CARE HOME ADULTS 18-65
Hillcrest 35 Carleton Road Pontefract West Yorks WF8 3ND Lead Inspector
Mr Tony Brindle Unannounced Inspection 10th December 2005 10:00 Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 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 Hillcrest DS0000006189.V265808.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 Adults 18-65. 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. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hillcrest Address 35 Carleton Road Pontefract West Yorks WF8 3ND 01977 702343 01977 705446 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) Mr Hunt Mrs Hunt Mrs Lynn Binns Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Can accommodate 4 named service users with learning disability over the age of 65 years, within a total of 20 places. (Category LD(E)) 5th July 2005 Date of last inspection Brief Description of the Service: Hillcrest was established in 1979 as a private care home for people with learning disabilities. The home currently accommodates 20 people. The fabric of the home is currently being extended to enhance the services provided within it. The home provides a variety of social spaces. The home’s décor is well maintained. The home has parking facilities to the front and a garden area to the rear. Hillcrest is situated on the outskirts of Pontefract and the town centre is about 10 minutes walk away. There is a selection of local shops opposite the home. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was positive and enjoyable. As much of the paperwork and records at the home was inspected at the last inspection, the inspector spent most of the time talking to service users and staff. The Commission would like to take the opportunity to thank the service users, the manager and support workers for their hospitality and patient co-operation throughout the inspection. There have been no additional or complaints visit to this home since the last inspection. There have been no changes to the Registered Person’s registration with CSCI. What the service does well: What has improved since the last inspection? What they could do better:
This visit did not identify any areas of service delivery that was in need of improvement. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 6 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. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the core standards within this section were assessed at this occasion. A full assessment of the core standards will take place at the next inspection. EVIDENCE: Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The systems and procedures operated by the staff at the home make sure that the assessed needs of the people living at the home are set out in a plan, ensuring that their health, physical and social needs are recorded, along with the actions needed to be taken by the staff. EVIDENCE: The service user plans of care were found to set out the actions which need to be taken by care staff to make sure that the health, personal and social care needs of the service users are met. The plans contain information and records relating to the ways in which the staff promote and maintain service users’ health and ensuring access to health care services. Three people living at the home explained how they had been supported by the staff to make their own arrangements for celebrating Christmas, and visiting their families and friends. A family member explained that her relative is very well supported by the staff and manager to make decisions about leisure pursuits, holidays and how they spend their time. She added that her relative is encouraged to get involved in a variety of activities, activities that involve managed risk. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People make choices and decisions about day-to-day aspects of their life and about how they spend their time. EVIDENCE: One staff member explained she has noticed that many of the people who live at Hillcrest have differing outlooks and preferences as to their everyday life within the home. One person said that she likes to take part in a range of activities inside and outside of the home. One person explained that she really enjoys it when her relatives visit, and the manager explained that relatives are welcome to visit as they please. A number of people said that they were looking forward to Christmas, some of them were going to stay with relatives, others were staying at Hillcrest. A few people said that they had been shopping for Christmas presents and had been given the opportunity to buy gifts and presents of their choosing rather than the staff deciding on what they should purchase. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Staff develop with people a personal plan that details their needs and preferences, which sets out how they will be met, in a way that the individual finds acceptable. The systems and procedures followed by the staff at the home make sure that the healthcare needs of people are assessed and recorded, and opportunities are created to make sure these needs are met. EVIDENCE: The staff have closely liaised with external healthcare providers. The responsible individual for the home said that, if and when people need it, they are given support and help to attend any consultations about their health and also have someone to help explain about their health if they have any difficulty with communication. People can expect the staff to be aware of issues of assessing and managing any symptoms, including pain, that they may have, and how to access specialist services. If people want to, they are encouraged to take part in physical activities in or outside the home which help maintain a healthy lifestyle. The records show that people routinely receive an assessment
Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 12 of their health to find out all their healthcare needs. This includes the need for any emergency treatment, for example, treatment seizures. The staff routinely record all assessments and reviews of people’s healthcare needs. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the core standards within this section were assessed at this occasion. A full assessment of the core standards will take place at the next inspection. EVIDENCE: Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The people at the home live in a spacious, clean and comfortable home with furniture and equipment available, both communally and individually, to meet their needs. EVIDENCE: The communal areas were clean and comfortable and furnishings are modern and suitable for the needs and lifestyles of the residents. One relative explained that the bedrooms are spacious, nicely furnished, personalised and include equipment as needed by her relative. All areas of the home appeared clean and hygienic. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the core standards within this section were assessed at this occasion. A full assessment of the core standards will take place at the next inspection. EVIDENCE: Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health and welfare of the service users and staff is protected by the safety systems operated by the home. EVIDENCE: The records relating to health and safety, including fire alarm testing, emergency lighting and environmental risk assessments, were seen to be up to date and in good order. Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Hillcrest Score 3 4 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 x DS0000006189.V265808.R01.S.doc Version 5.0 Page 18 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. 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 Hillcrest DS0000006189.V265808.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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