Inspection on 18/08/09 for Hillesden House

This inspection was carried out on 18th August 2009.

CQC found this care home to be providing an Adequate service.

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 10/09/08

Hillesden House 16/09/07

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hillesden House Mount Road Leek Staffordshire ST13 6NQ Lead Inspector Joy Hoelzel Key Unannounced Inspection 18th August 2009 09:45 DS0000063416.V377127.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hillesden House DS0000063416.V377127.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 Vacant Care Home 22 Category(ies) of Dementia (22), Old age, not falling within any registration, with number other category (22) of places Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Older People (OP) 22 Dementia (DE) 22 The maximum number of service users to be accommodated is 22. 2. Date of last inspection 10th September 2008 Brief Description of the Service: Hillesden House is a two storey extended Victorian villa situated on a quiet road on the outskirts of Leek close to the town centre. The Home is privately owned and provides accommodation and personal care for up to twenty two people. Communal accommodation is provided on the ground floor, comprising of three lounges and a dining room. There are a number of single and shared bedrooms some of which benefit from an ensuite facility. There are parking facilities to the front of the home, and a small garden at the rear. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are available directly from the service. The service user guide does not include information on the current level of fees for the service. The reader may wish to obtain more up to date information from the care service. Care Quality Commission reports for this service are available from the provider or can be obtained from www.cqc.org.uk Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The home did not know that we would be visiting on this occasion to conduct a full inspection of the service. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of seven people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. Discussions were held with people living, visiting and working at the home. Some people were unable to fully comment about their experience of life at the home. Observations were made of how they spent the day and of the interactions offered by staff in an attempt to obtain an overview of how they may be feeling. We asked for our Have Your Say surveys to be distributed to people living in, working in and visiting the home. Six were returned from people living in the home (all indicated that they had help to complete the form) and four were completed by members of staff. The responses and comments are included in this report. Unfortunately no surveys were completed by relatives or the representatives of people using the service due to a delay in sending the surveys to the home. However, we spoke with visitors at the home during this inspection and their comments are included in this report. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. We had to remind the providers to return the form to us. Comments from the AQAA are included within this inspection report. What the service does well: People using the service told us The home is quiet and the food is good. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 6 It’s a nice home, you have to make the best of what youve got, and the accommodation is good. People visiting the home told us that The staff are very good they look after my relative very well, I have no complaints. Staff told us that They do their best to fulfil the needs of all residents, support their individual needs and try to make the home a happy place. What has improved since the last inspection? What they could do better: The information documents should be reviewed and updated at regular intervals. They should be readily available and in a variety of different formats. The service user guide should include full details of the weekly fees and what is and what is not included in the fees. The care plans should be reviewed at regular intervals and include full details of a persons assessed care needs. This will ensure that staff have full up to date information to fully meet the care needs in a way that the person prefers. More attention should be given to increasing the variety, frequency and range of social and leisure activities to meet the needs and personal preferences of all the people living at the home. Records should be maintained of the daily diet and fluids offered to people who may be at risk of malnutrition. The gardens need to be renovated so that they are safe and accessible for people to enjoy. Equipment in use should be safe and in good order. Hot water outlets accessible to people using the service should be maintained at a regular safe temperature. A sluicing facility is needed for the safe disposal of bodily waste and for the effective cleaning of the commode pots. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 7 Staffing levels, (care, domestic and laundry), should be in sufficient numbers to ensure the care needs of people are fully met in the way that they prefer, and that the home is kept clean and hygienic. Staff should receive training and regular updates in areas relevant to the service and to enable them to do their job. A quality assurance and monitoring system for the home should be developed to ensure the home runs as it states it does. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 8 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.V377127.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service or thinking of using the service cannot be fully assured that the information they receive is wholly correct. EVIDENCE: The AQAA informs us that We have produced a service user’s guide, Statement of Purpose and Brochure for Hillesden House. They are reviewed regularly to ensure that the information is correct and up-to-date. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 10 Prior to each resident that comes to stay at Hillesden; a full and comprehensive assessment is carried out to determine whether Hillesden house can meet the needs of the individual. We found that this information was not fully correct. We asked for copies of the information documents and were supplied with a copy of residents handbook, service user guide, a quick reference guide of our services to you. The handbook was not dated so it was not possible to determine when it was last updated but there are references to the previous manager, the new managerial arrangements, and the previous regulatory body. No details of the actual fees are included but state our fees are compatible with maintaining first class care. The document also states that it provides nursing care for our residents; the home is not registered to provide nursing care to people. We looked at the case file and records of the person who most recently moved into the home to see if information had been sought regarding this person’s needs prior to moving in. There was a document completed at the front of the file - long term needs assessment and care plan. The document was not dated but staff told us that it was completed as part of the admission process. We asked if there was any other information regarding the care needs of this person. Staff told us that there was information from people from other organisations but they were unable to find the paperwork for us to have a look at. We spoke with this person, they told us that their family had helped with finding a care home and although nothing is quite like your own home they were quite contented and satisfied with the care they received. The home does not provide and intermediate care service. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plan includes basic information but there are some gaps in important information. Staff are able to think in a person centred way and are able to give a verbal update. EVIDENCE: We selected three people’s care records to look at in depth with another four people’s plans looked at briefly to follow up observations made during the day. The plans included the signature of the persons relative or representative when they had been involved in the planning of the care. There was no evidence in any of the plans we looked at, of the actual individual being consulted as to their care needs and how they like the care to be delivered. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 12 A relative of a person using the service confirmed that staff discuss the care plan with them and they feel that the care needs of their relative are being met. There is no recording that the plans are being reviewed at regular intervals. The plans we looked at did not contain sufficient or specific details of how a person’s care needs can be fully met. Staff were able to tell us of the very individual care needs of people using the service, but without the back up of clear information in the care plans it may be possible that people’s care needs are not being provided fully or in the way that they prefer. For example one person requires very close monitoring on a regular basis for a specific condition. A care plan had been developed indicating this person had this condition but there were no specific guide lines of what staff should do if they found anything unusual or different. In another of the plans an assessment for identifying concerns with eating and drinking had been completed. It was noted that the person was at moderate risk of malnutrition. No specific care plan had been developed to give staff instructions for following the information on the risk assessment. Staff told us that it is very difficult to monitor the weight of this person as they are reluctant to sit on the weighing scales. The last time a record was made of the weight of this person was in October 2008. Staff were unable to tell us of any alternative ways of how they monitor whether or not this person is losing or gaining weight. But they told us that this person has a good appetite and eats well. However as there are only limited records kept of the diet offered and taken daily, it was not possible to determine whether a diet suitable to the persons preferences and needs has been provided. We observed the lunch time meal offered to this person and do not feel that it was sufficient to maintain good nutritional status. We spoke to the owners of our concerns who offered an assurance that action would be taken. We also advised staff to complete daily records of the diet and fluids offered and taken and to look for alternative ways of monitoring their condition. This person was unable to tell us how they were feeling but they appeared quite frail. We saw that they were able to move about and staff appeared to be very supportive and seemed to know what this person wanted. There was some conflicting information in one of the plans we looked at. The moving and handling risk assessment and the care plan had different instructions as to the support a person requires for getting in and out of the bath. We consider that the care plans that we looked at do not provide staff with the information needed to enable them to support people to meet their health care needs. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 13 Medication is administered to people by the care staff using a monitored dose system with additional boxes and bottles of medicines. We advised staff to review the procedures for the administration of medications that require extra secure storage. Staff offered an assurance that this would be actioned. We looked at the other procedures in place, staff explained the processes and all evidence points to satisfactory arrangements being in place for the safe administration of medications. We observed staff throughout the day being very patient, understanding, caring and assisting people with care needs in a discreet and respectful way. The care records recorded the name that people preferred to be called and throughout the day we heard staff addressing people accordingly. To uphold a persons privacy and dignity, privacy curtains have been positioned in the shared bedrooms and privacy indicators have been placed on toilet and bathroom doors. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are given the opportunity to take part in activities both within the home and in the community, however this could be improved. EVIDENCE: The AQAA lists a range of activities that are available to people and the Residents Handbook records that the home arranges day trips, in house entertainment and garden parties on a regular basis. Staff informed us that a person has been recruited to help organise activities to people twice a week. The care staff then help people with their preferred activity at other times. During the time of our inspection there appeared to be very little structured activity for people to enjoy. The activity person was not at the home and the three care staff were all extremely busy attending to their Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 15 care duties. In addition to this the care staff were also attending to domestic and laundry tasks as there were no ancillary staff on duty. The owners of the home described the improvements that have been made in providing the equipment for recreational activities and confirmed that there is an active activity programme for people to enjoy. There is a form for recording participation in social and leisure activities included in the care plan file. The care plans that we looked at did not record any activity arranged by the home they only recorded the visits from family and friends. It is therefore difficult to determine whether sufficient or suitable activities are arranged for people. People indicated in the surveys that they completed, suggesting improvements for the service more games and activities for them to do. People told us, its very boring there is never anything to do. One person told us that they spend their day sleeping. In two of the three lounges the television was on for most of the day. We heard staff discussing the programmes on the television and offering a choice of programme. One person told us how they enjoy visiting their church each week and how much they look forward to this. Staff told us that a monthly religious service is held at the home offering people an opportunity for worship. We saw that visitors to the home were welcomed by the staff and appeared to be at ease when visiting. People said that they found the visiting arrangements satisfactory and they felt that their relatives needs were met. The main front door is kept locked for security reasons; entry to the home is gained by staff answering the door. A domestic type lock is sited on the door for ease of exiting. No other doors around the home were seen to be locked, with the exception of storage cupboards and the treatment room, people can have free access to all communal areas if they so wish. Meals are prepared by the catering staff and served by the care staff mainly in the dining areas, but people are able to have their meals in their preferred place. People commented that they have a choice of food and that generally they are satisfied with the menu. Currently there are only very limited records of the diet offered to people each day so for some people it would not be possible to determine if their dietary needs are being met. As discussed earlier in this report. The Aqaa records: All our residents are provided with breakfast, lunch tea and supper, along with refreshments and snacks throughout including fresh fruit and variety of hot and cold drinks. Residents are offered a choice of dishes at each meal, by means of a menu, if they still not wish for the choices provided then an alternative is provided. Staff told us of the plans to improve the menu and are going to Introduce taster evenings so that we can determine a new and exciting menu. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns with their care, they or people close to them know how to complain. EVIDENCE: The complaints procedure is included in the Residents Handbook and a copy is displayed in the entrance to the home. Five people using the service indicated in our survey that they were aware of the complaint procedure and knew how and to whom to make a complaint. One person was unsure of this. People we spoke to stated they would speak with one of the owners or their family if they had any concerns. A log is maintained of the complaints received and includes details of the complaint and the action taken. We, the commission, have received a complaint regarding the service from someone wishing to remain anonymous. The concerns were mainly regarding the environment- unpleasant odours and general feeling of the home becoming Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 17 run down. We discussed these issues with the owners who acknowledged some of the areas of concern. The home offers a facility for residents to deposit personal monies for safekeeping. We saw that the records and the cash is all kept in separate wallets with each transaction being recorded. Staff explained the procedures in place to ensure the accuracy and safety of holding the money. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. EVIDENCE: Hillesden House is a Victorian property in a quiet residential area of the town. It has a selection of communal areas, with both single and double occupancy bedrooms. The AQAA informs us of the improvements that have been made in the last twelve months with the owners explaining the plans for further improvements. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 19 The owners told us that work is in progress to overhaul and renovate the rear garden to provide a safe and welcoming area for people to enjoy. The concerns of the rear garden were discussed with the provider on the review of the registration of the service in September 2007 with plans for the work to be carried out in the spring/summer of 2008. Outside space is severely limited as people are unable to use the garden area. People told us that they were satisfied with the accommodation, it’s a nice home, you have to make the best of what youve got, and the accommodation is good. We looked around the home which included a selection of the bedrooms. The furniture provided by the service is of varying quality and standards, some looks quite old and in need of replacing. Most of the bedrooms were very individual, with many of the rooms being highly personalised with the residents belongings. During the tour of the premises we saw a few areas that may potentially be a risk to people. For example not all wardrobes are secured and if pulled could topple over and cause injury. Not all areas where personal care is provided have been supplied with suitable hand wash facilities for effective hand washing and for infection control purposes. Some people require the use of a commode for night time use. Some commodes are a wooden type and as such not easily cleanable and should be replaced. There is no sluicing facility for the safe disposal of bodily waste or for effectively cleaning the commodes pots. Not all of the private bedroom doors have been fitted with a locking facility, without a facility on the door people do not have a true choice of whether to lock their door or not. A wall mounted lockable cupboard has been provided in all bedrooms. Not all hot water outlets accessible to people using the service have been fitted with a device to ensure that the water is not too hot. The owners explained the difficulties encountered with installing such devices. We advised that a risk assessment should be completed for each room where potentially a person may be at harm from scalding. Some areas of the home had a slight malodour, the owners offered an explanation and of the action taken to reduce the unpleasant odour. The AQAA tells us that there are two cleaners who carry out a robust cleaning programme, ensuring a programme of deep clean within the Home. The care staff, at the time of our inspection, were dealing with domestic and laundry duties in addition to their care work as no ancillary staff were on the premises. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are generally satisfied that the care they receive meets their needs. The manager is aware that there are some gaps in the training programme and plans to deal with this. EVIDENCE: People using the service told us The girls are very good I cant grumble they look after us very well. Visitors told us that the care staff work very hard to look after people living at the home. Staff told us thatThey do their best to fulfil the needs of all residents and are always looking for improvements to be made to make the home a happy place. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 21 We looked at the staffing rotas and saw that during the day and into the evening there are always three care staff on the premises. During the night the care staff levels decrease to two with a senior care staff being on call and available if there are any problems. During the time of this inspection we saw that the three care staff were extremely busy attending to care, domestic and laundry duties. They told us that they had very little time to spare and were on the go throughout their shift. The current staffing levels are not in sufficient numbers to ensure that each of the communal areas are supervised. One person unfortunately had a fall while we were at the home. Another person using the service had to summon the help of the staff from another area within the home. The care plans include a falls risk assessment and where there is an identified risk, people are provided with a pressure pad for use on their chair or in their bed. This then alerts staff of when a person is moving from their chair or bed. We saw that many people had such a pad in their chair. We saw that staff reacted very quickly when the buzzer was activated. We also saw that baby alarms are currently being used to monitor people whilst they are in bed. We advised the owners that the use of such baby alarms was a gross invasion of privacy and to discard their use. While we understand the need for the use of the pressure pads in helping to keep people safe and free from potential harm of falls, these pads should not be used as a substitute for having sufficient numbers of staff on duty. No domestic staff were at the home during our visit, some areas of the home were not adequately clean and in need of attention. The AQAA tells us 11 out of 14 full time care staff have achieved National Vocational Qualification 2 or above and 2 are currently achieving the qualification. Staff spoken with confirmed that they had gained this qualification with one staff telling us that they are planning to study at the next level. We sampled the files of two staff holding various positions within the home. The files were well presented and contained the information required to ensure that checks had been made prior to them starting work at the home. The AQAA tells us All staff receive mandatory training in respect of: Fire safety Manual handling Induction training Dementia training And all other mandatory training. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 22 The owner of the home told us that the training is, more or less all up to date with plans to update the fire safety training. The training matrix, however, indicates that some of the training is out of date for example the fire awareness was last completed in 2006, as was dementia awareness and protection of vulnerable adults. Care staff have not received any basic food hygiene training since 2003. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that the management team are aware of the improvements needed to ensure that their health, safety and welfare are upheld. EVIDENCE: Since the last key inspection there has been a change of management of the service, the registered care manager resigned from the position earlier this year. Ms Teri Malhotra, one of the owners of the service, has taken over the Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 24 role of acting care manager. Mrs Malhotra has completed the Registered Managers Award and will currently be applying for registration with us. Mrs Malhotra sent us the AQAA after we had reminded her to. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. Mrs Malhotra told us the improvements that had been made within the last twelve months and went on to explain the plans for making further improvements in the coming year. The AQAA tells us that the quality assurance and monitoring of the service has not been implemented robustly and is something that the owners will be looking to improve within the next twelve months. We looked at systems for safekeeping of people’s money and found they were in good order. The home has good records of all transactions and obtains receipts and two signatures. This will reduce the risk of errors occurring with people’s money and give the added peace of mind to the people living in the home. A lockable wall mounted unit has been provided in bedrooms for people to be able to lock away their cash and/or valuables if they wish to. Records, documents and certificates are available for inspection to ensure that the weekly, monthly and annual health and safety checks are being carried out. Risk assessments for maintaining safe working practices have been completed, with the fire risk assessment for the home being reviewed in November 2008. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 25 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 X 2 X X n/a 2 X X X X 2 2 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 3 17 X 18 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 3 Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 26 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 Standard OP8 Regulation 14(2)(a) (b) Requirement The nutritional needs of people using the service must be assessed, the findings fully documented with the action that is required. Staff will then have the necessary information to ensure that people are not at risk of malnutrition. The ratio of care staff must be determined according to the assessed needs of the people living at the home. This will ensure the needs, preferences and aspirations of people are met. Timescale for action 30/11/09 2 OP27 12(1)(a) (b) 30/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 27 1 2 OP1 OP1 The information documents should be reviewed at regular intervals to ensure that the information is current and correct. The service user guide (Residents Handbook) should include full details of the weekly fees and what is and what is not included in the fees. The care plans should be reviewed at least once a month or more often if a change in a person’s care needs has been identified. The care plans must set out in detail the information of a persons health, personal and social care needs. This will ensure that staff have the full details of how to fully meet a persons care needs and in the way that they prefer. More attention should be given to increasing the variety, frequency and range of social and leisure activities to meet the needs and personal preferences of all the people living at the home. A record must be made of the diet offered and taken to people. Checks can then be made to ensure that the diet is satisfactory and that people remain well nourished. The gardens must be renovated and made safe and accessible. This will ensure that people are able to go outside to a safe area when they wish to. The wardrobes provided by the home should be securely fixed to ensure the safety of people living, working and visiting the home. For the safety and comfort of people the hot water temperatures should be maintained at close to 43 degrees Celsius For general hygiene and infection control purposes, suitable hand wash facilities should be provided in areas where personal care is offered. A sluicing facility should be available for the safe disposal of bodily waste and for the effective cleaning of the commode pots. Domestic and laundry staff should be employed in sufficient numbers to ensure the home is maintained in a clean hygienic way. Staff must receive training and regular updates in the mandatory subjects and specialist topics relevant to their job. The application for the position of registered manager of the service should be completed as soon as practicable A quality assurance and monitoring system for the service should be developed. To ensure that the home is running DS0000063416.V377127.R01.S.doc Version 5.2 Page 28 3 4 OP7 OP7 5 OP12 6 7 OP15 OP19 8 9 10 11 12 13 14 15 OP24 OP25 OP26 OP26 OP27 OP30 OP31 OP33 Hillesden House as it says it does. Hillesden House DS0000063416.V377127.R01.S.doc Version 5.2 Page 29 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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