Inspection on 05/07/07 for Hillbrow Residential Home

This inspection was carried out on 5th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillbrow Residential Home 01/08/06

Hillbrow Residential Home 01/12/05

Hillbrow Residential Home 27/06/05

Hillbrow Residential Home 21/12/04

Hillbrow Residential Home 04/11/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hillbrow Residential Home Hillbrow 18 Mill Road Epsom Surrey KT17 4AR Lead Inspector Kenneth Dunn Unannounced Inspection 5th July 2007 09:00 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.V342287.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. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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) v_sumessur@hotmail.com Mrs Soomit Sumessur Mr Vinod Sumessur Mrs Soomit Sumessur Care Home 12 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number disorder, excluding learning disability or of places dementia (3), Old age, not falling within any other category (7) Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. The three (3) service users to be accommodated in the category Mental Disorder may be 55 years of age and over 1st August 2006 Date of last inspection Brief Description of the Service: The home is located near to Epsom Town Centre. The registered providers have managed the home 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 cares for 7 residents. The accommodation at the home has four single and four double bedrooms. Two male residents share a room at present and there is ample space throughout the premises. The home is located near to Epsom Town Centre. Weekly fees: £375.00 to £450.00pw. Hillbrow Residential Home DS0000061265.V342287.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 site visit as part of the key inspection process by the Commission for Social Care Inspection (CSCI). The visit was carried out by Mr K. Dunn, regulation inspector and included a full tour of the premises, informal interviews with staff and the people who use the service. A request was made that the people who use the service would prefer to be referred to as residents. The inspection process included a review of documents, policies, procedures and any other relevant records. The visit commenced at 09:00hrs and finished at 13:00hrs. The inspector would like to thank the registered manager, the staff, residents, and others for their contribution. What the service does well: What has improved since the last inspection? The statement of purpose contains had been improved however the document is not updated effectively to demonstrate changes within the staff group especially in respect to new qualifications. The Garden area to the rear of the home has been landscaped. The service has made considerable efforts to obtain original care assessments from resident’s local Social Care teams. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 6 Staff have updated their statutory training, ‘The Safeguarding Vulnerable Adults ’. The provider has redesigned the service area at the rear of the home to ensure that the residents are safe. 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. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service users guide has been updated and offers sufficient information to potential residents to allow them to make an informed choice about the home. All potential residents are assessed prior to admission to the home to ensure that their needs can be met. EVIDENCE: The manager has reviewed and updated the statement of purpose and the service users guide in line with a requirement made in the previous CSCI report. A review of both documents indicated that all potential residents are provided with basic information to allow them to make an informed decision about moving into the home. It is however recommended that the manager make regular reviews of both documents to ensure that they accurately reflect the home current staffing levels and any new qualifications undertaken by the staff. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 9 Clear and concise assessments are in place for all residents in the home, including the social and healthcare needs of the individual. Information contained within the assessment identifies the cultural and diverse needs of potential residents. The registered provider informed the inspector that the home does not offer any form of intermediated care. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s health and welfare is effectively met by the policies and procedures in place at the home and by the effective staff being employed to meet with their individual and collective needs. EVIDENCE: The manager informed the inspector that all care plans are developed according to the indaviduals assessed needs using all available information, encompassing health, personal and social needs. The care plans are reviewed and updated monthly or more frequently if changes occur. There is evidence of relatives bening invited to discuss the contents of care plans to esure that their family members are getting appropteate and effective care . Where ever possible the manager ensures that the care plans are signed by the residents and or their representatives. A basic risk assessment is undertaken by the manager on the resident’s however for varriouse activities. The inspector reviewed a set of risk Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 11 assessments and discussed with the manager the need to fully develop, expanded and detail the risk and to then ensure that the measures that have been introduced to minimise the risk are clear and workable. Health assessments are carried out by qualified staff who are experienced in assessing the needs of service users in this client group. There is a policy and procedure in place for the administration, storage and recording of medication. The inspector cunducted a random sample of medications one arithmetic error was found resulting in a incorrect total being recorded on a residents MAR sheet. This was discussed with the manager who accepted the error and immediately actioned a review of the audit tool used by the home to record medication held and new suppplies coming into the home. Each service user has a photo on file and whenever medication is received from the pharmacy the medication administration record is highlighted. The culture of the home is around person centred care, which looks at the individuals existing abilities rather than their loss of abilities. Staff are encouraged to gain permission before entering the rooms. Staff were seen to knock on residents doors prior to entering and were observed ensuring that residents clothes covered them appropriately ensuring their privacy and dignity. Please see requirments and recommendations section of this report. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities at the home satisfy the social, recreational, religious and leisure needs of the residents. The arrangements for community contact are good promoting family links. Policies and procedures are good enabling the residents to exercise choice over their lives with assistance as needed. Meals at the home are good and offer variety, choice and healthy eating options. EVIDENCE: Residents are supported to access a range of recreational and social activities, which meet their needs and preferences. The social needs, hobbies and interests of individuals are recorded in their care plan. The individual care files clearly demonstrate that the person expectations and preferences are discussed and developed to ensure that the home can meet these. The rights of the residents are discussed and detailed within their individual care plans. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 13 There was clear evidence of the resident’s rights being upheld and one member of staff stated that, “we ensure that all residents are treated equally and the home recognises the diversity of the individuals within the group it is our job to ensure that they are supported in every aspect of their daily living”. The manager informed the inspector that all staff employed at the home have undertaken equality and diversity training to ensure that the residents rights are respected and the their diverse needs can be identified and the home can establish appropriate ways in which to support the residents maintain their diversity. The file of one resident clearly demonstrated the ways in which the staff team have assisted one gentleman to settle into his life at Hillbrow without impeding upon his needs and level of support to maintain his individualism within the confines of a care home and to ensure that he can continue to be as independent as he has always been in the local community. The inspector noted the home had arrangements for meeting the religious needs of the residents. The home has visit from a local minister who offers the residents Holy Communion if they wish or to offer a friendly face to chat to. A review of menu plans confirmed meals offered variety, choice and healthy eating options. The home uses a flipchart menu, which shows the daily menu and the alternatives if the residents do not like the main choice. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 14 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 and 18 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home procedures in place to ensure that in the event of a complaint being made they will responds appropriately, listens to the complainant and takes any actions necessary to ensure a positive outcome. Staff understand the process for reporting any incidence of suspected or actual abuse. EVIDENCE: There is a complaints procedure in place, which complies with the National Minimum Standards. A review of the complaints log indicated that there have been no complaints made since the last inspection. The CSCI have not received any complaint regarding the home or the service the residents receive since the last inspection. There are no current safeguarding adults investigations within this home. The manager confirmed that all staff has now received protection of vulnerable adult training. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed during this inspection. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are areas within the home that are in need of updating and arranging in a non-institutional fashion in order to provide a more homely, comfortable environment for people to live in. EVIDENCE: The home is relatively spacious, maintained and safe for the residents to live in. Some areas of the home are decorated and furnished to a good standard. There is evidence of the residents making choices about the colour and layout of their bedrooms. All areas in the home are accessible by a chair lift. The kitchen was clean and tidy. Generally the home meets its stated purpose and the residents appeared to enjoy the friendliness of the home. However there is a tendency to retain items of unused furniture that serve no purpose in the communal areas of the home. The conservatory to the rear of the property was cluttered with unused chairs, an old wardrobe with no doors Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 16 and several other items, which essentially turned an asset into a storage area. A requirement has made to ensure that this area is reassessed to ensure that the residents on day-to-day basis can effectively use it. In discussion with the manager it was also recommended that a full audit be undertaken of all areas within the home to ensure that the only relevant items to the residents should retained within the home. The outside area at the rear of the property is well maintained for residents to access. However again there was a pertinacity to use a great asset as a storage area for unwanted household items, excess floor tiles, a sideboard and other discarded items these items could be considered as a hazard to the residents while accessing the garden. The inspector issued an immediate requirement to remove all hazardous items from the garden, the manager organised for their removal and the requirement was fully actioned before the inspector left the premises. The premises were generally clean and free from mal odours. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring sufficient numbers of staff on duty to meet the needs of the residents. Training is well funded and the commitment to National Vocational Qualification (NVQ) training is good. Recruitment and vetting practices ensure that the residents are safeguard. EVIDENCE: The manager stated the home had adequate staffing levels that were calculated using an approved formula and the inspector noted the manager had responsibility for planning the home’s duty roster. The home had a policy on staff recruitment and the manager confirmed prospective employees are vetted before being employed by the home. The inspector sampled staff recruitment files which contained completed application forms, written references, statement of terms and conditions, training records, CRB (Criminal Record Bureau) disclosure information, a recent photograph of the employee and staff have copies of the GSCC (General Social Care Council) code of practice to safeguard the welfare of service users. The inspector noted staff recruitment files were securely stored to promote confidentiality. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 were assessed during this inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day-to-day management of the home ensure service users live in a home, which is run in their best interests. EVIDENCE: The inspector noted the home had a management structure with clear lines of communication and accountability and during discussions a member of staff stated ‘‘management is good, fine and I have no problems’’. The home had a policy on health and safety and staff have training in health and safety, fire safety, food hygiene, infection control and other relevant and appropriate training. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products stored in a locked cupboard to promote safety. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 19 A review of the homes records demonstrated that systems and procedures were in place for routine service and maintenance arrangements for the environment. The manager provided evidence to the inspector, which indicated that regular water temperature monitoring takes place. Appropriate food storage and temperature records were maintained. Fire maintenance records and checks were recorded. The inspector discussed with the manager the potential risk to the residents if the continuing habit of storing items of little or no practical use to the home, the residents or staff. Items that are no longer used or are damaged must be removed from the home to clear areas for the safe use of the residents. This was an existing requirement from the previous inspection report. Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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 3 X 3 X X 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23.1(a) & .2(BC0) Requirement All communal areas must be assessed to ensure that the residents can make appropriate use of the space they are provided. The registered manager must ensure that ensure that all parts of the home to which the residents have access are reasonably free from hazards and external grounds are suitable, safe and well maintained. (Timescale 01/09/06 not met) Timescale for action 05/08/07 3. OP38 13.4 & 23 01/08/07 Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 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. Refer to Standard OP1 Good Practice Recommendations The manager should make regular reviews of the statement of purpose and the service users guide to ensure that they accurately reflect the home current staffing levels and any new qualifications undertaken by the staff. Medication risk assessments should be developed for all residents. It is recommended that when positioning furniture throughout the home health and safety is always considered. 2. 6. OP9 OP38 Hillbrow Residential Home DS0000061265.V342287.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. 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