Inspection on 14/08/06 for Hillcroft

This inspection was carried out on 14th August 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

Hillcroft 30/08/07

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

CARE HOME ADULTS 18-65 Hillcroft St. Ebbas Hook Road Epsom Surrey KT19 8QJ Lead Inspector Damian Griffiths Unannounced Inspection 14th August 2006 10:00 Hillcroft DS0000067525.V302592.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 Hillcroft DS0000067525.V302592.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. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcroft Address St. Ebbas Hook Road Epsom Surrey KT19 8QJ 01372 203020 01372 203035 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) Surrey Borders Partnership NHS Trust. Miss Julia Schmidtkeke Care Home 10 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1), Physical disability (1), of places Sensory impairment (1) Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: The age/age range of the persons to be accommodated will be: 39 AND OVER. Date of last inspection New Service Brief Description of the Service: Hillcroft is a large detached property recently built and situated within the grounds of the old St Ebbas hospital site. A residential home for Young Adults the accommodation is registered for 10 service users with learning disabilities and ages ranging from 39 years to over 65 years, and part of the Surrey and Borders Partnership NHS Trust (SABP). The home is near to Epsom town but public transport or car is needed to reach the shopping centre. However there are some local shops nearby within walking distance. The home is in the shape of an arrow and has two main living areas either side of the entrance lobby that forms the tip of the ‘arrow’ shape, each of the sides containing ground floor en suite bedrooms. Communal bathrooms and shower/wet rooms enable wheelchair users access and independence, as do four of the ten bedrooms available that are also wheelchair friendly. There are two-lounge areas and a quiet room for service users to relax or use as an activity room. Each ‘arm’ of the ‘arrow’ shaped building converges into the service area consisting of the laundry and kitchen areas. Two dining areas have been tucked into the inside of each of the ‘arms’ of the home and adjoin the kitchen area and a tow ‘dead’ area that have been converted into courtyard’s, open to the elements and accessible by a door situated in the dining areas. Practical and stylishly designed to take full advantage of the space available, a lovely bright, airy home within the spacious grounds available to the SABP. Weekly cost; Was not Available. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by the Manager, yet to be registered, Miss Julia Schmidtke representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire from the home and notifications of significant events known as regulation 37. Comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page this Inspection report. The inspector was with staff and residents at Hillcroft for a period of 6½ hrs. This time was spent sampling resident’s care need assessments, care plans, contracts, and activities and talking to residents and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, allocation of staff skills, daily rotas and training. A tour of the premises was completed to ensure there was a reasonable balance of care, the active promotion of health and safety and the provision of a homely environment for the service users. CSCI surveys were sent to the home before the inspection for completion by service users, relatives and social and health care practitioners. The service users at the home live with a range of complex needs that included: physical, sensory and learning disabilities, Some service users were more able than others to communicate their care needs and opinions therefore staff had helped some to complete the CSCI surveys. It was not always appropriate or possible for service users to consult with the inspector during the inspection therefore observations of the care being delivered, at the time, form the basis of this report. The inspector would like to extend thanks to the residents staff and management at Hillcroft for their assistance and hospitality. What the service does well: Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 6 The Statement of Purpose was very informative and provided useful information about the home. Service users had each received a comprehensive assessment from their social care and health practitioners including: Care Managers, Psychiatrist’s and sensory impairment specialists. Service users were able to access the local community facilities and were encouraged and supported to maintain links with family and friends; Careful measures were taken to ensure the service users received nutritious food regularly at the home. Service users were able to make informed choices about matters of personal importance and staff responsibility for the administration of prescribed medication was beneficial to service users. Service users and their relatives were satisfied with the complaints process and measures taken regarding adult protection safeguards. The home complaint procedure was clearly written and placed in the statement of purpose. All interactions observed between staff and service users evidenced a degree of sensitivity. Consultation with service users and their representatives to the quality of care had been addressed. Records were generally in good order and services users participated fully when able. Health and Safety of staff and service users was respected and a staff will receive the required training to ensure adequate knowledge is available in all areas. What has improved since the last inspection? What they could do better: Staff Administering medication must provide a sample of their signature and initials to identify the when completing the MAR sheet and a copy placed with the MAR sheets. It was not always apparent whether the activities at the home and day centres were beneficial to the service user. Arrangements must be made for all staff to receive training for the safeguarding of vulnerable adults and all other policies regarding the promotion of protection such as acquiring knowledge of the whistle blowing procedures. Proper provision must be arranged for the health and welfare of service users by ensuring that adequate insurance is arranged to cover all possible risks and certificates to be displayed in a prominent position within the home and the manager must complete her Registered Managers Award. Recommendations included: That the Statement of Purpose would be complete by additional details of staff qualifications and room size and house plan and that it ensures that all parties Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 7 involved with the home receive a copy of the updated document and that the service review and update all long-term staff files A section is included in the service user ‘healthcare plan’ being developed that could be taken along to each appointment with the appropriate healthcare practitioner to complete, briefly detailing what action/treatment was required. A contact number for the sister home to Hillcroft, be included in the PRN action plan and the pharmacist was requested to use pharmacy stamp to authorise all return drugs that are not required. . 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. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 8 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 Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 9 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 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose that was very informative and provided useful information about the principles of the home but neglected to inform in other areas as defined by ‘The Care Homes Regulations’. Service users had received a thorough person centred assessment of care need but details of their contractual arrangements with the ‘SABP’ were not in evidence. EVIDENCE: The homes Statement of Purpose was in place in a predominant position located in the entrance lobby and contained important information about the homes philosophy and mission statement. Visitors to the home would be able to formulate a very good impression of the home and organisation of the Surrey and Borders Partnership (SABP) from reading this statement however there were no details highlighting the staff’s qualifications other than the managers or information about the structure of the house and size of the rooms. The new home is still developing the statement of purpose therefore it is recommended that the appropriate details be added and that it ensures that all parties involved with the home receive a copy of the updated document. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 10 A sample of three service user files were examined to establish whether adequate assessment of needs had been recorded to ensure care needs were able to be met at the home and form the basis of a care plan to be designed and used by the home. The principles of the care to be delivered were set out in the Statement of Purpose. Service users had each received a comprehensive assessment from appropriate social care and health practitioners including: Care Managers, Psychiatrist’s and sensory impairment specialists. Service users had recently moved into the new home and it was understood that their individual contracts were in place at the SABP’s head office. Please see the recommendations and requirements section of this report Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were good but were not always in the format most suitable for the service users who were encouraged to be actively involved. Service users could make good use of the local community despite complex and challenging behavioural care needs. EVIDENCE: Three service users care plan folders were sampled to confirmed how details of the comprehensive assessment had been transferred to an understandable and descriptive document that would direct and involve both staff and service user Clear care plan objectives of support were stated such as the ‘Relationship circle, containing details of family and significant other in the service users life. Care plans were easy to follow and comprehensive containing: details of disability, routines specific to the person, like and dislikes. Details of disability stated what kind of help and support was required: ‘I can’t see if clothes are dirty or clean’ and I suffer from dry skin for example. Important details about how service users communicated were included in the care plan detailing that were crucial to understanding how decisions could Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 12 be made, such as: finger in mouth indicates ‘that I am thirsty’ and the service user, ‘ points or states what he/she needs are and another service user ‘with will use just one word’. One care plan was not very specific detailing how one of the female service users indicated what her care needs were therefore this area of need was recommended for attention. The home was expected to support service `users to take acceptable risks in everyday lives. Under regulation 37 of the Care Standards Act (2001) the home must notify CSCI of any incident or accident that has involved the service user, therefore, a comparison of notification and risk assessment was made. Complete detailed assessments of risk were in evidence and comparable with the notifications received by CSCI these included the following examples: staff were directed to be aware of the service users : drinking too much fluid, choking, travelling, weight loss, bathing alone, travel sickness, picking up foreign objects and self harm. The correct procedures for staff to follow were in place and advised what action to take. Care plans were in need of review by the home and this process was in hand. The home were developing a more satisfactory care plan format to encourage and maximise the participation of the service users. Social care practitioners had reviewed two out of three care plans sampled. Please see the requirement section of this report. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 13 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, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were able to access the local community facilities and were encouraged and supported to maintain links with family and friends; however, it was not always apparent whether activities were beneficial to the service user. Careful measures were taken to ensure the service users received nutritious food regularly at the home. EVIDENCE: Service users were able to participate in activities appropriate to their needs and these included: daily walks around the ample and semi wild area were the home is situated and the there was also a day centre close by and within the St Ebbas complex and another in the local area. There were no specific details relating to the activities available at the day centres. Service users were able to access local community facilities and these were detailed in the each of their care plans. Bowling, visits to the local shops, Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 14 drives around the area and visiting the cinema were some of the activities listed. Holidays were planned for next year. Service users with complex needs observed during the inspection did not seem to be involved with any obvious activity although care was being provided. Day care services were being reviewed. Cultural and religious need was also in evidence such as regular church attendance Family links were maintained and welcomed to the home. Some service users relatives were also their advocates. One service user was paid the minimum wage to collect the post. Daily routines important to the service user were found it two of the three care plans, descriptions of routines such as; ‘I like to sit with my legs up and ‘always say my name before talking to me’ were to be found and the assertion ‘I am allowed to carry out my own rituals’ was listed in one of these. Relatives completing the CSCI survey were all satisfied with the overall care provided but some were concerned about the activities being ‘too passive’ and lacking in stimulation. A choice of food was available and displayed in menu provided and a food record book was kept. Service user care plans sampled showed that the service users were able to make their choices known and this was sometimes discussed at the service users meetings. Some service users required a specialised diet of pureed food and care plans showed favourite foods and advice about the requirements of service user preferences, such as, ‘sits at the same table, enjoys most foods, especially puddings however fresh fruit was available as an alternative. Staff take turns to cook the main meal in evening and encouraged service users to cook and make sandwiches at lunchtime. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were able to make informed choices about matters of personal importance. Staff responsibility for the administration of prescribed medication was beneficial to service users, however, recommendations were made. EVIDENCE: Hillcroft’s statement of purpose supports the aims of ‘individual choice’ in it’s mission statement and all other areas of service user preference were respected as much as practicable; clothes bought, daily choice of clothing to wear and other areas were being employed by the home. Some areas of care choice were limited due to particular health care need and were subject to guidance through the appropriate channel of need assessment. New booklets issued by the SABP, in a cartoon-pictorial format were considered to be patronising and childish by some of the service users, therefore, work with service users to develop appropriate healthcare plan formats were being actioned. Care plans contained details of health practitioners’ involved and up-to-date records of appointments and the ‘Care Plan Approach’ were appropriate. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 16 It was recommended that a section be included in the plan that can be taken along to each appointment for the appropriate health practitioners to complete briefly detailing what action/treatment was required. A sample of service user’s receiving regular prescribed medication was used to follow the audit trail recorded by the home and as stated in the policy and practice used at Hillcroft. Each service user’s photograph was visible and defined their prescribed medication record. Staff had completed training in this area before being allowed to administer the medication and training certificates were in place. Medication administration records (MAR) of the prescribed medication issued daily showed no irregularities and was clearly recorded Drug returns were all in place, dated and signed by the pharmacist. Staff administering medication had not supplied a sample of their signature and initials for ease of identification, when completing the MAR sheet. This must be completed and a copy placed with the MAR sheets. In the event of medication being required such as ‘pain-killers’ and epilepsy medication, safeguards were in place to ensure that staff that were not trained to administer medication, could contact a sister home nearby for assistance. It was recommended that the contact details, such as name and telephone number, despite being well known by staff, should be recorded and available in the homes policy and procedures. It was recommended that the pharmacist be requested to use pharmacy stamp to authorise each return. Please see the recommendation section of this report. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives were satisfied with the complaints process and measures taken regarding adult protection safeguards, however staff would benefit from regular training in the area. EVIDENCE: The home complaint procedure was clearly written and placed in the statement of purpose. There were no complaints recorded or reported during the inspection and there had been no reported incidents requiring the implementation of the Surrey Vulnerable Adults Procedures. Most staff were aware of the procedures for safeguarding vulnerable adults however some did not know what the procedures were or have any knowledge of the ‘Whistle-blowing’ procedures. The CSCI survey confirmed that the majority of relatives were aware of the complaints procedure, were satisfied with the overall care and that service users felt safe. It is recommended that the statement of purpose amend the section detailing contact with CSCI to include the following statement; complainants can contact the CSCI at any time during the complaint process. Please see the requirements section of this report. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users and staff had both benefited from the move into the new premises that was sensitively decorated and provided a clean, airy and comfortable environment. EVIDENCE: A tour of the premises revealed generous grounds surrounded by stout fencing enclosing; a tasteful wooden cabin styled summerhouse and separate shed used for storage. Grass had suffered due to draught order in place however patio plants were well looked after by the service users. Plans for the gardens cultivation were ongoing and may include a vegetable garden. The accommodation is a ‘listed building’ that has been carefully modernized creating a light and airy environment that was appreciated by staff and S/U’s consulted. The home is designed to accommodate the service users in two main areas that are either side of the entrance lobby each containing ground floor bedrooms, well equipped shared bathrooms, toilets, wet rooms and lounge Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 19 converging to meet the one main kitchen that was clean tidy and conformed with safety standards. The laundry room was well equipment with sluice, drying and hand, washing faculties. Access to the garden is by use of patio doors in the lounge areas. Small Lounge areas also offer choice of a quiet room for the service user. The home has two small courtyard areas open to the elements and assessable from doors off each of the two comfortable dining areas, this area may offer more possibilities for development. A service user showed the inspector around the home and his room that was nicely decorated, the furniture in the room was robust, stylish and the room had been decorated in the colour of his choice. Other service users were also able express the choice of wall colour, fixtures and fittings whenever possible. The flooring area situated over drain pipes and reported by the home to CSCI in June had been repaired and a good risk assessment completed: plans were available clearly showing the location of each of the drains in case of any future problems. Lighting was flush to ceilings throughout the home and were necessary created a pleasant ambience that was both restful and sufficient to provide adequate light to complete daily tasks. Overall the home had been refurbished in a practical and stylishly designed to take full advantage of the space available and maintain the integrity of the listed building to the benefit of the service users and staff who all said how nice the home was. The spacious grounds available to the SABP immediately outside the home and beyond is also waiting to be redevelopment. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 20 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): 32,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and service users evidenced a degree of sensitivity and respect. Staffing is kept under review and provided to meet the needs of the service users at all times. Action to ensure staff training was comprehensive and appraised within the supervision framework was required. EVIDENCE: The manager (yet to be registered) was well supported by staff and this was reflected by the good quality of care observed on the day of the inspection. Service users were not involved in any activity at the home and were observed relaxing and in some cases sleeping in various locations throughout the home. Staff were observed helping and talking with the service users, reassuring those that were anxious or busy with chores or chatting to those that had recently arrived and assisting at lunchtime. The three files randomly sampled were from long serving staff members totalling approximately 42 years of service. Inspection of the files showed there were some shortfalls with training needs. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 21 Some staff had received only one hours training for ‘adult protection awareness’ and others that were consulted did not know what to do in event of key client having and seizure or knowledge of whistle blowing procedures. Staff training in other areas, however, was sufficient to meet the needs of the service users adequately Two out of the three staff files sampled to confirm that adequate recruitment details were in place showed that in one case there was insufficient proof of ID but references and criminal records checks had been completed and were in place. The manager was satisfied of the suitability of the staff member in question due to their long service record it was recommended therefore that these details should be updated. The SABP is currently undergoing a huge change to the way it currently works. Information about the changes, for further details please contact their head office or access their website All staff has begun their supervision sessions with the manager and her deputy. The newness of the home has meant that there was a lot of catching up to do in relation to the training program. Staff will all have their appraisals completed by the end of September. Please see the requirements and recommendations section of this report. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Consultation with service users, their representatives and family relating to the quality of care had been addressed. Records were generally in good order and were appropriate services users participated. Health and Safety of staff and service users was respected and staff received the necessary training to promote health and safety in all areas, however, insurance details for the home were not available. EVIDENCE: The manager was waiting to complete her Registered Managers Award (RMA) and was confident that her recent experience gained from organising the successful move to the new home will help her to obtain. Written ‘Aims and Objectives’ was evidenced and included plans for the year regarding staff training and ‘quality assurance’, details of the quality assurance Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 23 exercise and a much needed review of activities of each ‘day-care’ service used by service users was listed for action. A sample copy of the homes quality assurance comment card, completed by a relative of a service user had been forwarded to the inspector. Quality assurance to ensure the inclusion of service users and their relatives and friends, health and care practitioners and other involved at the home are given the chance to comment on the quality of the care at the home was in place. A meeting with relatives had been arranged for later on in the month and the home had been actively recruiting new family members. Special care had been taken to keep in touch with families abroad. The home had worked extremely hard to ensure that all the people involved with the transfer of service users to the new property had been consulted. Health and safety training was in place for September, RIDDOR requirements were in place as were all other areas OK, Coshh cupboard, Repairs to drains completed and risk assessed. However, details of insurances were not available including: staff insurance for covering the driving of service users in the leased vehicle available, building insurance and public liability insurance. Risk assessment of the premises due in three months time. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 24 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 4 X X 2 X Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 25 NA 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 YA5 Regulation 5(1)(b)(c) &(2) Requirement Timescale for action 18/10/06 2. YA6 15(2)(b) 3. YA20 13(2)Sched’3 3(m) 4. YA23 13(6) The service shall provide a written guide to the care home which shall include: the terms and conditions in respect of accommodation to be provided for service users including the amount of fee’s, a standard form of contract for the provision of services and facilities. The registered person shall supply a copy of the service users guide to CSCI and to each service user. The Service must ensure that 18/10/06 care plans are regularly reviewed by the home and in a format that is appropriate and inclusive to the service user. The service must ensure that 18/10/06 arrangements for the recording, handling, safekeeping and disposal of medicines received into the care home is in place. The service must ensure that 18/10/06 arrangements for training staff and to prevent service users from being harmed or suffer abuse or being placed at risk DS0000067525.V302592.R01.S.doc Version 5.2 Hillcroft Page 26 of harm and abuse. 5. YA35 18(1)(c) (i) The service must ensure that at all times suitably qualified competent and experienced persons working at the care home receive training appropriate to the work they are to perform. 18(1)(c)(i)(ii) The service must ensure that at all times suitably qualified competent and experienced persons working at the care home receive training appropriate to the work they are to perform and suitable assistance including, time off, for the purpose of obtaining further qualifications appropriate to such work. 12(1)(a) The service must promote and make proper provision for the health and welfare of service users by ensuring that adequate insurance is arranged to cover all possible risk and certificates to be displayed in a prominent position within the home and staff files as appropriate. 18/10/06 6. YA37 18/10/06 7. YA42 18/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations It was recommended that the Statement of Purpose would be complete by additional details of staff qualifications and room’s size and house plan and that it ensures that all parties involved with the home receive a copy of the updated document. It was recommended that a section be included in the health plan being developed that can be taken along to each appointment for the appropriate health practitioners DS0000067525.V302592.R01.S.doc Version 5.2 Page 27 2. YA18 Hillcroft 3. 4. 5. YA20 YA20 YA34 to complete briefly detailing what action/treatment was required. It was recommendation that the pharmacist be requested to use pharmacy stamp to authorise each return. It was recommended that the contact details of the sister home to Hillcroft be included in the PRN action plan. It was recommended that the service review and update all long-term staff files. Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Hillcroft DS0000067525.V302592.R01.S.doc Version 5.2 Page 29 - 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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