Inspection on 16/09/07 for Hillesden House

This inspection was carried out on 16th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillesden House 18/08/09

Hillesden House 10/09/08

Hillesden House 08/06/06

Hillesden House 23/12/05

Hillesden House 30/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Hillesden House Mount Road Leek Staffordshire ST13 6NQ Lead Inspector Peter Dawson Key Unannounced Inspection 16th September 2007 09:00 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 Hillesden House DS0000063416.V343340.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. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillesden House Address Mount Road Leek Staffordshire ST13 6NQ 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) 01538 373397 caremanager@hillesdenhouse.co.uk Mrs Tervinder Kaur Malhotra Mr Sarbjeet Singh Malhotra Miss Jane Mansell Care Home 22 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (22) of places Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Key inspection 8th June 2006 Random Inspection 13th February 2007 Brief Description of the Service: Hillesden House is a two storey extended Victorian villa situated on a quiet road on the outskirts of Leek, being under 1 mile from Leek town centre. The Home provides long term and respite care provision for up to 22 older people over the age of 65 years, and eight of these people may have dementia as their primary diagnosis. Communal accommodation is provided on the ground floor, comprising of three comfortable lounges and a dining room. There are also six single bedrooms on the ground floor, while the first floor offers eight single bedrooms, one with ensuite facilities, and four shared rooms. There is an assisted bathroom on each floor and adequate numbers of additional toilet areas throughout the building. The accommodation is comfortably furnished and offers a homely environment. There are spacious grounds with adequate parking facilities to the front of the home, while there are extensive views over the surrounding countryside from the first floor windows. A programme of refurbishing of the home has been underway over the past 2 years by the current owners and is now at an advanced stage. Fees range from £357 - £397 per week currently, dependent on the level of care needs and choice of room. The only additional charges are for those of a personal nature, such as for hairdressing services, magazines or newspapers, or for the private chiropodist who visits some people through their choice. These items are funded be the residents on an individual basis through their personal allowance or other private means. The home accepts both private and publicly funded service users. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out by one in inspector on one day from 8:45 a.m. – 5:00 pm. The National Minimum Standards for Older People was used as the criteria for the inspection. The last key inspection was 8th June 2006 when 15 requirements and 9 recommendations were made. A Random Inspection was carried out on 13th February 2007 to monitor the progress on the previous requirements. Most had been addressed or partially addressed and 4 further requirements were made. At the time of this inspection all requirements made had been satisfactorily addressed by the home. An Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission prior to the inspection and provides the basis of some information in this report. There were 17 people in residence (including 1 in hospital) at the time of the inspection. The majority were seen and spoken with. Written feedback to the Commission was received from 12 residens/relatives and from 3 Health Care Professionals prior to inspection. Two relatives were spoken with by telephone. There was an inspection of the physical environment excluding the basement but including a sample of bedrooms and all the communal areas. The over-riding comments about the service were very positive. Some commented that the much-needed refurbishment/improvement programme had made the required positive improvements, the home being formerly described as “shabby” but was now “vastly improved”. One relative felt the food at teatime could be improved from just “sandwiches” but it was clear that food provision has changed and improved for many people after the home sought the views of residents. One relative felt that personal hygiene could be improved, another said “personal hygiene” was one of the things the home does well. When asked how the home could improve a relative commented “I do not believe the care can be improved upon. The home is being renovated and that was necessary”. Residents spoken with during the inspection were similarly positive about the care provided for them and pleased with the improvements made to the home. Three health care professionals made positive comments about care including “A well managed home with individualised care”. One highlighted the “very small bathroom its half-size bath, making it difficult for some resident to get Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 6 into”. The inspector concurs with that view and a requirement for improvement made in this report. What the service does well: What has improved since the last inspection? Many things have improved since the last inspection. Particularly relating to the environment. Most areas required upgrading/refurbishment and virtually the whole environment has been re-carpeted and re-decorated. The kitchen has been completed refurbished to a high commercial standard. The presentation of the home has vastly improved. There are many positive comments from residents and visitors about this. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 7 The swimming pool has been made safe with chain-linked fencing. Some improvements in risk assessments have been input but there are still some omissions. Menus and food provision have been reviewed with residents and improved the variety and choice. The complaints procedure has been re-written to provide a more concise and user-friendly document. Staff recruitment procedures have improved with all necessary checks and references obtained prior to employment. There has been first-time and updated training in areas of statutory training. Most now up to date, only Food Hygiene training for all care staff is needed. The Manager and Provider are involved in study for the Registered Managers Award and hopefully will complete the award early next year. Fire risk assessments have been completed for each resident as needed under changed Fire Regulations. There has been training for all staff in the Protection of Vulnerable Adults. A record of minor “grumbles” and complaints is now kept. Its use being to provide feedback about the service provided. What they could do better: The number of people with dementia care needs have increased and it is important that risk assessments cover all aspects of daily living, with particular reference to the environment and the need to ensure safety. Self-funding residents should always be provided with a contract with the home. – Funded residents automatically have one from the Local Authority. A suitable assisted bathing facility is needed which can meet the needs of all residents. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 8 The laundry door must be kept shut to ensure fire safety and bleach kept in a locked cupboard to ensure resident safety. In the interests of infection control, dressings must be removed from the laundry area where they are in contact with residents clothing. Inspection reports should be readily available in the reception area of the home, providing access by residents, staff and visitors. The reports are public documents. The Moving & Handling Trainer should have annual updated training. A list of diagnosed medical conditions should be provided with care planning information for easy reference by staff and other professionals visiting the home. 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. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 9 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 Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate Information is available to prospective residents with sufficient information to make an informed decision about the home. Contracts must be provided at the point of admission for self-funding residents. Pre-admission assessments and procedures are good. Assessments carried out prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of Purpose and Service Users Guide available in the home for all residents and visitors. Each resident is provided with an individual copy. The guides have been updated to include the changes made in all areas of the Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 11 home. There is adequate information in the guides to enable prospective residents and their families to make an informed decision about the suitability of the home. This information is available in large print with plans to produced them in audio form. From a sample of records of recently admitted residents, all contained preadmission assessments carried out by the homes Manager prior to admission. Additionally Care Management assessments had been obtained prior to admission. Residents funded by the Local Authority are provided with contracts. Self funding residents are not and these are provided by the home. In relation to a self-funding person admitted in June 2007 a contract had not been provided by the home. This must always be provided. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. Care plans are based upon assessments and set out details of actions to meet needs. Risk assessments have improved but some additions still required. There is a positive approach to health care needs which are fully met. The medication system in the home is safe and well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several care plans were inspected including those of recently admitted residents. The format for completing care planning information is good, any shortfalls only due to lack of information input. Adequate details were entered in the care plans to outline health, personal and social care needs. The main omission was in listing the diagnosed conditions Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 13 of each resident, there is space for this in the format but details were not entered: for example it was not recorded that a resident had a diagnosed dementia, some physical diagnoses were not included. It is important that staff are aware of pre-existing medical conditions and able to provide the information to others e.g. locum GP’s/paramedics in urgent situations. Lists for recording GP visits were in place and completed satisfactorily. Previous requirements have been made to improve personal risk assessments for residents, to cover all aspects of daily living. This has generally improved however there was no risk assessment in relation to a resident with dementia who wanders daily throughout the home. Some external doors are not alarmed and requirement made elsewhere in this report in relation to that, but a risk assessment and plan to monitor the whereabouts of the person throughout the day is needed. The person does not wander presently during the night and a sensor provided to warn staff or movement at night – this needs to be included in the risk assessment and plan. The daily notes records for residents are completed regularly, accurately and were to a good standard Care plans are reviewed as required on a monthly basis by the Senior Carer who is the key worker. Relatives are invited to each review and many attend. This is a useful way of involving relatives regularly in the care of the resident and keeping them informed of progress. A good service and working relationships with visiting District Nurses were reported. Nurses are visiting twice weekly to treat and monitor a resident who has severe cellulites. Bed-rest is required each afternoon and this is included in the care plan and staff ensure it takes place. There are no pressure area management issues in the home at this time – a previous skin break referred immediately to the nursing service, care plan and treatment established and was resolved swiftly. Staff spoken to have a good awareness of health care issues and the need to refer to health care professionals at an early stage. Positive written comments were received from 3 visiting healthcare professionals prior to the inspection and included: “Staff are willing to learn new skills to improve care” and “Staff link well with the District Nursing Team and inform us immediately of any problems relating to residents”. From discussions with residents and observations of care delivery during the inspection there was evidence that the principles of privacy and dignity are practised. The medication system is supplied by Lloyds Pharmacy in monitored dose format. Only Senior staff administer medication and all have received accredited training. The Manager regularly monitors the system including the Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 14 Medication Administration Records (MAR sheets). There is a now a controlled drugs record which was completed accurately and satisfactorily. It was noted in a care plan that a resident was allergic to penicillin but on the MAR sheet “no allergies” were recorded. This must be amended. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. Routines are flexible to meet individual preferences and satisfy social, cultural, religious and recreational needs. Contacts with family, friends and other visitors are promoted with community contacts where possible. Residents said they had choice and control over their lives. Food provision is good. Changes have been made to accommodate individual choices and suggestions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence of chosen lifestyles. Some residents said they woke early and like to come to the lounge. On the day of inspection most had risen since the early staff shift change at 8.00 am and some came to the dining room later Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 16 from breakfast. There were no pressures to rise/have breakfast on the Sunday morning of this inspection. Residents were waiting in the lounge in a leisurely way to go to the dining room for breakfast, providing a good opportunity to seek their views about lifestyles. They confirmed that routines were flexible and also that they were satisfied with the social activities in the home they spoke of film nights which were made a social occasion and talked about a local history DVD they had seen the previous day which had provoked interest and discussion. Some residents prefer to spend time in their bedrooms during the day or even the majority of the time. Meals are served in bedrooms or the lounge area if residents prefer this. Since last year there has been an Activities Co-ordinator to lead on activities. The range of activities extended and geared to individual interests as well as small group activity. This is working well and new ideas being introduced. All activities are recorded in information in care plans. The changes were evidenced in written feedback to the Commission from residents and relatives. Fun mobility sessions and entertainers by external providers regularly visit the home. Some residents go to church and visiting clergy provide an individual or group service to residents. The homes objective is to further extend the use of community facilities. Some residents go to, or are taken to the local town, some supported by relatives or staff – the home is looking at ways of extending this- reviewing transport and staffing arrangements. Residents confirmed their visitors are received warmly and can visit at any time. There is the choice of receiving visitors in communal areas or privacy of bedrooms. This was confirmed in written feedback from relatives. There have been previous differing views about food provision. The home have listened to residents in residents meetings and individually and made changes to the menu which is a 4 weekly one changed when suggestions are made by residents. A relative in written feedback spoke about repetitive bland sandwich provision at teatime, although a resident during the inspection said that apart from sandwiches there were hot choices at teatime including toasted teacakes, crumpet, cheese and oatcakes and sandwiches were accompanied by salads. This was confirmed by the cook, although not clear from menus. There is a catering presence in the home 8.30 – 5.30 weekdays and 9 – 2 at weekends. The Sunday lunch provided during this inspection was roast pork with vegetables and potatoes, followed by choice of sweet - seen served, well presented, appetising and enjoyed by residents. This was listed on the menu board, residents said if they did not like the Sunday roast alternatives were available. Home baking included cakes, malt-loaf and tea-bread (traditional recipe suggested by a resident). Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 17 Residents spoken with were satisfied with the quality, quantity and choice of food. The home have listened to residents and moved to improve and provide a menu geared to meet individual choices. Hillesden House DS0000063416.V343340.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): Quality in this outcome area is good. The revised complaints procedure is clear, concise and available to all. All staff have received training in Adult Protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was revised following the last key inspection and now provides clear, concise procedures for making complaints. A copy of the procedure is posted in the home for residents and visitors. The information is also included in the Service Users Guide/Statement of Purpose. No complaints have been received by the home or CSCI since the last inspection. As recommended the home have introduced a log to record grumbles (minor domestic type complaints). In compliance with a previous requirement, all staff have received training in the Protection of Vulnerable Adults (Safeguarding). No Safeguarding referrals have been made in the past year. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 19 Hillesden House DS0000063416.V343340.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): Quality in this outcome area is adequate Considerable improvements have been made to the environment. Some aspects of safety must be actioned. Suitable assisted bathing facilities should be provided. Bedrooms are generally well equipped, well personalised and meet residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last key inspection in June 2006 the environment was poor and considerable improvements required. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 21 At the time of the Random inspection in February 2007 some improvements had been made or were in progress. On this visit considerable improvements had been made to the environment and all previous requirements had been met: Carpets have been replaced throughout the building including all communal areas and corridors on both floors and the bedrooms. Re-decoration of most areas has taken place simultaneously and the presentation of the home vastly improved. Completion of the redecoration of some remaining rooms are also planned. Residents commented upon the changes made and they have been involved in carpet and redecoration choices. Additionally the swimming pool has been made safe and risk assessment for hot water outlets in bedrooms completed for those not fitted with fail-safe valves and a programme of additional replacements completed. The kitchen has been completely refurbished. The area has been fitted with quality commercial stainless steel fittings throughout and in consultation with the Environmental Health Officer. All radiators in the home have been replaced with low-surface ones with thermostats to vary the temperature of individual areas. This has been carried out over the 2 years of the present ownership of the home. There was an inspection of all parts of the environment including a sample of bedrooms. As stated above virtually all bedrooms have been re-carpeted and redecorated. All were well personalised reflecting the individuality of residents, there were examples of small items of furniture and personal effects brought from home. In one bedroom a bedside drawer-pack had virtually disintegrated and not possible to use – this should be replaced. There are 2 bathrooms, one on each floor. The ground floor bathroom which is small, has a half-size bath with a bath hoist giving restricted space for bathing and limited use of water due to size and depth. This bathroom is used by all residents with the exception of one at this time and is not a suitable bathing facility able to meet the needs of residents. A requirement is made to provide a suitable assisted bathing facility on the ground floor to meet the needs of residents. There is an assisted bath on the first floor (used only by 1 resident) incorporating a stand-alone powered chair to reach bath level. A member of staff had not seen this in use and would not know how to use it. Whilst this may be an alternative for some residents to the main bathroom on the ground floor, at this time there is not a suitable assisted bathing facility to meet the needs of residents. This was discussed with the providers who may consider a walk-in shower facility as an option. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 22 There were no hand-drying facilities in one toilet area, the paper towel holder had been removed from the wall and there was no alternative. The 3 lounge areas and dining room showed considerable improvements with new carpet and redecoration. A curtain rail in the main lounge area requires replacement and the providers will arrange this. It was noted that the TV in the smaller lounge area had a poor quality picture and was blurred/flickering continuous watching would be detrimental to residents. The laundry door which has a keypad lock was open (later confirmed broken by providers). This allowed free access by residents and there were 2 bottles of bleach in the room. Requirements in relation to this are made under Standards 31 – 38 of this report. Additionally it was noted that dressings and bandages were stored alongside residents clothes. These should be removed in the interests of good infection control practice. A resident with dementia wanders around the home throughout the day. It was noted that whilst the front door is alarmed there are several other exit doors which either are not alarmed or have alarms but not fitted correctly. This included 3 exit doors on the ground floor and a fire exit door on the first floor metres away from the bedroom of the person who wanders. This was not alarmed, although she is reported to sleep throughout the night at present and has a pressure-pad fitted to her bed to detect movement. A requirement is made to risk assess this situation and ensure that all exit doors are alarmed to monitor people leaving the building. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. Improvements have been made in the areas of staff recruitment and staff training. Staffing numbers are adequate for current resident need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 17 people in residence at the time of this inspection (including 1 in hospital). The staffing level of the home is 3:3:2 for the 3 shifts throughout the 24 hour period. This number is adequate for the needs of the current resident group. A staff training matrix identified that statutory training has been improved in the past year with courses arranged for dementia care, fire safety and adult protection. Further food hygiene training is required for care staff, all serve food and also prepare some food at weekends. This should be arranged. As the home is providing care for more people with dementia additional training is being sourced and arranged through the Alzheimer’s Society. Suitable training is also being sought in relation to mental health needs. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 24 At this time 70 of staff have trained to NVQ2 level or above and 7 presently involved in NVQ study. The required minimum level is 50 . There is good induction training to Skills for Care Standards. On the last 2 inspections requirements have been made due to CRB checks and suitable references not being obtained prior to employment. It was pleasing to see on this visit from a sample of recently appointed staff that all required checks and documents were present as required under Schedule 2. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate There is an open atmosphere in the home and evidence of positive management. Resident and relatives comment positively upon the recent changes and improvements in the home. Regular residents meetings would provide the forum for formal feedback from residents. The safety of residents could be further improved as outlined below. This judgement has been made using available evidence including a visit to this service. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Manager has worked at the home for 20 years and been the Registered Manager for the past 12 years. She therefore has considerable experience in managing a service for older people. She is presently studying for the Registered Managers Award, along with a Provider. The course should be completed in early 2008. The Manager was not present during this inspection, she was on holiday. The 2 providers joined the inspection mid-morning and able to provide detailed information about progress in the home. The providers clearly have regular positive input into the home supporting the Manager but allowing her to manage the home and quality of care. The inspection was carried out initially with the Senior Carer and later with the 2 Providers. There appeared an open atmosphere in the home. Residents spoke highly of staff and said that if they had any concerns staff listened to them and would resolve issues raised. They confirmed they had regular discussions/dialogue with both the Manager and Providers. Residents meetings are held but the last one was November 2006. More regular meetings should be arranged. Customer satisfaction questionnaires are sent to all residents/relatives and the results incorporated into a report which is available with the Service Users Guide. The home engage a private company to carry out Health & Safety audits and report on the outcomes. A requirement of the last reports to provide individual fire risk assessments for residents has been met. There are now fire risk assessments with care plans and a list available in the event of fire. Annual Fire training took place on 3/8/07. The Registered Manager is an approved Moving & Handling Trainer and trains all staff. Her certificate as approved trainer was dated 2003 and it is recommended that annual updated training is needed to ensure her continued training status. A visitor commented that Inspection Reports were not seen in the home. The reports are apparently filed in the office area and it is recommended that these are readily available in the home for residents, relatives, staff and visitors. This was also recommended in the last key inspection report. Requirements made in relation to the Health & Safety of residents are: Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 27 All external doors should be alarmed. The laundry door should be closed at all times in the interests of fire safety – this is a high fire risk area Bleach should be removed from the laundry immediately (done during the inspection) and kept securely locked in the COSHH storage area in the interests of resident safety. The home may wish to review the use of bleach and possible alternatives. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 28 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 2 Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 6 7 Standard OP2 OP7 OP19 OP21 OP26 OP38 OP38 Regulation 5(1) (c ) 13(4)(a) (c) 13(4)(a) 23(2)(j) (n) 13(3) 23(4)(a) (b) 13(4) Requirement Self funding residents muswt be provided with a written contract at the point of admission. Provide risk assessment for resident identified in light of her diagnosis, needs & risks. All external doors must be alarmed to ensure safety of residents. Provide suitable bathing facilities to meet the needs of service users. Dressings/bandages stored in laundry area must be removed in the interests of infection control. Laundry door must be closed at all times in the interests of fire safety. Bleach must be removed from laundry immediately and stored in locked COSHH storage cupboard. Timescale for action 23/09/07 23/09/07 23/09/07 31/12/07 23/09/07 24/09/07 23/09/07 Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 30 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 Refer to Standard OP38 OP38 OP38 OP8 Good Practice Recommendations Inspection reports should be available in the home for residents, staff and visitors. All care staff should preparing or serving food should have Food Hygiene training. The Moving & Handling Trainer should receive annual updated training. A list of known diagnosed medical conditions should be completed for each resident. Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ 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 Hillesden House DS0000063416.V343340.R01.S.doc Version 5.2 Page 32 - 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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