Inspection on 22/03/06 for Hillbro Nursing Home

This inspection was carried out on 22nd March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillbro Nursing Home 22/11/07

Hillbro Nursing Home 12/09/06

Hillbro Nursing Home 01/09/05

Hillbro Nursing Home 17/12/04

Hillbro Nursing Home 21/06/04

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

CARE HOMES FOR OLDER PEOPLE Hillbro Nursing Home Holden Lane Baildon Shipley West Yorkshire BD17 6RZ Lead Inspector Steve Marsh Unannounced Inspection 09:30 22 March 2006 nd 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 Hillbro Nursing Home DS0000019896.V273200.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. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillbro Nursing Home Address Holden Lane Baildon Shipley West Yorkshire BD17 6RZ 01274 592723 01274 532699 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) Mr Ronald Berry Mrs Doreen Berry Care Home 42 Category(ies) of Dementia - over 65 years of age (41), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (41), Physical disability (1) Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the category of MD be used only for the persons named in connection with the variation applications That the category of PD be used only for the person named on the notice that accompanies this certificate. 1st September 2005 Date of last inspection Brief Description of the Service: Hillbro Nursing Home is situated in an elevated position in the village of Baildon, which is located on the outskirts of the city of Bradford. At the present time the home provides care (including nursing) for forty-two residents diagnosed with Alzheimer’s Disease (or other types of dementia), or a functional mental illness. The home is close to the shops and other facilities in the village centre and there is a car park to the front of the property. The older part of the building is imposing and dates back to the nineteenth century, retaining many of its original features. More recent extensions to the property have been added in a sympathetic manner and complement the original building. The home is accessible to residents/visitors in wheelchairs (side entrance) and there is a passenger lift available to the bedrooms and other facilities on the upper floors of the building. Bedroom accommodation is provided in both double and single rooms the majority having en-suite facilities. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection visit for the year ending 31st March 2006, and was carried out by one Inspector over approximately seven hours. The methods used during this inspection included the examination of records, observation of work practices, discussions with residents, staff and management and a partial tour of the premises. At the time of the inspection there was one ongoing adult protection investigation at the home, however since the inspection a second referral has been made to the Adult Protection Unit. The manager recently left the homes employment and until a new manager is appointed the deputy manager is responsible for maintaining the standard of care/service. Due to their illness some residents were unable to express their opinions and opinions of the care/service provided, however those that were able felt that the staff continue to provide a very good standard of care and attention. Comment cards were also left for the residents and relatives to enable them to share their views of the service with the Commission. Feedback was given to the senior management team at the end of the visit. Requirements and recommendations from this inspection are detailed at the end of the report. What the service does well: The home continues to provide a warm and comfortable environment for the residents and the staff team appear caring and approachable. Residents are encouraged to make as many decisions and choices as possible in relation to their daily lives and maintain strong links with family and friends. Relatives confirmed that they are always made to feel welcome when they visit the home and kept informed of any significant changes in the resident’s health and/or general well being. All concerns/complaints are taken seriously and action is taken to resolve matters. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 6 What has improved since 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. Hillbro Nursing Home DS0000019896.V273200.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 Hillbro Nursing Home DS0000019896.V273200.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): These standards were not assessed on this inspection visit. EVIDENCE: These standards were not assessed on this inspection visit. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 11 Care plans are completed to a good standard and give clear guidelines to the staff on how to meet the individual needs. However, the nursing staff must ensure that failing to follow standard policies and procedures and poor record keeping does not compromise the residents’ healthcare. EVIDENCE: Care plans are in place for all residents and cover all aspects of their health and general welfare. The care plans are reviewed at least monthly or sooner if the resident’s needs change significantly. The six care plans reviewed were completed to a good standard and there was evidence to show that the residents and/or relatives are involved in the care planning process. However, on reviewing the records relating to two residents recently admitted to the Accident and Emergency Department concerns were raised about the length of time it had taken the qualified nurse on duty to call for an ambulance. Concerns were also raised about the standard of reports completed by the nurse at the time of the incidents as they were unclear and appeared to be inconsistent. In addition, a second nurse had failed to record old bruising Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 10 observed on the resident prior to the incident and there was nothing in the day and night reports to indicate what had caused the bruising or when it had occurred. The incident had been referred to the adult protection team and a senior member of the management team has already carried out an internal investigation. However, in view of the new findings brought to light during the course of the inspection the manager was requested to look at the matter again. All residents are registered with a general practitioner and have access to the full range of NHS services. The input of other healthcare professional is clearly recorded in the residents care plans and specialist equipment is provided if required. The deputy manager confirmed that at present no residents self medicate although new admissions to the home would be encouraged to do if they had the capability. On reviewing the medication system in place no discrepancies were noted. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 the following standard(s): 14 Residents are encouraged and supported to make informed decisions and choices about their daily lives for as long as it is practical for them to do so. EVIDENCE: The daily routines appear flexible and the staff confirmed that the residents are encouraged to make as many decisions as possible in relation to their daily lives. Due to the nature of their illness residents are unable to manage their own financial affairs, however residents and/or relatives are made aware of external agencies that will act in their best interest if necessary. Residents are able to furnish their rooms with personal possessions if they wish to do so, although all soft furnishings brought into the home must be fire retardant. The deputy manager confirmed that access to personal records is in line with the Data Protection Act 1998. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 There are robust policies and procedures in place to protect the residents, however the registered provider must ensure that the present adult protection issues are thoroughly investigated. EVIDENCE: The home has a complaints procedure and the relatives spoken to said that if they had any concerns they would feel able to raise them with any of the senior staff team. They were also confident that their concerns would be taken seriously and resolved without them having to make a formal complaint. The deputy manager confirmed that no formal complaints had been received since the last inspection. Adult protection policies and procedures are in place and the deputy manager confirmed that staff receive appropriate training. There is an ongoing adult protection investigation at the home, which has not yet reached a satisfactory conclusion. Staff spoken to appeared aware of the home’s policy on “whistle blowing” and were able to detail what they would do if they felt any practices were not in the residents best interest. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 Some areas of the home continue to require refurbishment to improve the standard of accommodation and facilities available to the residents. EVIDENCE: There is a planned programme of refurbishment and over the past two years considerable work has been carried out to improve the environment. Unfortunately due to unforeseen circumstances the home has not been able to complete the work within the agreed timescales. The registered providers have therefore been requested to provide the Commission with a new schedule of work. Communal areas and bedrooms that have been refurbished are bright and airy and the proprietors are committed to providing the same standards throughout the home. Smoking is not allowed in the communal areas or bedrooms but there is a small smoke room on the ground floor, which is used by residents and staff. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 14 The standard of cleanliness and hygiene throughout the home was found to be good and no unpleasant odours were noted. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 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 and 30 To safeguard the residents the registered providers must ensure that two written references are obtained for all staff prior to employment. Although the level of training made available to the care staff is sufficient to meet the residents needs, more emphasis must be placed on providing NVQ training. EVIDENCE: A staff rota for the week of inspection was taken and showed that sufficient staff are employed on both day and night duty to meet the needs of the residents. There are also sufficient catering and cleaning staff employed to ensure that the residents dietary needs are met and the home is kept clean and free from unpleasant odours. There appears to be a good skill/experience mix within the staff team and care staff confirmed that they were well supported by the qualified nurses. The home has a robust staff recruitment and selection procedure in place, which includes formal interviews and Criminal Record Bureau checks. However, on reviewing the employment file for one recently appointed member of care staff it was noted that only one written reference had been received prior to them starting work. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 16 The deputy manager confirmed that all new staff receive induction training. Additional training both to meet the needs of the residents, and for personal development continues to be encouraged. There is also an expectation that all members of care staff will study for a National Vocational Qualification (NVQ) at level two (or equivalent) although at present only two staff have achieved the award and no one is currently on the course. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 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 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): 31, 35 and 36, In the absence of a registered manager the home’s management and staff appear committed to maintaining the residents quality of life and the standard of care/service provided. EVIDENCE: The registered manager recently left and until a new manager is appointed the deputy manager will be responsible for managing the service, supported by the senior management team. The registered providers are however looking to appoint a manager on a temporary basis prior to the position being advertised and permanently filled. In the absent of a registered manager the home are to ensure clear channels of communication with the staff by holding regular staff meetings and formal one-to-one supervision will continue in line with the National Minimum Standards. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 18 In addition, the senior management team are available on a daily basis to answer any queries raised by residents, relatives or staff. Wherever possible relatives are encouraged to manage the resident’s financial affairs although Holden Grange Care Group will assist/advise in financial matters if requested to do so. Robust systems are in place regarding the safekeeping of resident’s money and valuables, which protects them from financial abuse. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff and they are reviewed on a regular basis. Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 19 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 3 X 3 Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 20 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 OP8 Regulation 12(1) Requirement The registered providers must ensure that all records/reports relating to the residents healthcare are recorded accurately. The registered providers must ensure that where appropriate referrals to the Accident and Emergency Department are made without delay. The registered providers must ensure that adult protection issue are thoroughly investigated. The registered providers must provide the Commission with a new schedule of planned refurbishment work. The registered providers must ensure that at least 50 of the care staff team achieve a NVQ at level two (or equivalent). The registered providers must ensure that two written references are obtained for all new members of staff prior to employment. The registered providers must ensure that in the absence of a DS0000019896.V273200.R01.S.doc Timescale for action 22/03/06 2 OP18 13(6) 30/04/06 3 OP19 23(2) 31/05/06 4 OP28 18 31/12/06 5 OP29 19 22/03/06 6 OP31 8 30/04/06 Hillbro Nursing Home Version 5.0 Page 21 registered manager suitable management arrangements are put in place at the 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 Hillbro Nursing Home DS0000019896.V273200.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Hillbro Nursing Home DS0000019896.V273200.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. 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