Inspection on 16/08/05 for Hillbrook Grange

This inspection was carried out on 16th August 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

Hillbrook Grange 17/04/07

Hillbrook Grange 09/01/06

Hillbrook Grange 09/02/05

Hillbrook Grange 07/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hillbrook Grange Ack Lane East Bramhall Stockport SK7 2BY Lead Inspector Jackie Kelly Announced 16 August 2005, 09:30 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. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hillbrook Grange Address Ack Lane East, Bramhall, Stockport, Cheshire SK7 2BY 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) 0161 439 7377 0161 439 3880 None Bramhall & Woodford Old Peoples Welfare Committee Dawn Nixon Care Home 36 Category(ies) of OP - Old Age - 35 registration, with number DE(E) - Dementia - over 65 of places Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 36 OP and up to 1 DE(E) Registered Manager to be supernumary Date of last inspection 9 February 2005 Brief Description of the Service: Hillbrook Grange is a care home providing personal care and accommodation for 36 older people. The registration allows for up to one older person who may have a dementia type illness. The home is administered by Bramhall and Woodford Old People’s Welfare Committee and is a registered charity. Hillbrook Grange is located in the Bramhall district of Stockport and is close to local shops and other amenities, such as cafés, restaurants, public houses, banks, chemists and post office. There are also churches of differing denominations, a library, a selection of health centres, dentists and opticians. Stockport town centre, motorway network and public transport are easily accessible. The original Victorian house has had a small annex and a larger two-storey extension added. Two passenger lifts had been installed (one for each side of the house).The grounds are extensive, combining lawns, a small wood and flowerbeds. A number of benches are situated around the grounds for the service users and relatives/visitors to use. There is a car park to the rear of the building. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an annual announced inspection, which took place over two days. Time was spent talking with the chairperson of the home and executive committees, Mrs Hilda Renn and Mr Wilson the committee treasurer who is registered with the Commission for Social Care Inspection as the responsible person. Care workers and residents were also spoken with. Care plans, staff files, and drug administration records were looked at. A tour of the home took place. Questionnaires were sent to the home for the residents and relatives to complete; at the time of writing this report twelve resident and eleven relatives questionnaires had been completed and returned to the Commission. A completed GP questionnaire was also received. All of the questions were answered positively and no one had made a complaint. There were a number of comments written on the questionnaires; ‘I feel that she (my friend) is in a beautiful home where she is well cared for and safe’; the grounds are beautifully maintained’; ‘kind and caring staff’ were just a few. What the service does well: What has improved since the last inspection? The previous report of the 9 February 2005 had no requirements or recommendations. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 6 The home continues to be committed to providing a safe and caring environment for the residents. The home is open to suggestions from care workers, relatives and residents in order to make Hillbrook Grange a pleasant and safe place to live. 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. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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) 3,4,5. Standard 6 is not applicable. Prospective residents receive a full assessment that assures them their needs will be met. EVIDENCE: The home has an ‘assessment flat’ that all prospective residents are admitted to for two weeks. When the two weeks are completed the person goes home to consider their future. Should a person decide that Hillbrook Grange is for them and the home feels that they can care for the person they are then admitted into the home with a view to permanent residency. Mrs Hilda Renn the chairperson of the committee usually visited prospective residents before they were offered the initial two-week assessment visit. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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. The owners and care workers met the health care needs and privacy of the residents. Medication for the most part was handled safely. EVIDENCE: The care plans were for the most part satisfactory although there was some duplication with the forms that were being used. Information was recorded in a number of different places therefore the care staff must make sure that the care plan which is considered to be the main record is kept up to date and contains all information relevant to the residents care. The residents who were spoken with said that they were happy with the care they received; one resident said that it was ‘the best thing I ever did (coming to live at Hillbrook) – never regretted one second’, ‘staff knock and wait before entering your room’, ‘we are spoiled – nothing to grumble about‘. Medication records were looked at and had been completed properly. One resident was in charge of her own medication and a risk assessment had been done when the resident had been admitted. As this was some time ago it needs to be reviewed and updated; a review must be done on a regular basis. All risk assessments were not dated. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 10 Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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) 12,13,14,15 Residents were given choices so that they could maintain control over their daily life as far as their capabilities would allow. EVIDENCE: The chairperson Mrs Hilda Renn had given out the homes own questionnaires, for residents to complete. A suggestion box is situated in the main entrance. The residents who were spoken to on the day of the inspection were happy with the food. It was a set menu however should someone not like what was on the menu an alternative would be available. Mrs Renn had given out questionnaires, which had been provided by the Commission for Social Care Inspection to residents and relatives. The majority had been returned and all indicated they were happy with the home, well cared for and had no complaints. Mrs Renn visited the home every day and was available to talk with residents and relatives. Each resident was allocated a care worker known as a ‘key worker’ with whom the resident could also talk with on a personal and private level. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 12 Friends and relatives were welcomed at the home at all reasonable times of the day and evening. On the day of the inspection a number of relatives or friends were visiting the home. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 standard(s) 16,17,18. Bramhall and Woodford Old People’s Welfare Committee and the care staff protected the residents through the complaints procedure, training and daily monitoring of care workers. EVIDENCE: None of the residents or relatives with whom the inspector had contact with had any complaints. The home was not responsible for any of the residents’ finances. Training on the protection of vulnerable adults had been given to the care workers who had done the National Vocational Qualification in Direct Care Level 2. The policy and procedure regarding the investigation of complaints where there were allegations of abuse needs to be amended in line with the recent legislation for the Protection of Vulnerable Adults (POVA) and the POVA register. It is recommended that senior staff attend one of the courses provided by Stockport Social Services on the protection of vulnerable adults. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25,26. The home was clean, well maintained and decorated to a high standard. All furnishings, fittings and equipment were in good condition and suitable for the needs of the residents. EVIDENCE: The inspector looked round home which was comfortable, very well maintained and decorated, clean, and pleasant. There are a number of different areas on the ground floor where residents can sit to chat, read or watch television. The bedrooms that were seen by the inspector were well furnished and contained personal items. None of the rooms have an en-suite facility but there were a sufficient number bathrooms and toilets available. There are two passenger lifts one for each side of the home. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 15 The grounds are extensive and are used by the residents and their relatives, weather permitting. A full time gardener is employed. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 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) 27,28,29,30. The recruitment and selection methods used ensured that suitable care workers are employed. Experienced care workers looked after the residents. EVIDENCE: The rotas seen by the inspector showed that there were sufficient numbers of care workers on duty to meet the needs of the residents. The total number of care hours, which were put into the home each week, was higher than the minimum, which the Department of Health say are necessary. The Chairman of the Committee Mrs Hilda Renn spends a considerable amount of time at the home most days. The treasurer who is also registered with the Commission for Social Care Inspection as the Responsible Person visits the home regularly. A manager was employed but unfortunately had recently resigned. Many of the care workers have been working at the home for a number of years. Thirty five percent of the care staff have a National Vocational Qualification; others are registered to start their training. The care workers who were spoken with were happy with the care the residents received and the general management of the home. The inspectors received a number of comments from the residents and relatives praising the staff team. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 17 It is recommended that the application form be amended to include the statement; ‘all previous employment from leaving school or full time education and explain any gaps’. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 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) 31,33,35,36,38. The home was run for the residents by a staff team who were experienced and were aware of the health and safety of residents. EVIDENCE: A committee who have many years of experience runs the home. The committee employ a manager who is registered with Commission for Social Care Inspection to manage the personal care of the residents and the staff team on a day-to-day basis. As stated previously the manager had recently resigned. A meeting of the committee was to be called to discuss advertising for a replacement. The residents were asked their views through individual talks with the chairman of the committee, key-workers and questionnaires. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 19 The home was not responsible for any of the residents’ finances other small amounts of ‘pocket money’. Training for care workers on first aid, administration of medication and moving and handling was in place. Formal supervision had taken place with the manager however this would now be ‘on hold’ due to her resignation. Staff meetings will continue to take place with the chairman of the committee. The home had produced a written annual development/building maintenance programme. The chairman also produces an annual report for the Committee. This report (or one similar) could be sent to the Commission for Social Care Inspection, which would fulfil the requirement for the home to produce an annual quality assurance report, which is sent to the Commission and made a available to the residents or relatives. The Chairman and Committe oversaw the health and safety of the residents and workers. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x 2 x 3 3 x 3 Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? 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) Requirement The registered person must ensure that up to date risk assessments are kept for those residents who manage their own medication and that all risk assessments are dated. The registered person must produce a quality assurance report. A copy of the report must be sent to the Commission and made available to residents. Timescale for action 12 October 2005 2. 33 24 12 August 2006. 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 7 18 Good Practice Recommendations The registered person should ensure that the care plans contain all the relevant information regarding the residents day to day care. The registered person should include in the policy and procedure for the protection of vulnerable adults information about the Protection of vulnerable Adults (POVA) legislation. The registered person should also provide training for all staff on the protection of vulnerable adults from abuse. The registered person should include a statement in the F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 22 3. 29 Hillbrook Grange application form asking for full employement history from leaving school or full time education and explain any gaps. Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 0QD 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 Hillbrook Grange F54-F04 s8559 Hillbrook Grange v236533 160805 Stage 4.doc Version 1.40 Page 24 - 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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