CARE HOMES FOR OLDER PEOPLE
Hillbrow Residential Home Hillbrow 18 Mill Road Epsom Surrey KT17 4AR Lead Inspector
Damian Griffiths Unannounced Inspection 1st December 2005 10:00 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 Hillbrow Residential Home DS0000061265.V272167.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. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hillbrow Residential Home Address Hillbrow 18 Mill Road Epsom Surrey KT17 4AR 01372 720633 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) Mrs Soomit Sumessur Mr Vinod Sumessur Mrs Soomit Sumessur Care Home 12 Category(ies) of Dementia (5), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (1), Old age, not falling within any other category (7) Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Up to seven (7) service users in the category Old Age (OP) may be accommodated. Up to five (5) service users in the category Dementia, aged over 65 (DE(E)) may be accommodated. Additionally one named service user (as per letter dated 13th August 2004) in the category Mental Disorder aged over 65 (MD(E)) may be accommodated. 27th June 2005 Date of last inspection Brief Description of the Service: The home is located near to Epsom Town Centre . The home has been managed by the registered providers since August 2004 and major renovation work has been completed in order to update the premises. The home is currently registered for twelve older people and currently cares for 7 residents. The accomodation at the home has four single and four double bedrooms. No resident shares a room at present and there is ample space throughout the premises. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of two, to be undertaken by the Commission for Social Care Inspection (CSCI) year beginning April 2005. It was an unannounced inspection and took place over a period of 7hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by the registered Manager Mrs. S. Sumessur and Mr. V. Sumessur, representing Hillbrow Residential Home. An additional unannounced visit took place on the 26 October 2005 following and anonymous complaint. There were four main elements to the complaint investigated. None of the elements of the complaint were upheld but two requirements were made. A tour of the premises took place and the inspector was able to meet six residents, a relative and two members of the staff who were happy to contribute to the inspection report. The inspector was also able to discuss the health needs of the residents with a health service practitioner. The inspector would like to extend thanks to the residents, their relatives, management and staff at Hillbrow for their time and hospitality. What the service does well:
New residents were welcomed and well informed about the service and could visit in order to make an informed decision about the home. If they decided to become a resident and accept the terms conditions of the home a contract was provided. The Residents care needs were well assessed and delivered allowing the residents to identify what activities they enjoyed and what needed to allow them the maximum amount of independence with the least amount of risk. Resident’s health care needs were accommodated and health care practitioners were available as required. Regular hospital and clinic appointments were respected and residents supported to attend. A friendly, warm and homely environment that was unfussy and did not patronise the residents was observed. Residents may help out with domestic chores that they enjoy such as washing up or tidying away the dinner plates if they wish and care was taken to ensure their safety was considered and assessed regularly. The staff were well trained and could provide the residents with a range of skills including first aid to ensure their health and welfare was protected.
Hillbrow Residential Home DS0000061265.V272167.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
Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 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 Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5. New residents will receive a thorough assessment of need from the registered manager before becoming a permanent resident. Potential residents will be able to take their time to adjust to the home and will be able to undergo a sixweek trial period. The home was able to demonstrate their capacity to meet the assessed needs of the service users accommodated at the home. EVIDENCE: The statement of purpose informs the visitor of the homes philosophy and details what the resident can expect of the home if they become a resident. This publication did not contain enough information about the number and relevant qualifications of the staff. Six-care plans, including two of the most recent residents were inspected. The care plans contained the required information about care needs and how they would be met. Relatives stated that they were impressed with the friendliness and ‘can-do’ attitude of the manager and staff and this had helped them confirm the choice of the home.
Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 10 Contracts were in place and including details of third party financial arrangements and costs of chiropody, newspapers and hairdressing. The assessments of two prospective residents were inspected and they contained the relevant information recorded during a one-day assessment visit. Trial visits were available and the visitors’ book confirmed the dates that the visits had taken place. Residents and relatives consulted confirmed that the home was providing the care that had been agreed and identified during the assessment period. The residents were settled and happy with their accommodation and the care provided. Please see the requirements section of this report. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. Residents at Hillbrow received full provision of care that was set out in an individual and detailed care plan. EVIDENCE: Six care plans were inspected they contained a full details necessary for the provision of care needs on a daily basis. Included in these were details of health care needs: appointments for hospital, medication details, GP and other health practitioner’s details. The care plan had a section made ready for the GP to complete each time he visited enabling the resident and home mangers to monitor their health needs in a consistent way. A health practitioner consulted while visiting the home commented on the good relationship fostered by the home managers and health practitioners to ensure the residents’ health and social care needs were fully met. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected: EVIDENCE: Not inspected: Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. The home has clearly written complaints procedure in place and residents’ legal rights were protected. Policies and procedures were in place to ensure that service users were safeguarded from harm or abuse. There was one inconsistency in evidence relating to a member of staff that was actioned immediately. EVIDENCE: The complaints policy and procedures were in place: they were clear and succinct and all residents had their own copy. There had been one anonymous complaint made since the last inspection that proved to be unsubstantiated when investigated. There had been no further complaints recorded or reported to the inspector. Residents were able to vote in the recent election using the postal voting systems available to them. Protections of vulnerable adult procedures were evident with copies of Surrey’s Multi-Agency Procedures in evidence. The staff were aware of the whistleblowing and adult protection policies and procedures that were in place. A Criminal Bureau Record check was not in evidence for a member of staff due on night duty on the day of inspection. Another member of staff confirmed that they would cover this shift and ensure she was supervised.
Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 14 Please see the recommendations and requirements section of this report. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 15 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): 19,21,23, 25 and 26. The standard of the environment within this home was good providing residents with a comfortable and homely place to live. EVIDENCE: Residents enjoyed a warm and homely environment that was pleasant, light and airy. The communal areas and individual rooms were clean, tidy and clearly reflected the personality of each resident. Bathrooms and communal toilets were clean and well stocked but residents own hot water supply required attention. A lot of work had been completed including decoration of resident’s rooms and communal area since the last inspection. The standard of the work was better although there was stillroom for improvement. Residents and relatives consulted, however were satisfied with the standard of improvements to the premises. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 16 The hot-water supply located in residents’ rooms was cold-to-luke-warm when tested. The double room on the ground floor was fitted with screens to allow two people to share or a couple to occupy. Sings alerted residents and staff of fire safety, direction and other advise needs to be reviewed and some were hand written and did not enhance the homes appearance or help inform. Other signs were old and worn and needed replacing. Please see the recommendations and requirements section of this report. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 17 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 and 29. There was adequate training available for staff, however, the manager needed to make sure that staff had the adequate skill mix to ensure residents safety at all times. The recruitment procedures were in place but the safety of residents was at risk of being compromised. EVIDENCE: Training of staff identified and available and listed to attend the overnight rota was inspected to ensure that the skill mix and training of staff reflected the needs of the residents. Four staff files were inspected and showed that the appropriate training had been completed. A requirement made at the last unannounced inspection for one member of staff, to complete an up-to-date first aid certificate had been met. The recruitment procedures were in place however one staff member’s files were inadequate and did not contain all the necessary documentation as stated earlier in this report. Please see the recommendations and requirements section of this report. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 37. The managers had a good staff team and worked well with meeting their responsibilities and progressive steps were being taken towards developing a thorough quality monitoring and improvement system. Residents were encouraged to manage their own finances but support was` available to residents needing help. EVIDENCE: The management team at the home works well and there were no issues arising about the management style of the home. Residents were satisfied with the care they received and a resident’s representative commented on the friendly and approachable nature of managers and staff. A quality assurance questioner had been prepared by the managers of the home and was ready for use. This exercise must be conducted at least once per year to establish what others feel about the quality of care at the home.
Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 19 The residents were encouraged by the staff to manage their own finances and two residents were able to continue to do this. Other resident’s finances were managed partially by relatives, one relative had Power of Attorney and another resident had their small weekly allowance from the Department of Work and Pensions that she managed adequately. Some residents were able to keep an amount of up to one hundred pounds in the homes safe. There had been no reported concerns in this area of care. Staff files evidenced that staff received supervision on a regular basis. The deputy manager and manager were mutually supportive of each other for supervision but had not enter into any formal arrangement. The overall record keeping inspected at the home was satisfactorily but due to staff records being incomplete this standard was only partially met. Please see the recommendations and requirements section of this report. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X 2 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 X Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 4.(1)(c) Requirement The registered person must ensure that the statement of purpose contains information as listed in Schedule 1 of the Care Homes Regulations (2001). It was recommended that all signage be reviewed and unnecessary signs be removed. Signs need to be of good quality and fit for purpose. The responsible person must ensure that the pre-set valves are set to ensure the correct water temperatures are maintained at around 43C. The registered person must ensure that he is satisfied on reasonable grounds of the authenticity of the references referred to in schedule 2 of the Care Homes Regulations (2001). The registered person must ensure that a review of the quality of care is undertaken at appropriate intervals to establish through consultation of service users and other professionals improvements to the service. Timescale for action 28/02/06 2. OP19 23(1)(a) (b) 30/03/06 3. OP25 13(4)(a) 28/02/06 4. OP29 19(1)(a) (b) (c) 28/02/06 5. OP33 24(1)(a) (b)(2)(3) 30/03/06 Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 22 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 OP17 OP36 Good Practice Recommendations It was recommended that the home explore an appropriate advocacy service and display their services in the hallway for the convenience of the residents. It was recommended that the managers explore formal supervision arrangements with the Deputy Manager on a regular basis. Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hillbrow Residential Home DS0000061265.V272167.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
