Inspection on 17/04/07 for Hillbrook Grange

This inspection was carried out on 17th April 2007.

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 09/01/06

Hillbrook Grange 16/08/05

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 Cheshire SK7 2BY Lead Inspector Jacqueline Kelly Unannounced Inspection 17th April 2007 10:15 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 Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillbrook Grange Address Ack Lane East Bramhall Stockport Cheshire SK7 2BY 0161-439 7377 0161 439 3880 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) Bramhall & Woodford Old People`s Welfare Committee Margaret Johnson Care Home 36 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (35) of places Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users to include: *up to 35 service users in the category of OP (Old age not falling within any other category). *up to 1 service user in the category of DE(E) (Dementia over 65 years age). The registered manager to be supernumerary. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th January 2006 2. 3. Date of last inspection 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 Peoples 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 have 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. There is a statement of purpose and service user guide. The inspection reports are also available on request. The fees range from £280.00 to £340.00. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 5 hours. Time was spent talking with the Mrs Hilda Renn the chairperson of the home and executive committees, and the registered manager, Mrs Margaret Johnson. The residents and relative who were spoken with were happy with the care provided. Care plans, health and safety risk assessments, and drug administration records were looked at. The home had thirty-four residents on the day of the inspection. Comment cards from the Commission for Social Care Inspection were sent to three GP’s. At the time of writing this report two had been returned both of which were positive and stated that they were satisfied with the overall care provided. Eighteen survey forms were sent to the home for distribution amongst the residents none had been returned in time to include the comments in this report. The home had received six complaints; three of which were substantiated. All had been documented and dealt with in a satisfactory manner. None of the residents with whom the inspector had contact with had any complaints. The Commission for Social Care Inspection had received one report of a concern, which had been dealt with appropriately by the manager, and no further action was required. There had been no complaints or safe guarding adult referrals made to the Commission. The home had conducted surveys with District Nurses, residents and relatives. A small number were seen during the inspection all of which were complimentary as were the thank you cards, which had been received from satisfied relatives and residents. What the service does well: The home and grounds are well maintained with a number of different areas for people to sit, both inside and outside of the home. The home is clean and free from any offensive odours. Residents are encouraged to personalise their bedrooms. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 6 There is an ‘assessment flat’ where residents (who are thinking of moving into the home) can live for two weeks to help them and the staff decide if Hillbrook Grange will be suitable and will be able meet their needs. A varied programme of activities was available for residents to choose from with regular outings taking place throughout the summer months and special events organised for specific events such as Easter and Christmas. The home had a stable staff team of care workers, many of whom had worked at the home for a number of years. The inspector received favourable comments from the residents who were spoken with regarding the kindness and caring attitude of the staff group. The staff team respected the residents privacy and independence and their right to exert choice over their daily lives. The total number of care hours, which were put into the home each week, was higher than the minimum required by the Department of Health. The organisation employs consultants to assist with health and safety, record keeping and employment legislation. A programme of staff meetings and formal supervision was in place all of which were recorded. What has improved since the last inspection? The management team had been increased with the appointment of a care supervisor who with the deputy manager was responsible for the day-to-day care needs of the residents. Both said that the new system was working well. The manager had implemented monitoring and audit systems for care plans and administration of medication to ensure that the records are kept up to date and contain relevant information. This enabled the manager and care workers to work in a safe environment and provide the care necessary in a manner, which respected the residents and other workers. Training was continuous with mandatory and National Vocational Qualifications being taken by the care workers. The medication and safe guarding adult’s policies plus the assessment form had been updated to improve on the information provided and further protect residents. The management responsible for the day-to-day management of the home continued to look for ways they could improve the service for the residents and staff team. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 8 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 Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3,6. Quality in this outcome area is excellent. Prospective residents receive a full assessment that assures them their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager and the Homes Committee chairperson visited people in their home to introduce Hillbrook Grange and make an initial assessment. The person would then be admitted into the assessment flat, usually for two weeks at the end of which the person returned home to consider their future. Should the person and the home decide that Hillbrook Grange was for them, they were admitted with a view to permanent residency. The records of the last person who went to live at Hillbrook Grange showed that the home’s procedures had been followed. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 10 A new Service User Assessment form was to be introduced which would further improve the assessment information available. Standard 6 was not applicable, as the home did not have any intermediate care beds. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. Quality in this outcome area is good. The manager and care workers met the health care needs and privacy of the residents. Monitoring procedures ensured that medication was handled safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans were satisfactory and were monitored by the manager to ensure that they were kept up to date and reflected the residents’ health and social care needs. Those people who were spoken with said that they were happy with the care provided and that their privacy and choice was respected. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 12 Medication records were looked at and found to be satisfactory. New systems had been put in place to audit the records for the health and safety of the residents. One person was responsible for their medication and a risk assessment was in place. Those care workers who administered medication had received training. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15. Quality in this outcome area is good. Residents were given choices so that they could maintain control over their daily life, as far as their capabilities would allow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the residents were looking forward to Stockport Male Voice Choir who were giving a concert that evening. Other activities, which took, place on a regular basis such were craft classes, drives out and theatre trips. A suggestion box was situated in the main entrance. Surveys were also undertaken on a regular basis and comments acted on. The residents who were spoken to on the day of the inspection were happy with the food. It was a set menu, however if someone did not like what was on the menu, an alternative would be available. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 14 Mrs Renn, the chairperson of both the Executive and Homes Committees, 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 too on a personal and private level. Friends and relatives were welcomed at the home at all reasonable times of the day and evening. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18. Quality in this outcome area is good. Bramhall and Woodford Old People’s Welfare Committee and the care staff protected the residents through the complaints procedure, training and daily monitoring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: None of the residents the inspector had contact with had any complaints. There had been no formal written complaints. However, there had been six complaints about general everyday matters, which had been investigated and resolved; three were substantiated. The complaints were recorded in the logbook. 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 with further courses planned. An issue, which had caused concern, was raised directly with the Commission for Social Care Inspection. The matter was resolved and no further action was necessary. The Commission had received no complaints or any safeguarding adults referrals. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 16 Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector looked round the communal areas of the home which were comfortable, very well maintained and decorated, clean, and free from unpleasant odours. Two bedrooms were also seen; both had been personalised. There are a number of different areas on the ground floor where residents can sit to chat, read or watch television. None of the rooms have an en-suite facility but there were a sufficient number of bathrooms and toilets available. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 18 There are two passenger lifts, one for each side of the home. The grounds were extensive and were used by the residents and their relatives, weather permitting. A full time gardener was employed. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is good. The recruitment and selection methods used together with a full training programme ensured that suitable care workers are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota was seen by the inspector, which showed that there were sufficient numbers of care workers on duty to meet the needs of the residents. Mrs Hilda Renn the chairperson of both the Executive and Home committees spent a considerable amount of time at the home most days. The treasurer, who is registered with the Commission for Social Care Inspection as the Responsible Person, visited the home regularly. The home is managed by the registered manager; Mrs Margaret Johnson who has many years of experience. Many of the care workers had been working at the home for a number of years and had a National Vocational Qualification (NVQ) level 2 or level 3. Other care workers were registered to undertake the training. The inspector received comments from the residents praising the staff team. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 20 There had been a misunderstanding regarding the application form and recent legislation regarding age discrimination. This was dealt with during the inspection. Due to a number of retirements and changes of designation a new deputy manager had been appointed. A new post of care supervisor had been introduced which was working well. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38. Quality in this outcome area is excellent. The home had monitoring procedures and a management team in place to ensure that residents were kept safe and provided with a service to suit their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A committee who have many years of experience runs the home. A small management team which includes the registered manager, deputy manager and care supervisor are responsible for the day to day health and social care needs of the residents. A representative from the committee works at the home daily offering support to the manager. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 22 The home was not responsible for any of the residents’ finances, other than small amounts of ‘pocket money’ for which a record was kept. Training for care workers such as first aid, administration of medication, moving and handling and safeguarding adults was ongoing. A formal supervision programme was in place. The home had produced a written annual development/building maintenance programme, which was constantly updated to reflect the needs of the home and residents and any changes in legislation. The chairman also produces an annual report for the Committee. A Quality Assurance Report dated August 2006 was sent to the Commission for Social Care Inspection. The Chairman and Committee oversaw the health and safety of the residents and workers. Residents spoken too were very complimentary about the staff and the care they received at the home. Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 23 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x x x x x x 3 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 3 X 4 x 3 X 3 4 Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillbrook Grange DS0000008559.V338422.R01.S.doc Version 5.2 Page 26 - 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. 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