Inspection on 01/11/05 for Hillersdon Court

This inspection was carried out on 1st November 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Hillersdon Court 12/06/07

Hillersdon Court 01/08/06

Hillersdon Court 11/07/05

Hillersdon Court 16/11/04

Hillersdon Court 17/06/04

Hillersdon Court 23/09/03

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hillersdon Court 18 College Road Seaford East Sussex BN25 1JD Lead Inspector Nigel Thompson Announced Inspection 1st November 2005 09:30 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 Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 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. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillersdon Court Address 18 College Road Seaford East Sussex BN25 1JD 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) 01323 897706 Mr James Lord Mrs Sylvia Lord Mrs Kathleen Waller Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That service users must be aged sixty-five (65) years or over on admission. That a maximum of twenty (20) service users are accommodated. Date of last inspection 11 July 2005 Brief Description of the Service: Hillersdon Court is registered to provide residential care and support for up to twenty older people. The premises comprise of a large detached house, which has been extended over the years. The home is situated close to the shops and railway station in Seaford town centre and within walking distance of the seafront. Service user accommodation comprises of seventeen single rooms and one double room, eleven of which have en suite facilities. All rooms are fitted with a call bell system. The proprietors of Hillersdon Court also own Bybuckle Court, another care home for older people situated in the Seaford area. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over five hours in November 2005. It found that all of the twenty National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were fifteen service users living at the home. The inspection involved a tour of the premises, examination of the homes records, discussion with the manager and consultation with two members of staff and six service users. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. What the service does well: The relaxed, homely and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. The level of care provided to service uses continues to be of a high standard and this is reflected by the ‘word of mouth’ recommendations and referrals to the home and by the number of service users from different generations of the same families who live and have lived at Hillersdon Court. Effective systems are in place for the admission and ongoing care of service users. Individual care plans developed from comprehensive pre-admission assessments, ensure that an individual’s needs are met in a structured and consistent manner. Communication and consultation with service users’ family members is effective and ongoing. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. Staff receive effective induction and foundation training, regular supervision and are clearly valued and supported by the manager. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 The improved admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. EVIDENCE: Since the previous inspection there have been five service users admitted to Hillersdon Court and it is evident from documentation examined that the relevant procedures have been improved. Service users’ files were found to contain completed assessment forms, however it was noted and discussed with the manager that the recording format itself could be reviewed and restructured. At present there is insufficient detail or inappropriate information recorded by the use of tick boxes. As an example, the first section deals with ‘foot-care’, which it is acknowledged does not constitute a priority need and would certainly not determine whether or not an individual should be admitted to the home. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 9 The overall structure and organisation of the files has been improved, as recommended, since the last inspection, making information more readily accessible. It was also noted in files that were examined that the ‘Contract of Residence’, relating to new service users, was fully completed and had been signed by both the individual service user (or their representative) and the manager, on behalf of Hillersdon Court. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Service users’ care plans are developed from a comprehensive assessment of an individual’s needs and enable staff to meet such needs in a structured and consistent manner. EVIDENCE: Improvements to the admission process and on going care provision were evident since the previous inspection, particularly with regard to appropriate documentation. Service users’ care plans that were examined were found to be more structured and organised, making information more readily accessible. It was also evident that, as required, care plans now contain more detail regarding action to be taken by staff. As discussed with members of staff, this is important to ensure that service users’ care is provided and their individual support needs are met in both a structured and consistent manner. Service users commented positively on the care that they receive: ‘I am quite satisfied with the care and attention that I receive. Help is at hand when I need it’. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 11 It was evident that regular reviews of individual care plans are carried out, involving the service user and, where appropriate, a relative or other representative. However, following discussion with the manager, it is recommended that the recording format for these reviews be amended and improved, to reflect any significant changes in need or circumstances. The manager emphasised that the health, safety and welfare of service users is a priority within the home. She confirmed that all service users are registered with local GPs and are able to access additional health care services, including district nurses and chiropodists, via the surgeries, as necessary. Nutritional screening is carried out as part of the initial assessment procedure. The manager confirmed that there is currently no incidence of pressure sores in the home. Regular ‘gentle exercise’ classes, provided as part of the home’s activities programme, continue to be popular among service users. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 11 July 2005. EVIDENCE: Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 11 July 2005. EVIDENCE: Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26 The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: It was noted that furniture in some service users’ rooms had been replaced or upgraded and that rooms were looking cleaner, fresher and generally better maintained than during the last inspection. Many of the rooms have been personalised, with pictures, family photographs and other small items of furniture and personal belongings, to reflect individual taste, choice and preference. There are sufficient baths and toilets throughout the home. Eleven of the service user’s rooms are fitted with en-suite toilet and washbasin facilities. An assisted bathroom is situated on each floor. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 15 The possibility of converting an unassisted and currently unused bathroom into a shower room has been considered for some time and was discussed with the manager during a previous inspection. Such a conversion would clearly be of benefit to the more independent service user. One of the two bath seats has been upgraded, as recommended, since the previous inspection. The light and spacious lounge provides a comfortable focus for many of the daily recreational and leisure activities in the home and clearly meets the individual and collective needs of the service users. A pleasant dining area provides a relaxed, homely and sociable setting for meal times. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 There are sufficient trained and competent staff on duty at all times to meet the assessed care and support needs of the service users. Thorough recruitment procedures help to ensure the safety and protection of service users. EVIDENCE: The stable and dedicated staff team is clearly able to meet the assessed, individual and collective needs of service users within the home. The manager confirmed that additional staff are employed at peak times to assist with the personal care needs of service users. Personal files, relating to recently appointed members of staff, were examined and found to be well maintained, containing all necessary information, including two written references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. All new staff are provided with and sign a written contract, including a statement of terms and conditions. However it was noted that one individual contract had not been fully completed or signed. This was discussed with the manager, who is to address the matter. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 17 Although staff training is currently recorded in individual files, following discussion with the manager, it is recommended that a ‘training matrix’ be developed to provide a diarised programme of all training and enable relevant information to be appropriately recorded and readily accessible. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Service users and staff benefit from the manager’s calm, open and approachable style of leadership and clear and positive sense of direction. Staff are aware of and adhere to up to date policies and procedures relating to health and safety, ensuring the health, safety and welfare of service users and staff. EVIDENCE: The registered manager is competent and experienced and has been in her current post since 1993. She has completed the City and Guild Advanced Management for Care and undertakes periodic relevant training, including refresher training to update her Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 19 knowledge and skills. She has recently attended a ‘Staff supervision and appraisal’ workshop. The manager continues to provide all care staff with formal supervision on a six weekly basis. As previously documented, she also operates an ‘open door’ policy, with staff able to discuss any issues at anytime. Staff spoken with confirmed the support and training they receive and acknowledged the personal benefit of effective supervision. Despite a previous requirement, there is still no evidence that the registered providers carry out regular monitoring visits to the home, in accordance with Regulation 26 of the Care home Regulations 2001. To ensure compliance with this regulation, the providers shall visit the home, unannounced, at least once a month, inspect the premises and consult with staff, service users and where appropriate their representatives. A subsequent report of their findings is to be forwarded to the CSCI. Notwithstanding the evident lack of involvement of the providers, the home operates effective quality monitoring systems, including regular residents’ meetings and recently introduced satisfaction questionnaires for both service users and relatives. Since the previous inspection, relatives’ questionnaires have been sent out – with a limited but generally positive response: ‘Staff treat residents and visitors alike with kindness and courtesy’. ‘The care shown to everyone is top quality’. ‘The friendliness and warmth of the home is very apparent’. The manager confirmed that the health, safety and welfare of service users and staff remains of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 21 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 OP33 Regulation 26 (1,2,3,4 & 5) Requirement It is required that the provider visits the home at least once a month to inspect the premises, monitor the conduct of the home and prepare a written report. A copy of this report is to be forwarded to the CSCI. (Previous timescale of 31.08.2005 not met). Timescale for action 01/11/05 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 OP2 Good Practice Recommendations It is recommended that the recording format for the preadmission assessment be reviewed and restructured to contain more relevant and detailed information, than currently obtained through tick boxes. It is recommended that a ‘training matrix’ be developed to provide a diarised programme of all training and enable relevant information to be appropriately recorded and readily accessible. 2 OP30 Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 22 Hillersdon Court DS0000021137.V249238.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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