comfortably shared and screening is available if required. One service user commented, “I share a room, we have a laugh and get on well.” Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12, 15 Residents are respected and treated as individuals. Their individual, social, cultural, religious and recreational interests are respected and promoted. Residents receive a good choice of meals. EVIDENCE: Care plans record residents interests and their social, spiritual and occupational needs. Staff said that residents have choice about whether to join in an activity. When asked about activities in the home, one resident said, “we have a sing-song, bingo and quizzes.” One resident told the inspector he liked going out for walks. Another resident said she enjoyed being taken around the garden in a wheelchair by a member of staff. Some residents chose to have a mid-morning drink in their rooms, lounges or in the conservatory. Lunch on the day of the inspection was either steak and mushroom pie or vegetable casserole, followed by summer pudding or milk pudding. The cook said that the home uses meat, fruit and vegetables from local suppliers. One resident said, “It’s lovely here, the food’s good.” Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 12 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 standard(s) EVIDENCE: Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 24, 26 The importance of residents having access to comfortable communal facilities is promoted. Bedrooms are comfortable, clean and tidy, offering accommodation to meet residents’ needs. Hygiene is considered essential and is a priority in the home. EVIDENCE: The home was seen to be extremely clean, homely and comfortably furnished. Residents spoken to said the home is kept very clean and tidy. 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. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 14 All residents have lockable drawers in their rooms in which to store personal items, although residents are discouraged from bringing items of value into the home. When asked about her bedroom, one resident said, “It’s a nice room…. often change the sheets.” Another resident said, “It’s a lovely clean home.” One resident was seen accessing an outside patio area, which was slippery with moss. One staff member told the inspector that the gardener was due to steam clean this area. In the interim period, the use of this area needs to be reviewed to establish whether it poses a threat to residents’ safety. The Fire Service last visited the home in September 2003 and assessed that the fire safety measures were being satisfactorily maintained. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Residents are supported by caring staff. An appropriate number of staff are working at the home and there is an emphasis on regular training. The recruitment procedure needs to be reviewed to ensure that residents are protected. EVIDENCE: Four staff files were read during the inspection. The home had accepted for one member of staff, an enhanced CRB check from a previous job. One member of staff had recently started work on a supervised basis awaiting the return of the CRB, and one member of staff did not have a CRB check. All staff should have Criminal Records Bureau (CRB) and Protection Of Vulnerable Adult (POVA) checks completed by the home on appointment. Assumptions should not be made that checks staff have brought with them from their previous jobs are valid. A full programme of training is available to staff at the home. Examples from the 2005 training calendar include skin conditions and wound care, drugs and manual handling. Currently two members of care staff have completed NVQ Level 2 training in Care and one has obtained the NVQ Level 3 in Care. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 16 The staff duty rota was read and the inspector felt that staffing levels were satisfactory, with sufficient staff on duty at different times of the day to meet the needs of the residents. Staff spoken to, were clear about what was expected of them whilst on shift. Residents spoke highly of the staff team. One resident said, “The staff are very good, nice in every way.” Another resident commented, “The staff are good “ and “Everyone’s friendly.” Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38 The home is run by an experienced, well qualified and professional manager. Overall, the home promotes the health, safety and welfare of service users and staff. EVIDENCE: Mrs Shearn is an experienced nurse and has worked for fourteen years as manager of Hilgay. In 2004, she obtained the National Vocational Qualification Level 4 in Management. Mrs Shearn was not present for the inspection, but other staff members ably assisted the inspector. The cellar is kept locked and is used for storage. The inspector saw cooked cauliflower stored in the cellar refrigerator was not covered, labelled or dated. Mrs Shearn is advised to undertake a review of the cellar looking at the way food is refrigerated and the refrigeration of medication. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 3 x x STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x x 2 Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 (2) Timescale for action The registered person shall make 9th July arrangements for the recording, 2005 handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall undertake a review on the use of one patio area to ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. CRB/POVA checks are to be undertaken on staff by the home, before they commence employment. 9th July 2005 Requirement 2. 19 13 (4c) 3. 29 19 9th August 2005 4. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Hilgay Refer to Standard Good Practice Recommendations H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 20 1. 38 The registered manager ensures the safe storage of refrigerated food including the labelling and dating of stored food. Hilgay H60 H11 S14566 Hilgay V229321 090605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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. 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