Inspection on 17/06/05 for Hillcrest Care Home

This inspection was carried out on 17th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hillcrest Care Home 13/02/06

Hillcrest Care Home 09/11/05

Hillcrest Care Home 31/01/05

Hillcrest Care Home 06/05/04

Hillcrest Care Home 23/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hillcrest Care Home Kenilworth Drive Kirk Hallam, Ilkeston Derbyshire DE7 4FJ Lead Inspector Tony Barker Unannounced 10:45 am 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. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillcrest Care Home Address Kenilworth Road Kirk Hallam Ilkeston Derbyshire DE7 4FJ 0115 909 8111 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) Derbyshire County Council Susan Hollingworth CRH 29 Category(ies) of OP registration, with number of places Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31/1/05 Brief Description of the Service: This is a Local Authority Care Home providing personal care only for 29 older people of either gender. The Home has 20 single rooms on two floors, and two double bedrooms. There is a shaft lift providing access to the upper floor. The Home is situated in the middle of a housing estate in Kirk Hallam. The local shops, pub and post office are within walking distances. The Home has gardens mainly to the rear of the building which include two central courtyards with seating areas. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 3.5 hours and was a routine unannounced inspection. The last inspection took place in January 2005 and was unannounced. Residents, visiting professionals, the Manager and one member of staff were spoken to and records were inspected, including a relative’s response to a satisfaction questionnaire. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. There was no tour of the premises at this inspection. What the service does well: What has improved since the last inspection? What they could do better: There were few areas that could be improved and these all related to recording systems. Residents’ contracts with the Home need to state those services to be paid for that are not included in the fees. Attention needs to be made to staff signatures on certain records. Further documents regarding the recruitment of staff must be held within the Home to ensure that the full protection of residents is assured by the Manager and the Commission. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 & 4 Each resident has a written contract and detailed admission information to enable staff to meet residents’ individual needs. EVIDENCE: Derbyshire County Council’s Terms and Conditions of Residence had been improved and included all the items from Standard 2, except for “additional services to be paid for above those included in the fees”. These additional services were limited to hairdressing, and chiropody for residents at low risk. Four residents’ files were seen as part of the case tracking methodology. These files contained pre-admission assessment information from care managers and residents’ signatures. Initial care plans were produced within the care management format. As well as identifying long term needs to be addressed, the Home’s care plans identified residents’ preferences for daily and weekly routines. District nurses provided nursing input and their notes were held in the Home. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 9 From discussions with the Manager it was clear that specialist needs of residents were sensitively assessed and met. Residents’ records showed that input and guidance is sought from specialist services and other professionals. Two visiting professionals were interviewed and they confirmed that the needs of service users’ were met. They praised the Home for “going that extra mile” to meet residents’ needs and described the staff as “caring and helpful”. They added that the Home had a “good atmosphere”. Residents sitting in the lounge and dining room made positive comments such as “I am happy here”. Due to these positive comments received, the Home is commended for its efforts in meeting needs and is given a score of 4, on this occasion, for Standard 4. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.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 Residents’ health and personal care needs were set out in an individual plan of care for staff to follow and this ensured that these needs were being fully met. However, shortfalls in recording of medication could potentially put residents at risk. EVIDENCE: Care plans were generated from a comprehensive assessment of individual residents’ needs and were reviewed monthly by key workers. Formal reviews took place every six months, including those residents who were privately funded. Residents’ signatures were seen on the four care plans viewed. Risk assessments and risk management statements were recorded, including the risk of falls. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 11 Tissue viability assessments and nutritional assessments were seen on files examined. The Manager undertakes the tissue viability assessments but had not been signing them and had not been recording any follow up action taken other than contact with the district nurse. Pressure relieving equipment, such as cushions, was available. ‘Fracture and Falls’ risk assessments were undertaken in September 2004 and this had led to the majority of residents being prescribed medication to address osteoporosis with the aim of reducing falls. Chair-based exercises had been another new initiative aimed improving health and reducing falls. Dietary improvements were in place, including the use of full fat milk and decaffeinated drinks. A number of residents had hip protectors. An interview with two visiting professionals confirmed that advice and help was sought appropriately from the health profession. The Medication Administration Record (MAR) sheets were seen for those residents whose care was case tracked. There was a Social Services Medicines Code in place for the management of medicines. There was evidence on the MAR sheets to support that medication was checked on receipt. However, handwritten additions to MAR sheets had not been signed, dated or witnessed. Loose tablets for destruction were stored in a medication bottle and recorded in a Returns Book. Photographs of residents were included on the MAR sheets and risk assessments had been completed on every resident in relation to the administration of their medication. A list of staff names, signatures and their initials was available. A separate medication refrigerator was in place and its temperature was being checked and recorded on a regular basis. Each resident signed a consent form agreeing to the Home managing their medication. The Manager said that a local authority pharmacist provides accredited training and that all managers had attended. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.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 The routines of daily living were flexible and the activities provided reflected residents’ individual needs and preferences. There were very good levels of contact with family and friends and with the local community EVIDENCE: Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 13 The four residents’ files viewed were seen to contain a ‘Personal Activities Record’. The activities programme for June 2005 was seen and described a range of 13 activities plus twice-weekly ‘bingo’. This Activities Sheet was displayed on the notice board. Calendars in bedrooms recorded the forthcoming week’s events of interest to each resident – including birthdays, appointments and ‘special dates’. These calendars were used by staff to make conversation with residents, the Manager said. The two visiting professionals spoke of good levels of stimulation within the Home and of residents being taken out regularly by staff. Residents confirmed that they were able to maintain their own routines. The Manager described links very good links with the local community. These included the local college and other local Derbyshire County Council Care Homes. Activities involving the other Homes included candlelit meals. There were also visits to a small local community centre and links with local churches. The Manager also described good links with relatives. A relatives group has been formed – 31 relatives attended the last meeting. Dementia training sessions for relatives have been held. Residents said they had regular visitors and the Home’s Quiet Room is often used by visitors. Information about this is contained in the Service Users’ Guide. The Home is commended for its efforts in creating and maintaining these links with the local community and is given a score of 4, on this occasion, for Standard 13. The Home was ensuring that residents were aware of the daily menu as evidenced by conversations with residents. The Home had won the Derbyshire County Council ‘Catering Team of the Year’ competition. Other aspects of catering practices were not assessed. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Outcomes in this section were not assessed. EVIDENCE: Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 standard(s) 26 The Home had consistently high standards of cleanliness and hygiene to provide a well maintained and safe environment for residents. EVIDENCE: The Home was clean, tidy and free from offensive odours. The two visiting professionals confirmed that the Home always smells fresh. Laundry facilities were sited separately to food preparation areas and policies and procedures were available for the control of infection. The washing machines had a sluicing facility and the Manager confirmed that they met disinfection standards. Bedding was washed off site. The visiting professionals said that bedding was always clean and that good levels of hygiene were maintained. The Manager said that staff mentor new workers to ensure high standards of care and hygiene. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.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) 28,29 & 30 Residents’ safety was being assured through a high proportion of trained care staff and generally sound recruitment procedures. However, recruitment procedures were not sufficiently robust to ensure full protection of residents is assured. EVIDENCE: 87 of care staff had achieved a National Vocational Qualification (NVQ) at level 2. The Home is commended for its efforts in training staff to NVQ level 2 standard before 31 December 2005 and is given a score of 4, on this occasion, for Standard 28. The Home had a recruitment and selection procedure in place. The Local Authority carries out recruitment of new staff and all staff files were held off site. However, photo-copies of recruitment documents were now being held in the Home. Two sets of these were seen but they did not meet all the requirements contained in Schedule 2 of the Regulations – for example, there was no recorded evidence of physical and mental fitness of the applicant. The Manager was not aware of changes made to the Regulations, in 2004, which added further requirements on employers regarding staff recruitment. All staff had signed a sheet to confirm that they had received a copy of the General Social Care Council code of conduct and practice. Additional copies were on display around the Home. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 17 Staff files were seen to contain a list of training undertaken. As well as mandatory training staff had attended other courses, including continence promotion, stroke awareness and computer training. The Manager held a training matrix giving a recorded overview of staff training. There was evidence that new staff undertake induction and foundation training. The Home’s ‘Chartermark’ assessment (see next section of this report) stated that there were “exceptional levels of staff training”. The Home is commended for its levels of staff training and is given a score of 4, on this occasion, for Standard 30. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 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) 32,33,34 & 37 The Home was run in the best interests of residents and they were benefiting from the Home’s high quality of management. Residents were safeguarded by the accounting and financial procedures of the Home and its record keeping, policies and procedures. EVIDENCE: Two visiting professionals spoke of the Home having a “good atmosphere”. The Home had been awarded ‘Chartermark’ status and the Chartermark Assessment Report included comments such as “feels like home”. It also commented that there was “often inspirational leadership”. A relative of a recently admitted resident had commented on a satisfaction questionnaire that Hillcrest provided a “superb public service” and was “well managed and highly rated in the community”. An inclusive approach to residents’ care was evidenced by, amongst other things, the strong involvement of relatives. Evidence of quality assurance measures undertaken include: • the Manager’s monitoring of residents’ files, Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 19 • the Home has been the first Derbyshire County Council’s (DCC) care home to achieve a ‘Chartermark’, • Age Concern spend a day annually talking to residents as part of a quality survey, • the Social Services Department send out service quality questionnaires to relatives and staff, • satisfaction questionnaire sheets are kept in the reception area - one was seen and the relative had ticked all in the ‘excellent’ column, • residents’ meetings are held bi-monthly and are minuted. Residents are being offered two places on a recently formed Residents Council, involving six local DCC homes. The Manager commented that she would like to see the residents taking even more responsibility for the running of the Home. The Home is commended for its quality of management and quality assurance measures and is given a score of 4, on this occasion, for Standards 32 & 33. The Home was four years into its five-year plan. This was seen to be a very well worded plan with positive achievements. The budget report for 2004/5 and the Annual Report were displayed in the entrance hall. There was, as yet, no business plan though the Manager said she had “ideas for this”. Improvements to the Home’s record system had been made, including a form for recording any physical restraint used on a resident. This had been developed by the Manager and sent to County Hall for comments. The Home’s two gas cookers were not being serviced regularly – DCC was still only servicing gas boilers. Other Health and Safety matters were not assessed. Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 4 4 3 x x 3 x Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 21 Yes 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 2 Regulation 5(1)(b) Requirement The registered person must provide each service user with a statement of terms and conditions/contract that contains all the information required by Standard 2 and Regulation 5(1)(b). (Previous timescale was 30/6/04 Tissue viability assessments must be signed and follow up action taken must be recorded. If the MAR chart is handwritten or altered by a member of staff this must be signed and dated by them. This is then checked, signed and dated by a second member of staff. The registered persons must ensure that all information and documents are obtained regarding new staff as detailed in the amended Schedule 2 of the Regulations. Recorded evidence of this information and documents must be kept in the Home for inspection at all times. Timescale for action 1 November 2005 2. 3. 8 9 17(1)(a) Sch3.3(n) 13(2) 17(1)(a) Sch 3.3(i) 1 September 2005 1 September 2005 4. 29 19 Sch 2 1 October 2005 Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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 34 Good Practice Recommendations A business plan should be available. (This was a previous recommendation) Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 Hillcrest Care Home C52 C02 S35712 HillcrestCareHome V233978 170605 Stage 4.doc Version 1.30 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. 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