CARE HOMES FOR OLDER PEOPLE
Hillbrow Residential Home 18 Mill Road Epsom Surrey KT17 4AR Lead Inspector
Mr D Griffiths Announced Inspection 27 June 2005 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. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Hillbrow Residential Home Address 18 Mill Road Epsom Surrey KT17 4AR 01372 720633 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) Mrs Soomit Sumessur & Mr Vinod Sumessur Mrs Soomit Sumessur CRH (PC) 12 Category(ies) of Dementia (DE) 5. registration, with number of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 1. Old age, not falling within any other category (OP) 7. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1) Up to seven (7) service users in the category Old Age (OP) may be accommodated. 2) Up to five (5) service users in the category Dementia, aged over 65 (DE(E)) may be accommodated. 3) Addittionally, one named service user (as per letter dated 13th August 2004) in the category Mental Disorder aged over 65 (MD(E)) may be accommodated. Date of last inspection 21 December 2004 Brief Description of the Service: Hillbrow is a care home providing 24-hour residential care for older people .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.There is ample space throughout the premises. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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 announced visit and took place over a period of 6hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by the registered Manager Mrs. S. Sumessur and Mr. V. Sumessur, representing Hillbrow Residential Home. A tour of the premises took place and the inspector was able to meet 4 residents, two relatives and three members of the staff who were happy to contribute to the inspection report. Three ‘comment cards’ produced by CSCI were completed by residents’. A comment card was also completed by the GP associated with the Hillbrow and another by a relative. The commission also received a completed PreInspection questionnaire from Mr and Mrs Sumessur. It is recommended that the reader should also look at the previous report that can be accessed by using the CSCI website details on the last page of this report. 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:
In the ten months under new management, Hillbrow is showing improvements in some areas of the home. Their plans for improvement include re-planting the garden area with flowers and shrubs, installing a small pond and building a new garage at the end of the garden. Internally a program of redecoration has begun. The residents are happy with the changes of management, and the home improvements. All the comment cards were positive and showed a level of satisfaction that match the national Minimum Standards for Older people. The residents were aware of the inspection and a notice had helpfully been placed in the living room to remind them of the date. Overall the home was clean and hygienic. Resident’s rooms were all personalised with photos, ornaments and pictures on their walls. All communal areas contained comfortable seating and were clean and tidy. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
The home is still undergoing refurbishment and there were some areas that required immediate attention. The inspection revealed the need for more minor refurbishment to ensure fire safety in the area immediately below the loft entrance. Three immediate requirements were necessary during the inspection. Two temporary measures were put in place while the inspector was present: The thermostat was adjusted to ensure the water temperature complied with recommended safety levels: loose floor covering in the upstairs bathroom was secured: A fire door to a resident’s room requires re-fitting. The loft door in the same area also requires attention by the Fire Safety Officer to ensure it complies with required standards. Storage units in the conservatory area and in one bedroom require replacing or repainting to a better standard.
Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 7 The first floor communal toilet and the bathroom area all require redecorating to a higher standard. 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. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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 standard(s) 3 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 6week trial period. EVIDENCE: The new owners have not admitted any new residents to Hillbrow since taking over management. The existing residents’ care plans showed evidence of previous assessments, needs and reviews. The Manager reported that new residents to Hillbrow will receive an assessment of their care needs and would be able to take time to decide whether they would like to begin residency. Hillbrow is not currently taking emergency admissions. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 10 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 and 11. Residents at Hillbrow receive provision of care that is set out in an individual care plan. These include details of health requirements, personal and social needs. These are reviewed regularly to ensure that any changing needs are met. One care plan evidenced, required more information relating to a health condition with treatment instructions. EVIDENCE: Care plans inspected included risk assessments. These include how to manage and monitor health conditions that may deteriorate. Residents have access to all community health care services. A GP for the service completed the Commission’s questionnaire confirming satisfaction with overall care provided to residents. One care plan did not include details of a medical condition that required treatment and care. There is no demand for residents to administer their own medication at Hillbrow. In samples viewed, staff had recorded daily medication, MAR charts were in order and lists of resident’s current medication and pharmaceutical information about medication was in evidence. Requirements from the previous inspection had been met.
Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 11 Staff were observed responding sensitively to residents’ at all times during the inspection, and respected residents privacy appropriately. Residents are able to plan funeral arrangements and discuss any concerns with the staff at the home. Arrangements were evidenced and are contained in their care plan folder. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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 standard(s) 12,13,14 and 15 The residents at Hillbrow benefit from a list of activities available at the home. Those asked were satisfied with the current arrangements and support from the staff. EVIDENCE: At the time of the inspection a group of residents were playing Jenga with a staff member, another resident relaxed after reading the daily papers. Other residents were out at the local day centre. Shopping and trips to the library are the most popular and one resident told me she would like more opportunity to visit the cinema. A Chaplin visits the home every Sunday and residents are also able to benefit from regular visits from the hairdresser. Staff provide foot massage and spa treatment. Two relatives informed the Inspector that they were satisfied with the home and had no concerns relating to care. The residents have regular house meetings where the can discuss topics of interest regarding social visits and any issues of importance. Residents benefit from a varied weekly menu and can be seen by a dietician if required. Residents reported they were satisfied with menus offered. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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) 18 The Staff at Hillbrow all receive training in Adult Protection and are aware of the procedures that are in place to protect the residents. There is one requirement relating to Protection of Vulnerable Adults. EVIDENCE: Surrey Multi-Agency procedures have been updated. Three staff files were inspected and the files show that all have received appropriate training. There have been no vulnerable adult investigations to date at Hillbrow. Surrey’s Multi-Agency Procedures are in place and staff have access to the Whistle blowing Policies in operation. General Social Care Council guidelines are available to all staff. It was recommended that the management make more copies available for staff. The new management is required to ensure that visitors providing services to residents provide an up to date Criminal Record Bureaux certificates. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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) 19,20,21,22,24,25,26 Since the last inspection there have been small improvements to the premises. Some decoration was substandard and some fixtures and fittings were worn and required repair or replacement. The premises do not meet current requirements. EVIDENCE: All widows and doors have been replaced and the conservatory has been altered slightly to accommodate space for the residents’ regular hairdressing sessions. A sink and second used storage cupboard has been installed. The cupboard requires repainting, as the quality is poor. A cupboard in a similar condition has been placed in a resident’s bedroom. This also requires attention and walls here need to be decorated to improve overall appearance and eliminate the rough surface. The stairs can be accessed by a stair lift that is positioned safely mid way on the staircase. Three of the residents’ rooms inspected on the first floor require new door handles as they did not operate effectively.
Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 15 The door to one resident’s room requires urgent attention as it does not close and therefore poses a fire risk. The room contains a newly installed en suit bathroom that can also be accessed by a door on the landing. This door requires a lock to ensure privacy and dignity. This door is not fireproof and there is a requirement for a fire safety check to be undertaken. Tiles in the bathroom require refurbishment or replacement and decoration completed. The loft door outside this room requires replacement. The laundry room was clean, tidy and airy. A sink is available for staff to wash their hands . Washing machines do not have a sluicing facility but meet the present needs of the residents. The management are aware that the present laundry facilities will need to develop as resident needs increases. Paper towels and soap dispensers are available in communal washing areas. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 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) 29 and 30 Staff files inspected at Hillbrow show an improvement in recruitment practices. GSCC guidelines are available for staff. EVIDENCE: Staff files contained the appropriate Criminal Records Bureaux (CRB) approvals, at least two written references and no gaps in employment. Statements of pay and conditions were also available as were job descriptions. Staff have received training in all areas required to meet the needs of the residents. e.g., First Aid, administration of Medicine, Health and Safety, Moving and Handling. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The Health and Safety of residents at Hillbrow were partially met. There were some fire safety concerns that required immediate attention. EVIDENCE: All residents’ bedrooms had received risk assessments in regard to C.O.S.H.H regulations. The C.O.S.H.H cabinet is a customised cupboard secured in the kitchen and kept locked and assessable to staff only. The Environmental health Officer is due to inspect in July. Gas and electrical equipment has been checked and certificates issued. Fire equipment has been inspected this year. An immediate requirement has been made for adequate Fire door protection and fire safety check. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 2 2 x 2 2 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x x x x x x 2 Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 19 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 19 Regulation 24 (4abc) Requirement The registered person must, after consulting the fire authority, take adequate precautions against the risk of fire. This will include refitting the bedroom door to residents bedroom ensuring it closes. The registered person must, consult the fire authority to confirm the suitabilty of the door leading to the en suit bedroom and the new partition that it is located in. Also to advise on the door to the loft that has a 2 inch gap. Adequate precautions against the risk of fire must be taken. The responsible person must ensure that suitable pre-set valves are fitted to ensure the correct water temperatures are maintained at around 43C. The responsible person must ensure that the home is free from all hazards as far as reasonably possible ensuring that the floor covering to the upstairs toilet is secured or replaced as this poses a trip hazard . The responsible person must Timescale for action 27-06-05 2. 19 24 (4abc) 30-06-05 3. 25 13(4)(a) 07-07-05 4. 19 13(4)(a) 07-07-05 5. 19 23(2)(d) 28-07-05
Page 20 Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 6. 19 23(2)b) 7. 19 23(2)(d) 8. 19 23(2)(b) 9. 21 13(3) 10. 19 23(2)(b) 11. 19 23(2)(d) 12. 19 23(2)(b) ensure that all parts of the home are reasonably decorated. Repaint the wall where shelving has been removed in the conservatory above the sink. Repaint adequately or replace the storage unit. The responsible person must ensure that the premises are kept in a good state of repair. Mrs Ts door handle is worn and does not work properly also 2 door handles to the spare rooms require replacement . The responsible person must ensure That Mrs Ts bedroom is reasonably decorted by painting/wallpaper of her choice, the walls and repainting or replacement ,to an acceptable standard, the storage unit in the room. The responsible person must ensure the upstairs toilet is reasonably painted so as to cover the previous wall colour. The responsible person must ensure that suitable arragements to prevent infection and the spread of infection by the removal of a mop and bucket found in the toilet on the 1st floor to a suitable staorage place and that the mop is always left to dry in an appropriate place away from residents. The responsible person must ensure that the broken bathroom tiles located next to the taps are replaced in the 1st floor bathroom and that it is kept in a reasonable state of repair. The responsible person must ensure the 1st floor bathroom is adequately painted so as to cover the previous wall colour. The responsible person must ensure that bath surround is 28-07-05 28-07-05 28-07-05 29-06-05 28-07-05 28-07-05 28-07-05
Page 21 Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 13. 19 23(2)(d) 14. 19 23(2)(e) 15. 18 2(3) 16. 7 12(1)(a) adequately sealed in the 1st floor bathroom to prevent leakage and the bathroom is kept in a reasonable state of repair. The responsible person must ensure that the door frame and door leading into the en-suit bathroom located in the residents room is painted adequately and to an acceptable standard and the tiles lining the bath require scraping to remove excess paint. The responsible person must ensure that landing door that leads into the en suite bathroom provides adequate privacy by providing a small locking bolt. The responsible person must ensure that volunteers or paid service providers have suitable references and CRB approval. The registered person must promote and make proper provison for the health and welfare of residents. Care plans must be updated to include any new medical conditions that arrise and require attention as noted during the inspection. 28-07-05 07-07-05 22-09-05 30-06-05 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. Refer to Standard 18 Good Practice Recommendations General Social Care Council guidelines are available to all staff. It was recommended that the management make more copies available for staff. Hillbrow Residential Home v230839 h58 h09 s61265 hillbrow v230839 270605 stage 4 ann.doc Version 1.30 Page 22 Commission for Social Care Inspection 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
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