Inspection on 30/08/07 for Hillcroft

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillcroft 14/08/06

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Suzanne Magnier Unannounced Inspection 30th August 2007 12.00 Hillcroft DS0000067525.V343626.R02.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.V343626.R02.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.V343626.R02.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 and Borders Partnership NHS Trust Miss Julia Schmidtke 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.V343626.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2006 Brief Description of the Service: Hillcroft is a large detached property owned by the Surrey and Borders Partnership NHS Trust and is situated within the grounds of the old St Ebba’s hospital site. The registered residential home offers accommodation and care for 10 individuals with learning disabilities whose ages range from 39 years to over 65 years. The home is near to Epsom town. Public or other transport would be required to reach the shopping centre however there are some local shops nearby within walking distance. The purpose built home is on ground level and offers ten individual bedrooms with en suite facilities. Communal bathrooms and shower/wet rooms are available and also accessible to people who use wheelchairs. There are two-lounge areas and two dining areas, a quiet room for people to relax or use as an activity room and a laundry and kitchen area all of which are accessible to people living in the home. The home has enclosed courtyards and garden areas, which can be used by people if they wish. The current fees of the home vary according the needs if the individual however some fees were noted as £ 1,741.36- £1766.20 per week. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection. The registered manager represented the home. For the purpose of the report the individuals using the service are referred to as people/individuals living in the home. The inspector arrived at the service at 12 midday and was in the home for three and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and the written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, and several of the services policies and procedures. Following the previous key inspection in August 2006 the service has met all the requirements made. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The inspector would like to thank the people living in the home, the staff and the manager for their time, assistance and hospitality during this inspection. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A previous requirement that the home must provide a written guide regarding the terms and conditions in respect of accommodation, the amount of fee’s and a standard form of contract for the provision of services and facilities had not been fully met. The inspector evidenced that the manager had sent electronic correspondence to the Trust yet this information had not been made available to the home. A further requirement has therefore been made. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillcroft DS0000067525.V343626.R02.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.V343626.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5, Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The arrangements for a needs assessment for prospective individuals ensure that their needs are assessed and identified before admission to the home. All individuals in the home must have an up to date copy of their terms and conditions of stay in the home. EVIDENCE: The home has had no admissions since the previous inspection. Arrangements are in place for the manager or senior staff to undertake assessments to assess the individual needs of people prior to moving into the home. The inspector sampled assessments of two people who had resided in the home since it opened last year and noted that the documents were robust to ensure that the home could meet the needs and choices of lifestyle for the individuals. A previous requirement that the home must provide a written guide regarding the terms and conditions in respect of accommodation, the amount of fee’s and a standard form of contract for the provision of services and facilities had not been fully met. The inspector evidenced that the manager had sent electronic Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 10 correspondence to the Trust yet this information had not been made available to the home. A further requirement has therefore been made. A comment regarding this matter was received by the CSCI and stated ‘The commissioners never tell us about care contracts and costs concerning our relative. Extracting information is difficult as queries tend to be treated as Freedom of Information request with consequent delays. Since May 2006 the County Council have been demanding contributions to care which would leave our relative with inadequate funds to cover clothing, personal affects, transport, holidays etc there is no explanation yet forthcoming why Section 28a transfer of funds from the primary care trust as an ex long stay hospital patient’. The home has maintained close bonds between people living in the home and staff and it is apparent through observation that the individuals diversity of needs and preferences of lifestyles are promoted to ensure that all people continue to have a sense and awareness of their individuality. Hillcroft DS0000067525.V343626.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has maintained robust care planning and risk assessments. The documents were current and well recorded to ensure individuals wellbeing and health needs were evidenced as being met. People make decisions regarding their lives and participate in the running of their home. EVIDENCE: The home has developed and maintained a good standard of care/person centred plans. The two plans sampled by the inspector, contained evidence that each person had been involved in some way with the development of their plan. For example each plan contained documentation of how the person liked to be addressed, how they chose to communicate, people that were important in their life, how they like and choose to receive support and personal care and the individuals ethnic and cultural background. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 12 It was also noted that each care plan had been kept under review to reflect the changing needs of the individual and arrangements in place to continue to support the person. Each person living in the home has an assigned key worker and the inspector noted that there were clear documented roles and responsibilities within the service regarding the key workers duties. The care plans contained well documented clear agreed working practice which staff implemented to offer a consistent and predicable response to the needs of people in the home. It was noted that the home offers support to individuals with a range of complex needs and this diversity was well managed by home. Comments received by CSCI regarding the home included ‘My brothers needs always appear to be met. He is very happy although his vocabulary is not vast I am sure he would let me know if something was amiss. I think the care home is perfect for my brother. I would like a bit more parking space outside the house’. ‘A great improvement in recent times since the relocation into a family like home. Our relative is very happy with his present life’. ‘Considerable effort is made to discover our sons wishes which is difficult as he has no language’. ‘From my own observations the service does appear to respect the persons dignity and privacy’. ‘From my observations the home does appear to provide support in relation to individuals different needs’. One individuals comments included ‘I came here for visits. The staff ask me about decisions I want to make. I’m living here at Hillcroft its much nicer than my previous home. They look after me’. During the site visit the inspector noticed that people were moving around their home freely and the inspector met with all the people living in the home. One individual answered the front door and told the inspector where the manager was, others showed the inspector several areas throughout the home whilst others preferred to stay in their own space and not openly engage. One individual was helping the staff assemble a computer table by working hand over hand with the screwdriver and engaging with a staff member whilst she was making lunch. The home has maintained robust risk assessments which include a variety of activities undertaken by individuals for example bathing, eating and drinking, using the homes vehicle, being in the kitchen, vulnerability in the home, accessing the community and incidences of behaviour which tests the service. All the risk assessments had been appropriately reviewed to ensure the safety and welfare of the individuals and staff. The home supports individuals from ethnic minorities and also has a multi cultural staff team. Individuals were eager to tell the inspector about the Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 13 home and all spoke or communicated that they liked living in the home and were happy. It was evident through sampling records and observation in the home that staff members continued to support people with diverse needs in a caring and individualised way in order to promote their individuality and sense of identity. The home has a flexible yet structured atmosphere, which was observed to promote peoples rights to freedom of choice in their home. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home promotes and maintains peoples involvement in their community, offers opportunities for personal development, appropriate activities and maintaining friendships. Individuals are encouraged to be involved in the running of the home and improving daily living skills. The available choice of food provided was of a good standard. EVIDENCE: During the inspection an external agency visited the home to participate in a singing and interactive sensory session with several people in the home. One person who had been out in the morning returned home and was noted to be calm and relaxed upon return. One person showed the inspector their bedroom, which contained photos of their family and also an achievement certificate. The person also showed the Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 15 inspector their weekly activity plan, which include horticulture and other meaningful activities. Several people in the home told the inspector that they had been on holiday to Butlins in Bognor Regis and really enjoyed the time away. The manager and inspector spoke at some length regarding the improvements the home has made in supporting individuals to make choices and have a voice. It was recognised by the home that both the people living at Hillcroft and the staff had become institutionalised (prior to moving to the home) over the years and this was now being addressed by both parties and had been a challenge throughout the last year. The manager explained that a new way of working which involved actively seeking the views of people living in the home had been adopted and the efforts were being observed in peoples daily lives and the choices they make on a day-to-day basis. As a result of these developments the manager explained that the staff have reconsidered their flexibility which enables outreach activities when people ask to go shopping, or buy some toiletries, want to go to the barbers, bowling or have a cappuccino. The manager explained that these may be small things to people who are used to making decisions and choices but to the individuals living at Hillcroft these have been breakthrough choices which reflect the ethos of the home to enable people to have as much choice as possible in their lives and have the right to say no when they do not wish to do something. The activities which people take part in are varied and include daily living skills such as dusting, hovering, sandwich making, and putting clothes in the washing machine/dryer. The manager and inspector spoke at some length regarding the development in the home of documentation to identify people’s goals relating to their strengths and building upon these of strengths to continue to empower and promote individual’s independence and self esteem. The manager advised that she was looking into this further development as all the people in the home had now settled in the last year and had made such progress. Some activities outside of the home included horse riding, going to the cinema, going to the beach, shopping and going to the supermarket and whilst there going to Starbucks for coffee and a sandwich. One person told the inspector that they wanted to go to Great Yarmouth and the Isle of Wight. Comments received from relatives regarding the home and activities offered by the home included ‘When I unable to take my relative home on a weekend which I have always and still do I would like him to be taken to church (which I do) as we are Roman Catholic’. ‘Finding suitable day services is not easy. Our son comes home each weekend, He enjoys his dual life style’. ‘More spontaneous communication about daily activities for example after a recent weekend holiday to Butlins in Bognor the only responses we achieved were Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 16 ‘fantastic’ ’everyone enjoyed it’ but no information about what they actually did’. ‘She has stated clearly that she likes living at Hillcroft and has a varied weekly routine. She decides the activities with the help of her carers’. One comment received by CSCI stated ‘Transport difficulties and a lack of staff to escort clients to outside activities e.g. gym swimming’ was discussed with the manager who advised the inspector that the home does not offer gym or swimming so was unsure regarding the meaning of the comment in relation to the home as individuals have physiotherapy and hydrotherapy if this is ascertained as a specific health care need. The inspector observed that the homes dining areas were spacious and airy and contained suitable furniture to support people to eat their meals in a comfortable setting. One member of staff was in the kitchen preparing the lunch, which comprised of homemade courgette pancakes, prawn vol au vent, sandwiches and cold drinks. People living in the home told the inspector that they liked the food and one person showed the inspector the menu board in the dining room, which advised that gammon and vegetables would be served for the evening meal. Although there was no documented evidence of an alternative meal it was evident that the staff would offer choice to someone if they did not wish to have the meal that was served due to the philosophy and ethos of the home in promoting peoples choice and rights. The homes fridges and freezers contained, appropriately stored foodstuffs and fresh fruit and vegetables were also available. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that individuals receive personal care and attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of individuals. EVIDENCE: The two care plans sampled included clear records to demonstrate that the individuals receive personal care in the way they prefer and health care appointments were attended for example visits to the dentist, optician, GP and chiropodist. Records to monitor the individuals specific health care concerns were also well documented and included weight charts, dietician advice, continence management, physiotherapy and occupational therapy with regard to specialist equipment. The health care records also evidenced that the home had close working relationships with health care professionals. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 18 Records indicated that care plan reviews had taken place and the home were active in seeking advise and support from healthcare professionals should the need arise to ensure the safety and well being of individuals. Comments received by CSCI from health care professionals included ‘this individual has an up to date health assessment and has regular access to her GP. The health action plan is in place, reviewed regularly with her and relevant professionals’. ‘this person is dependant on her carers in relation to her managing her medication’. ‘ is a person with complex issues who needs support from individuals who are confident and experienced. She is able to manage on a day-to-day basis if she feels supported’. ‘Staff are very experienced in managing the people they care for particularly from the health point of view. They have good care plans and staff from the local CTPLD team enjoy working with the home’. The home had followed the recommendation made at the last inspection and had implemented a section in the health plan for the appropriate health practitioners to complete to detail what action/treatment was required. The home has a comprehensive, medication policy and procedure regarding administration of medication. The medication is stored in a locked cabinet in the home in order to protect people from harm. The inspector sampled two medication administration charts, which were in good order. An audit by the dispensing chemist had been attended in 2006 and all staff have received training in the administration of medicines. Additionally some staff members had been trained to support one service user with specific medication needs. The home had followed the recommendation made at the last inspection to request that the dispensing pharmacy stamp to authorise each return of medication from the home. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made a range of evidence including a visit to this service. The home has a robust complaints procedure to demonstrate that complaints will be acted upon and a Safeguarding Adults (Adult Protection) policy and procedure to ensure that individuals are adequately protected by the same policy and procedure. EVIDENCE: The home has a complaints procedure and the manager explained that no complaints have been received by the home. During the site visit the inspector asked several individuals what they would do if they were unhappy. The individuals said they would go to their relatives, manager or staff and would feel confident that their concerns would be listened to and dealt with. The comment cards received by the inspector also indicated that people knew how to complain or raise concerns and comments included ‘ I want to stay at St Ebbas. I came for visits. I know who to speak to if I am not happy I would tell the doctor, my sister or staff I’m all right. They look after me’.’ I know what to do if I wasn’t happy I’d talk to staff, my community nurse and doctor’ Comments from visitors to the home regarding the complaints process advised that they did not know how to make a complaint and but stated that ‘they do a good job and I have no complaints’. Another comment stated ‘It can take a long time for the Trust to deal with issues combined with long periods of silence and no advice whether progress has been made (re complaints). Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 20 The home has not been subject to any safeguarding referrals since the previous inspection. The manager explained that staff had received training in safeguarding vulnerable adults and awareness of safeguarding issues were also explained in the staff induction training. Training plans were sampled by the inspection to verify this information. The manager advised that one person, with the support and knowledge of their care manager, visits local areas in the vicinity of his home. The neighbours have not been happy about the person’s presence in the local community and have contacted the home to address this concern. The manager explained that written guidelines have been shared with the parties concerned and the care manager has been fully informed and is aware if the situation. The inspector has advised that due to the concern it would be suggested to the home to formalise the concern and address it in writing detailing the guidelines already in place to the persons concerned. The inspector was advised that the documented guidelines and risk assessments are in place to safeguard the individual from harm. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30 Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home offers a clean, comfortable and homely environment. People’s bedrooms reflect their individuality. Communal areas, including bathrooms in the home were spacious, well decorated and maintained to meet the current needs of individuals. EVIDENCE: The homes continue to offer a homely, clean and comfortable environment. It was apparent that the manager and staff have made a significant effort to provide attractive ornaments and household furnishings, which greatly enhance the home to make it feel like home. The homes lounges, quiet area and dining areas were spacious and well decorated. The home has several dining tables and chairs, which offer people the opportunity to choose to sit in small groups rather than around a large table. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 22 One individual showed the inspector their room and said they were happy with the colour, as they had chosen it. The room contained personal possessions, including furniture of their choice, framed family photos, certificates of achievements and spiritual icons, which reflected their individuality. During the tour of the premises the inspector noted that all individuals rooms were decorated to a high standard and were areas, which offered individuality and peoples own space. The inspector noted that the homes bathrooms, showers and toilets were in working order, clean and well decorated with homely ornaments. Individual’s comments about their rooms were ‘ I have my own room’ ‘It’s a nice room’. Comments from visitors to the home included ‘ the environment is excellent, clients are happy’. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offer a good induction and training development programme to ensure that staff are competent to support the needs of the individuals. Robust staff recruitment practices have been maintained to ensure the protection of individuals. EVIDENCE: Comments received by the commission regarding ‘I believe that the carers are highly experienced and skilled professionals who also passionately care about the needs of the client group’. ‘Sometimes agency staff are employed. It helps but they are not really familiar with the residents’. ‘Often have to use agency staff, some regular staff are excellent, The staff are very caring and kind, my friend is very happy at Hillcroft’. It was observed that the staff on duty were confident and competent in supporting and encouraging individuals there was a sense of ease and it was noted that individuals responded favourably to staff. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 24 The home is currently employing eighteen staff including a deputy manager. The manager explained that the use of agency staff is kept to a minimum with only regular agency staff employed to offer continuity of service to the home. All agency staff have their CRB (Criminal Records Bureaux) checks confirmed with the agency by the home and have a full induction of the service. The manager advised that no recruitment of staff had been undertaken since the previous inspection. No requirements had been made regarding the homes recruitment practices at the last inspections and therefore no staff files were sampled. Training records evidenced that the home have a planned training programme which includes mandatory training for example fire safety, moving and handling, food hygiene, health and safety including risk assessments. In addition specialist training was also available for staff, which included epilepsy, medication, stress, eating awareness and nutrition, intensive interaction and stesolid training. The manager explained that three staff have achieved their level 2 National Vocational Qualification (NVQ) with three other staff having completed their application to commence their qualification. Staff spoken with during the inspection stated that they felt well-trained and equipped to do their work and that the home and management were supportive to their training needs. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The overall management of the home is robust and individuals and their representative’s views are considered. Health and safety arrangements are in place to ensure the safety and welfare of all people in the home. EVIDENCE: The management of the home has been maintained to provide a consistent, effective and happy atmosphere for people living in the home and also for staff working in the home. The registered manager is working towards achieving the registered managers award and throughout the inspection demonstrated a sound knowledge of the responsibilities of her position and skills in management of the home. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 26 Comments received by the commission regarding the management of the home included ‘I am quite happy with the care my relative receives and am aware that the staff at the home are constantly looking for ways to improve.’ ‘The shift system can cause information loss on occasion’. ‘Sometimes communication failures are hampered by language problems. Nevertheless the staff is a stable group committed to giving care’. The staff group spoke highly of the manager stating that they felt the home was well managed and the manager was approachable, clear in the homes objectives and it was good to work in such a happy place with a manager who was committed to the individuals living in the home and the staff. The inspector observed that the office location was central to the home and people and staff have access to the manager. It was evident during the site visit that some individuals were encouraged and able to voice their opinions about the service and attend home meetings if they chose to. The home has developed a quality assurance action group which actively seeks the views of all people connected to the home however the manager explained that the process is still in its infancy and during the year the assurance process will be further developed. The inspector sampled a variety of health and safety records, which included water, fridge and freezer temperatures, accident and incident records, fire drills, (a fire test was carried out during the inspection) practices and noted that the fire extinguishers had been serviced. In addition the Environmental Health Officer had recently inspected the home. Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 27 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 X 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 X 3 X 3 3 X X X Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(b)(c) Requirement 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. Timescale 18/10/06 not met. Timescale for action 30/10/07 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 Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillcroft DS0000067525.V343626.R02.S.doc Version 5.2 Page 30 - 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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