CARE HOMES FOR OLDER PEOPLE
Hillcroft Residential Care Home 16-18 Long Lane Aughton Ormskirk L39 5AT Lead Inspector
Mrs Jennifer M Turner Key Unannounced Inspection 30th November 2007 10:30 X10015.doc Version 1.40 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 Residential Care Home DS0000063777.V350100.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hillcroft Residential Care Home Address 16-18 Long Lane Aughton Ormskirk L39 5AT 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) 01695 422407 01695 420866 sv22susan@aol.com Raycare Limited Application for registration pending Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 29 service users in the category of OP - (Old age, not falling within any other category). 7th February 2007 Date of last inspection Brief Description of the Service: Hillcroft is a converted three-story building set within is own grounds. There is car parking space at the front and side of the building. At the time of the inspection it provided personal care for 29 older people. There was an occupancy level of 24. The home is situated in the village of Aughton on the outskirts of Ormskirk where there is a range of community and leisure facilities. Accommodation is provided on two floors. Some double bedrooms are used for single occupancy. There are bathroom and toilet facilities upon each floor. Communal space consists of lounges, of which one has a conservatory extension and there is a separate dining room. Both stairs and a passenger lift are available for access to the first floor. The secure, well-maintained gardens are easily accessible and there is a small courtyard and patio area at the back of the building. The fees at the time of the inspection ranged between £342.50p and £386.00p. There were arrangements for relatives to pay “top up” fees of £25.00p for an ensuite room and £20.00 for no ensuite facility. There were also additional charges for newspapers and periodicals; hairdressing; dry cleaning; chiropody; dentist; optician; clothing and personal effects. This information appeared in the “Terms and Conditions”. Information about Hillcroft can be obtained from the home in the form of the Statement of Purpose and the Service Users Guide. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Occupancy 24 A key unannounced inspection, which included a visit to the home, was conducted at Hillcroft by two inspectors, on 30th November 2007 over seven and three quarter hours. During the course of the inspection, the acting manager, the deputy manager, care staff, a number of residents and relatives were spoken to. A number of residents and staff files were examined, procedures and records were also examined, activities were observed and the premises were viewed. Feedback was offered to the manager at the end of the inspection. Since the last key inspection, two further inspections have taken place. One was an unannounced random inspection on 21st March 2007 following up the concerns of a visitor about “the attitude of a staff member and a shortage of staff”. It was ascertained that the manager had spoken with the visitor concerned but the staff member could not be identified. Staffing levels were also discussed. Two additional requirements were made following the inspection. On 11th October 2007 a monitoring inspection was made to follow up the progress made toward meeting the requirements and recommendations relating to care planning and healthcare, which were made following the key inspection of 7th February 2007. Two requirements were made following this inspection and five requirements that had not been met had their timescales for action extended. Information from an Annual Quality Assurance Assessment document, three questionnaires received from residents and two from staff, contributed towards the findings. Requirements and recommendations made following the previous inspections were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. A questionnaire relating to a document “Equality and Diversity – A Guide For Providers” which had been forwarded by the Commission was also completed. A review of the conditions of registration also took place. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better:
The Statement of Purpose must be reviewed on a regular basis. ensure that people have up to date information about the home. This will Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 7 Prospective residents must receive a letter confirming whether staff at the home can meet their assessed needs or not. Care plans for each individual resident must clearly set out their personal, health and social care needs and how they are to be met. This will ensure that all staff will work toward the same goal. Care plans must be regularly reviewed and where, as a result of review, changes in a resident’s care needs have been identified, the care plan must be revised and amended to reflect this. Residents and/or their representatives must have the opportunity to be involved with the drawing up and review of care plans. This will ensure that they are aware of the decisions made and the reasons why the decisions have been reached. Risk assessments for health care issues such as falls, tissue viability, fitting of bed rails and going out should be completed. Staff who administer medication must have received the appropriate training. This will ensure that both staff and residents are protected. There must be complete and accurate records of medication received, administered and leaving the home. In the interest of health and safety, the laundry area should be cleared of the bags of clothes and the passageway cleared of litter. The sink unit also needs to be replaced. In the interest of safety a digital type lock should be fitted to the cellar door. The registered person must operate a thorough recruitment procedure at all times. This will ensure that residents are protected from unsuitable staff. A system for reviewing and improving the quality of care must be established and maintained. The Commission must receive a monthly report as outlined in this Regulation The Commission will be informed in writing of any incidents which occur under this regulation Information obtained in respect of pre admission assessments should be collated together and be clear and concise. Actions to be taken to meet resident’s needs within the care plan should be clearly outlined. This ensures that all staff will be attending to the resident in the same way Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 8 Information in respect of care plans and reviews should be clearly identified. The daily progress notes should contain accurate information about the care provided. This gives a true picture of the resident The registered manager should contact professionals to take advice on nutritional and tissue viability assessment. In the interest of health and safety, footplates should be affixed to wheelchairs whenever people are being moved. Medication policies should be reviewed in line with the Royal Pharmaceutical Society of Great Britain. This will ensure that the correct practices are being carried out. There should be adequate facilities for the safe storage of medication. Medication should be administered as prescribed. shared. Creams etc should not be In the interest of safety, secondary dispensing should not take place. Products with a “short shelf life” should be dated when opened. Entries on MAR sheets should have two signatures. Entries should be deleted and re-written instead of being altered. A criteria should be shown when required/variable medication is administered. These should be recorded. Medication must be recorded and administered in order for an audit trail to take place. The activity book should be kept up to date with the names and number of residents taking part. Information was to be transferred into the to daily record in residents files. Staff should record what people ate for their supper. This will ensure that there is a full record of what residents eat. The complaints procedure should be reviewed on an annual basis. ensure that people are aware if there is a change in procedure. This will The address of the Commission requires to be updated on all relevant documents. Complaints should be recorded in a paginated book with no loose pages. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 9 There should be a lockable facility available in resident’s rooms. enable them to retain anything which is of value to them. This will There should be a minimum of two double electric sockets in resident’s bedrooms. This is to prevent the use of adaptors. Some of the downstairs bedrooms needed window restrictors in the interest of security. In the interest of privacy, the Pink bathroom needed the glass windowpane to be replaced by opaque glass or a blind to be fitted. Liquid soap and paper towels need to be supplied in all communal bathing and WC areas. Hairbrushes, combs and disposable razors need to be moved from communal bathrooms in order to prevent cross contamination. Bedrooms 1 and 17 needed the carpets to be replaced. The manager must apply to the Commission to register. 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 Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1;2;3;6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information available to people was “out of date”. This meant that they did not have current information about the home available to them to assist with any decisions they wished to make. There was little evidence of a clear pre admission assessment procedure. This could result in people being wrongly assessed. EVIDENCE: A copy of the Statement of Purpose was obtained from the information rack in the hallway. It had not been reviewed since January 2005 although it did state on the front cover that, “The document will be reviewed every six months unless circumstances dictate that it should be reviewed earlier”. One section relating to “Emergency Admission” referred to another home, (Homestead) and
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 12 the address of the Commission in the Complaints section had not been updated. From the three service user questionnaires returned to the Commission, two stated that they had received a contract, whilst the third said they hadn’t but had received a copy of the Service Users Guide. The Acting Manager submitted information in respect of new residents in the Annual Quality Assurance Assessment form. It stated, “We encourage relatives to come at any time of the day to view. Don’t have to make an appointment; they can bring the future service user with them to look around. They are welcome to bring their own stuff from home. They are welcome to come in for day care or respite”. However, from information seen in people’s files, there was little evidence of a clear pre admission assessment procedure. However, information from social services and hospital discharge information was seen. The acting manager said she usually visited prospective residents either in their own home or hospital. She discussed her findings with the deputy manager and they decide whether or not to admit the person. She said that she had started writing to people to confirm that their needs could be met, but no copies of this correspondence was seen on files examined. The home does not provide Intermediate Care. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7;8;9;10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ diverse healthcare needs were not always recorded correctly and this meant that staff were not consistent when giving care. Poor medication practices meant that people were not protected by a robust medication procedure. Personal care was delivered in a way that promoted residents’ privacy and dignity. EVIDENCE: The manager was still in the process of reorganising the care records. The new format was lengthy and was difficult to navigate. Recording tended to be repetitive and was not clear in respect of what was pre admission information, what was post admission and what was a review. Documentation was available to cover all the necessary assessments, risk assessments, care plans
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 14 and review documents. However, none of the files examined were fully completed. Of the five people’s care plans examined, there was a lack of completed risk assessments relating to individual needs and circumstances eg some healthcare issues – falls, tissue viability, fitting of bed rails and going out. The bedrails seen did not have “bumpers” fitted to them. Care plans did not contain enough information in respect of physical and mental health needs in relation to mobilising. Records showed that when care plans were reviewed, residents and/or relatives were not always involved. Information from the three questionnaires received from residents indicated that two “usually received the medical support needed”. The third one indicated that they “always” received medical support and commented, ”Staff had observed that I had trouble seeing without me mentioning it and organised an eye test to help me”. The diary showed appointments for monitoring ongoing health needs and investigating new issues eg GP, district nurses, Macmillan nurses, hospital appointments, opticians, dentist, chiropodist, etc for a number of residents but there was nothing written in peoples daily notes or care plans, with regard to outcomes or advice received. Various health care policies and procedures were available but some had not been reviewed for over a year. The inspector mentioned to staff that footplates should be affixed to wheelchairs whenever people were being moved around in them. Both relatives spoken with were satisfied with the overall care. The medication and records were checked for a number of residents. A number of concerns were discussed with the manager. Some controlled drugs were kept in a trolley in an unlocked room. Staff were unaware that these were controlled drugs. When it was pointed out to them, the medication was taken to the locked cupboard where the controlled drugs are kept and an entry made in the appropriate register. There were conflicting instructions for the administration of some medication. Medication administered sometimes differed from written instructions. Of the four staff that administered medication, the manager said that she was the only one who had completed the required accredited training although the other people were awaiting appropriate courses. There were several indications that medication was not being given as prescribed. There were some plastic medicine pots and caps with people’s names on. The manager said they were used if a resident refused medication and staff had to “go back later”. The medication procedures were not in line with the Royal Pharmaceutical Society, as they had not been reviewed since 2005. Some medication was in a monitored dosage system but others were either kept in the door shelves of the cupboard or in plastic baskets. Items were mixed up and not named. Items that should have been stored in a fridge were left in the trolley. There were indications that medicines may have been shared as a number of rooms had creams belonging to other people. Records were not in place to record the receipt, administration and disposal of medication. Variable doses were not recorded and there was no criteria for medicines prescribed “when required”. Packets of medication with a short shelf life were not dated when opened and it was
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 15 impossible to audit medication not in the monitored dosage system. Two people did not sign the handwritten entries on the Medicine Administration Record (MAR) sheet. Some entries were altered and not rewritten. One relative commented, “Some carers are very caring and dedicated. However things would be better if staff communicated to each other at the end of shifts.” Residents spoken to felt the staff respected their right to privacy. Staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12;13;14;15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ dietary, social, cultural and spiritual needs were being met. They were able to make choices and decisions about their life at the home so that their lifestyle met their preferences. EVIDENCE: Peoples preferred term of address was noted in all care records seen. There were some preferences for routines in the assessment documents – preferences for mealtimes all coincided with mealtimes in the home. Forthcoming events were displayed on a poster in the hallway by the lounge, with photographs of recent events. Daily activities were recorded in an activity diary but it was not always completed. Some residents go out alone whilst others go out with relatives. A “preferred activity list” was seen on people’s files. Extra staff are available for outings but there is no designated member of staff to organise activities “in house”. Spiritual Leaders visited the home on a regular basis to offer the Sacrament. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 17 Visitors spoken with said that they were made welcome at any reasonable time. They could see people in private in their room or in the lounge areas. Staff said that it would be recorded in people’s files if they did not want to see someone. Local school children were due to visit nearer Christmas to sing Carols. Residents’ finances were dealt with by either themselves or their family. locked facility was available in bedrooms. A Records were seen of what residents had for breakfast, dinner and tea but not supper. There were no special diets catered for. People were asked for suggestions about what they would like for their meals. Staff were seen to be available to assist those who required it at mealtimes. Specialist equipment was available. One resident who had been at Hillcroft for a few weeks said that, ”The food’s nice enough” The weekly cleaning rota was seen for the kitchen. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16;18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were protected from abuse and had access to the homes complaints procedure EVIDENCE: The complaints procedure was included in the Service Users Guide and the “Terms and Conditions”. The procedure contained the necessary information should a resident wish to raise a concern with the home or the Commission. However, the address of the Commission required to be updated. Copies of the procedure were seen in people’s rooms. There was also a copy in the “Employees Handbook”. All of the residents who completed the questionnaires knew who to speak to if they were not happy. Both staff who returned questionnaires indicated that they knew what to do if anyone had concerns about the home. The complaints policy had been reviewed on 25/01/06 with a further review date of 27/05/07. No complaints had been recorded since the last key
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 19 inspection. The record consisted of a loose leaved book. A recommendation was made for a paginated record book to be obtained. A copy of the Department of Health document “No Secrets” was readily available along with the homes “Whistle Blowing” policy. Staff spoken with were aware of their responsibilities toward residents and said that appropriate training was available. Records showed that “Protection Of Vulnerable Adult” training had taken place with an external trainer. The acting manager discussed the referral system for the Protection Of Vulnerable Adults register. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19;22;24;26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all areas of the home provided a safe environment. More care needed to be taken to prevent resident’s belongings being left in communal areas. EVIDENCE: Hillcroft is a mature property set in its own grounds. The residents had access to the garden areas and there was a patio area for use in fine weather. Garden furniture was available. All bedrooms had single occupancy and some had an ensuite facility. A maintenance file was seen signed and dated when jobs were completed.
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 21 Aids and adaptations were seen in place in bathrooms and toilets. A “pull” cord was needed in the ground floor “walk in” shower. Hoists were serviced regularly. All bedrooms had door locks fitted but not all rooms had a lockable facility. The Fire record book was seen and all entries for servicing and testing the fire equipment were up to date. Some bedrooms required more electric sockets and it was recommended that some of the downstairs bedroom windows be fitted with restrictors in the interests of security. The upstairs pink bathroom had a plain glass window and it overlooked the front of the home. There was only a half length curtain available. Liquid soap was recommended in communal wash areas. A number of disposable razors, hairbrushes and combs had been left in some bathrooms. It was suggested that these be returned to their owner (or disposed of) in order to reduce possible cross infection. The carpet in Room 1 was heavily stained and needed to be replaced. The carpet in Room 17 was ripped and need replacing. Some creams were seen in bedrooms of other people. . The laundry was situated in the basement and was accessed by a door with a slide lock. The door opened onto a flight of stairs. There was an industrial washing machine that kept breaking down and the manager was attempting to have it replaced. Industrial dryers were on contract. There was no sluice facility. There was a hand wash sink that was dirty. The Unit was broken and covered in washing powder and liquid detergent. There was no liquid soap or paper towels available. The passageway was littered with paper and torn signs. There were a number of black bags filled with clothes that were being stored. The manager was advised to move these in the interest of health and safety as the boiler was also sited in the cellar area. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27;28;29;30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment process did not fully meet current legislation. This meant that residents were not fully protected by the current recruitment practices. However, staff received a variety of appropriate training. This meant that the diverse needs of the residents were met. EVIDENCE: Records showed that there were sufficient numbers of staff on duty to meet the diverse needs of the residents. Staffing levels were increased if it was felt that residents required more support. There was a duty rota, which showed the names of staff and the hours they worked each day. Separate ancillary staff were employed. It was suggested that the manager and administrator add their names to the rota. Of the twelve care staff, records showed that ten had completed the National Vocational Qualification at level 2 or above (83 ). Some staff were undertaking the qualification at level 3. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 23 Records showed that there was a low turnover of staff. The new manager had not recruited staff since taking up her post in March 2007. The files of three staff members were viewed. All were found to have some shortfalls in the documentation required by legislation. The recruitment process was discussed with the manager. From reading records and talking with staff, induction training, based on the Skills for Care Standards was offered. Training records were available to examine and showed a variety of training being offered both “in house” and external. Staff said that training needs were identified during their supervision periods. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31;33;35;38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality Assurance systems were not fully in place and needed to be developed to ensure that the welfare of the residents was sufficiently protected. EVIDENCE: The manager has been in post since March 2007. At the time of the inspection she had not applied for registration with the Commission. She holds an NVQ 3 in Care and an NVQ 3 in Management. She has registered for the Registered Managers Award.
Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 25 Records showed that the management team were committed to Quality Assurance. In addition to the Investors In People Award, it is a “Preferred Provider” with Lancashire County Council. An annual development plan was not available as the manager said that the proprietor dealt with this, but as she meets with him on a weekly basis she said that she knew what the priorities were. Although Regulation 26 reports were being forwarded to the Commission there do not appear to have been any received between April and November 2007. The manager produced a further report during the inspection. Family and friends questionnaires were completed every two months and any comments were discussed at staff meetings. Residents’ comments were referred to in the Service Users Guide. It has been mentioned previously in the report that policies and procedures were being reviewed approximately every three years. The manager is aware that these must be done on an annual basis at least. The manager was not an appointee for any resident. The manager said that personal financial affairs were dealt with by the residents themselves, their next of kin or family. Training records showed that staff members had participated in training relating to safe working practices. Infection control procedures were available. Records showed that regular servicing of equipment takes place by authorised and qualified contractors. Cleaning materials were stored safely. The reporting of accidents was discussed and the manager was given advice in respect of how to store reports and what accidents needed to be reported to the Commission under Regulation 37. The manager felt that the home complied with relevant legislation. There was a set of health and safety procedures available although they were in need of reviewing. Staff said that meetings were held on a monthly basis but no minutes were available. An agenda was compiled before meetings. The manager said that she tried to meet with residents every two months, but again no minutes were available. No risk assessments were completed in respect of the storage of denture cleaner. The manager said that she was unaware of any potential risk. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 1 OP1 4,6 and The Statement of Purpose must 31/03/08 Sch 1 be reviewed on a regular basis. 2 OP3 14 (1) (d) Prospective residents must 31/03/08 receive a letter confirming whether staff at the home can meet their assessed needs or not. 3. OP7 15 Care plans for each individual 31/03/08 resident must clearly set out their personal, health and social care needs and how they are to be met. (Brought forward from 30/08/06). Timescale of 30/04/07 not met. 4 OP7 15(1)(2) Care plans must be regularly 31/01/08 reviewed and where, as a result of review, changes in a resident’s care needs have been identified, the care plan must be revised and amended to reflect this. (Brought forward from 30/08/06). Timescale of 30/04/07 not met. 5 OP7 15(1) Residents and/or their 31/01/08 representatives must have the opportunity to be involved with the drawing up and review of care plans. (Brought forward from 30/08/06). Timescale of 30/04/07 not met. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 28 6 OP7 12 (1)(a) (2) 18 (1)(a)(c) 17 (1)(a) Schedule 3 (i) 23 (2)(b)(l) 7 8 OP9 OP9 9 OP26 10 11 12 OP26 OP29 OP33 23 (2)(b) 19 24 13 14 OP38 OP38 26 37 Risk assessments for health care issues such as falls, tissue viability, fitting of bed rails and going out should be completed. Staff who administer medication must have received the appropriate training. There must be complete and accurate records of medication received, administered and leaving the home. In the interest of health and safety, the laundry area should be cleared of the bags of clothes and the passageway cleared of litter. The sink unit also needs to be replaced. In the interest of safety a digital type lock should be fitted to the cellar door. The registered person must operate a thorough recruitment procedure at all times. A system for reviewing and improving the quality of care must be established and maintained. Previous timescale of 30/04/07 not met. The Commission must receive a monthly report as outlined in this Regulation. The Commission will be informed in writing of any incidents which occur under this regulation. 31/01/08 31/01/08 31/01/08 31/03/08 31/12/07 31/01/08 31/03/08 31/12/07 31/12/07 Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 29 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 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Refer to Standard OP3 OP7 OP7 OP7 OP8 OP8 OP9 OP9 OP9 OP9 OP9 OP9 OP9 OP9 OP12 Good Practice Recommendations Information obtained in respect of pre admission assessments should be collated together and be clear and concise. Actions to be taken to meet resident’s needs within the care plan should be clearly outlined. Information in respect of care plans and reviews should be clearly identified. The daily progress notes should contain accurate information about the care provided. The registered manager should contact professionals to take advice on nutritional and tissue viability assessment. In the interest of health and safety, footplates should be affixed to wheelchairs whenever people are being moved. Medication policies should be reviewed in line with the Royal Pharmaceutical Society of Great Britain. There should be adequate facilities for the safe storage of medication. Medication should be administered as prescribed. Creams etc should not be shared between people In the interest of safety, secondary dispensing should not take place. Products with a “short shelf life” should be dated when opened. Entries on MAR sheets should have two signatures. Entries should be deleted and re-written instead of being altered. A criteria should be shown when required/variable medication is administered. These should be recorded. Medication must be recorded and administered in order for an audit trail to take place. The activity book should be kept up to date with the names and number of residents taking part. Information was to be transferred into the to daily record in residents files. Staff were to record what people ate for their supper. The complaints procedure should be reviewed on an annual basis.
DS0000063777.V350100.R01.S.doc Version 5.2 Page 30 16 17 OP15 OP16 Hillcroft Residential Care Home 18 19 20 21 22 23 24 25 26 27 28 OP16 OP16 OP22 OP24 OP24 OP24 OP24 OP24 OP24 OP24 OP31 The address of the Commission requires to be updated in the complaints procedure. Complaints should be recorded in a paginated book with no loose pages. An emergency pull cord was needed in the downstairs “walk in” shower There should be a lockable facility available in resident’s rooms. There should be a minimum of two double electric sockets in resident’s bedrooms. Some of the downstairs bedrooms needed window restrictors in the interest of security. The Pink bathroom needed the glass windowpane to be replaced by opaque glass or a blind to be fitted. Liquid soap and paper towels need to be supplied in all communal bathing and WC areas. Hairbrushes, combs and disposable razors need to be moved from communal bathrooms in order to prevent cross contamination. Bedrooms 1 and 17 needed the carpets to be replaced. The manager is to make an application to be registered with the Commission. Hillcroft Residential Care Home DS0000063777.V350100.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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