Inspection on 05/09/06 for Hillcrest (Smethwick)

This inspection was carried out on 5th September 2006.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillcrest (Smethwick) 15/05/07

Hillcrest (Smethwick) 14/02/06

Hillcrest (Smethwick) 16/12/05

Hillcrest (Smethwick) 31/03/05

Hillcrest (Smethwick) 21/10/04

Hillcrest (Smethwick) 20/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Hillcrest 13 William Road Smethwick West Midlands B67 6LN Lead Inspector Ms Linda Elsaleh Unannounced Inspection 5 September 2006 14:00 th Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 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 DS0000004781.V305730.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 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 DS0000004781.V305730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest Address 13 William Road Smethwick West Midlands B67 6LN 0121 429 4645 0121 429 2218 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 Michael Jenkins Mrs Deborah Fatile Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 11 November 2004 may be accommodated at the home in the category LD(E). This will remain until such time that the identified service users placement is terminated, The home may from time to time continue to provide care to service users who have lived in the home who have reached the age of 65 years of age. Once the placement is terminated the registration category reverts back to LD. 14th February 2006 2. Date of last inspection Brief Description of the Service: Hillcrest is a small home providing accommodation and care for three adults with learning difficulties. The property is a traditional semi-detached house, well maintained, and situated in a residential area of Smethwick. There is a small driveway with on-road parking to the front of the premises. To the rear of the premises is a garden, with a lawned area and greenhouse. The home benefits from close proximity to public transport routes. The ground floor of the house comprises a communal sitting room, kitchen, conservatory/dining area, laundry facilities and one service user bedroom. The first floor comprises two large service user bedrooms, a bathroom with toilet and office/sleeping in room for use by staff. The facilities are well maintained with décor and furnishings providing a warm, homely and comfortable ambience. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 5th September 2006. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Adults and report on the progress made in meeting requirements made at a previous inspection. The inspector’s findings are based on the information received by the Commission for Social Care Inspection (including responses to questionnaires sent to service users and relatives/visitors to the home), tour of the premises, examination of relevant records and documents kept by the home, discussions with the proprietor, manager, service users and a service user’s relative. Two requirements were made at the previous inspection. The home has fully met one of these requirements and working towards fully addressing the second. The atmosphere within the home was relaxed and friendly. Service users, and the relative who spoke with the inspector expressed satisfaction with the care being provided. The inspector would like to thank everyone at the home for their hospitality and co-operation during this inspection. What the service does well: Service users are provided with a good living environment. It has created a friendly and safe atmosphere for service users. Prospective service users are provided with suitable information by the home in order for them to make an informed choice about where they wish to live. Visits and short stays are arranged to meet individual needs and wishes. Service users confirmed their experience of being introduced to the home was a positive experience. The home makes suitable arrangements for ensuring personal, health care and social needs are appropriately met. It has systems for ensuring service users are consulted about the day-to-day running of the home, activities and their individual routines. Training programmes for staff include client-centred training as well as relevant health and safety. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 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 DS0000004781.V305730.R01.S.doc Version 5.2 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): 1, 2, 3, 4 & 5 The overall outcome for this group of standards is judged to be good. Prospective service users are provided with suitable information about the home. Suitable processes are in place for introducing service users to the home. Their individual needs are assessed prior to admission to ensure the home is able to meet these. Contract/statement of terms & conditions needs to be reviewed to ensure it continues to cover the needs of the service user. EVIDENCE: Service users stated they were provided with suitable information, met with the manager and visited the home prior to moving in. Visits are arranged to meet the needs and wishes of the individual prospective service user. These include short visits to view the home, partake in a meal with staff and current service users followed by overnight and weekend stays. The records examined demonstrate the registered manager carries out a needs assessment prior to a prospective service user is offered a place. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 9 The home’s Statement of Purpose and Service User Guide was examined at a previous inspection and reported to be concise, easy to read and met the required standards. The home identified that no changes were necessary to these documents during this visit. For reference purposes, the manager is requested to forward a copy of the Statement of Purpose and Service User Guide to the Commission for Social Care Inspection (CSCI). Service Users are provided with a Contract/Statement of Terms and Conditions detailing accommodation to be provided. Contracts need to be reviewed with all relevant parties on a regular basis to ensure the information contained is up to date and takes account of any changes. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 10 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, 8 & 9 The overall outcome for this group of standards is judged to be good. Service users’ care plans would benefit from more comprehensive recording of individual needs and personal goals. These must be formally reviewed on a regular basis with the service user and their representatives. The home consults with service users about the day-to-day running of the home and provides appropriate support in order for them to make their own decisions. However, additional guidance needs to be provided in respect of risk management strategies to support service users to take responsible risks. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home has produced a care plan and individual risk assessments for each service user based on their care needs assessments. There is little evidence to demonstrate that formal reviews are held with all relevant parties at least once every six months. However, the records show staff carry out regular internal reviews on service users’ progress. The inspector was informed these reviews are based on the observations made by staff and discussions held with the staff team. Examination of files and the discussions held with the manager indicated more effective recording is required to assist the review process. For example, more details need to be included in one service user’s care plan and risk assessment about road safety issues. The daily records for all service users should contain references to the issues identified in their care plans and risk assessments. Service users reported they were satisfied with the care being afforded them and they are provided with opportunities to participate in the day-to-day running of the home. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 & 17 The overall outcome for this group of standards is judged to be good. Service users are enabled to participate in a wide range of activities inside and outside of the home and to maintain appropriate relationships. The home encourages service users to participate in maintaining a clean and tidy living environment. Service users are provided with a healthy and varied choice of food that meets their individual preferences and dietary needs. EVIDENCE: Service users at Hillcrest have an active social life and an activity programme is tailored to meet their individual needs and wishes. They regularly attend various social clubs and church services. One service user informed the inspector how much he enjoyed attending local luncheon clubs and socialising with different groups of friends. Regular discussions are held with service users, on an individual and group basis, in order to promote and encourage new activities. Arrangements are made to support them to access local social venues and facilities. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 13 There is a range of in-house activities available such as board and computer games and selection of music to listen to and DVDs. Rug making is a particular pastime enjoyed by one service user. Service users’ individual records of achievement are displayed throughout the home. Service users spent time showing the inspector photographs of their annual holiday on the Costa Brava. The service users’ enthusiastic account of the holiday and the photographs clearly demonstrated a good time was had by all. An ‘open’ visiting policy is operated and staff respect the service user’s right to choose who they wish to see. A friendly welcome is afforded to family and friends and service users are able to receive visitors in the privacy of their own rooms if they so wish. The records show a review of the arrangements, and discussions held, with regard to providing each service user with a key to his/her bedroom door, and to the front door of the home, needs to be carried out and appropriately documented. The inspector observed discussions between staff and service users about the day’s events and arrangements for spending time with family and friends. Routines within the home are flexible to enable the needs and individual preferences of service users to be met. Service users reported they sometimes help with household tasks and are encouraged and assisted to keep their bedrooms tidy. No restrictions are placed on service users access to communal areas, however additional supervision is provided in areas identified as high risk, such as the kitchen. Mealtimes are flexible and centred around service users’ preferred routines and activities. Likes, dislikes and any specific dietary requirements are recorded on their individual files. Menus are discussed with service users on a daily basis and records are kept of the individual’s dietary in-take for monitoring purposes. All service users spoke positively about the meals provided. “I love the food” and “dinners are always good” are two comments received from service users. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 14 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 & 20 The overall outcome for this group of standards is judged to be good. Service users are assisted with their personal care, accessing health care facilities and suitable arrangements are in place for the safe handling and administration of medication to ensure personal and health care needs are appropriately met. EVIDENCE: Staff assist service users with their personal care in accordance with their individual needs and preferences. At the time of this visit no service users were identified as requiring any specific aids or adaptations. However, the manager confirmed, where applicable, these would be provided. There is evidence on service users’ records to show health care needs are addressed in a satisfactory manner. All service users have access to relevant professionals such as GP’s, Community learning disability teams, speech and language therapists and chiropody. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 15 Service users’ medication is managed on their behalf by the home. The home has recently reviewed its medication policy and procedure to ensure it remains fit for purpose. Each staff member is responsible for ensuring medication is handled and administered appropriately. There are satisfactory arrangements for the storage of medication and staff follow appropriate recording systems for the receipt, administration and disposal of medication. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 16 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): 22 & 23 The overall outcome for this group of standards is judged to be good. Service users’ views are listened to and acted upon. The home has suitable policies and procedures in place to ensure service users’ welfare and safety is promoted and staff receive training in the protection of vulnerable adults. EVIDENCE: Service users stated they are able to discuss any concerns they have with the manager or staff. A copy of the complaints procedure is available to them in picture format. Relatives informed the inspector they are aware of the home’s complaints procedure and have had no cause to make use of it. The manager confirmed the home had not received any complaints about the service it provides. Information provided by the home stated the procedure for the Protection of Vulnerable Adults and the Whistle-blowing policy had recently been reviewed. Training in respect of these issues have been provided for staff. No concerns were raised with regards to the safety and protection of service users. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 17 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 & 30 The overall outcome for this group of standards is judged to be good. Service users live in a homely environment that is clean, tidy and well maintained. EVIDENCE: The home is clean and tidy throughout. The décor is homely and the atmosphere friendly. The lounge is suitably furnished and there are lots of ornaments and mementoes from service users travels around the home. The conservatory is furnished to enable service users to dine together and also provides a pleasant view of the garden. There are adequate laundry facilities. Bedrooms are decorated to service users’ individual choice and preference. Their individual characters and interests are reflected in the personal belongings they have on display. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 18 The proprietor and manager work closely together to ensure appropriate action is taken in the regular redecoration and renewal of furnishings. Since the last inspection new blinds have been fitted throughout the home. One service user informed the inspector they “… have a new carpet in my bedroom and the blinds are very nice.” Since the last inspection the flooring in the toilet and bathroom has been replaced, wall tiles re-grouted and the bath re-sealed in order to reduce the risk of infection. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 19 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): 31, 32, 33, 34 & 35 The overall outcome for this group of standards is judged to be good. Service users receive support from experienced and competent staff. Training is provided to ensure staff are able to meet the individual and joint needs of services users. EVIDENCE: Service users receive care from a consistent, experienced and suitably qualified staff team. There have been no new appointments during the last 12 months and there are no outstanding recruitment issues. The home does not use the services of agency staff or volunteers. During the last 12 months staff have received training in Fire Safety, Manual Handling, Basic Food Hygiene and Risk Assessments. Training is also planned for client-centred issues such as Person Centred Planning, Communicating with People with Learning Disabilities and Understanding Sexual Expression. Suitable staffing levels are maintained within the home to ensure service users needs are met. Additional arrangements are made to escort service users to social activities and provide them with support at appointments. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 20 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): 37, 39, 40, 41 & 42 The overall outcome for this group of standards is judged to be good. Service users benefit from a well run home. The home regularly reviews its policies, procedures and working practices to ensure service users health, safety and welfare is promoted and protected. More effective recording and full implementation of an effective quality assurance and monitoring system will further enhance this further. EVIDENCE: The home is run by a suitably experienced and qualified manager. The proprietor supports the manager by being actively involved in the general running of the home. Service users were observed discussing a range of issues with the manager. Each one received a caring and constructive response to the issues they raised. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 21 Service users’ files are well compiled. A content index is available at the front of the file enabling the reader to easily access information. However, as previously mentioned, in standard 6, some improvements need to be made with respect of effective recording. All records kept in the home are stored appropriately. The inspector was informed service users rarely request to see their written records. During this visit service users appeared aware that written information was maintained about them and there is evidence that they have been involved in maintaining some of the records on their file. The views of service users are sought by the home through various methods including individual and group discussions and questionnaires. It is evident the views of stakeholders are also sought. The manager discussed the work being carried on in producing a more comprehensive and formal quality assurance system. The inspector looks forward to reporting on the home’s full implementation of this process. Health and safety policies and procedures have recently been reviewed by the home. Regular safety checks are carried out on the premises and equipment and staff are provided with training in health and safety matters. Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 2 3 2 3 X Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement Contract/statement of terms & conditions must be periodically reviewed to ensure the information contained is up to date. Care plans must contain detailed information of care needs and how care is to be provided. Daily recordings must make reference to issues detailed in the service user’s care plan and risk assessments. Care plans must be formally reviewed with the service user and their representative/s at least once every six months. Risk assessments must contain detailed information of how risks are to be managed. Timescale for action 19/03/07 2 YA6 15 22/12/06 3 YA6 14. 15 22/12/06 4 YA6 14 19/03/07 5 YA9 12, 13 22/12/06 Hillcrest DS0000004781.V305730.R01.S.doc Version 5.2 Page 24 6 YA16 12 The home must regularly review with service users decisions made for not holding or issuing a key to bedroom doors or the front door of the home. Suitable records must be kept of the discussions and decisions. The registered manager needs to further develop the quality assurance system to demonstrate a clear reviewingaction-planning cycle that meets all the requirements. Previous timescale for compliance, 1st May 2006, has been partly met. 22/12/06 7 YA39 24 22/12/06 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 DS0000004781.V305730.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 DS0000004781.V305730.R01.S.doc Version 5.2 Page 26 - 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. 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