Inspection on 08/06/06 for Hillesden House

This inspection was carried out on 8th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Hillesden House 18/08/09

Hillesden House 10/09/08

Hillesden House 16/09/07

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 Irene Wilkes Key Unannounced Inspection 8 June 2006 10:00 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.V296358.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.V296358.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 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.V296358.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd December 2005 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 approximately 1.5 miles from the town centre. The Home provides long term and respite care provision for up to 22 older people over the age of 65 years, and six 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. Adequate toilet and bathing facilities are provided, offering both domestic type baths and assisted bathing. 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. The home is in need of considerable refurbishment, which the proprietors are slowly addressing. Fees range from £326 - £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. The home is developing a brochure about the home and plans to distribute this when completed in public locations around the area. The availability of inspection reports about the home has not been particularly advertised to date, but discussion with the manager evidenced that this would be rectified in the future, such as making a copy of the report available in the reception area. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was undertaken in early June over a whole day by one inspector. Prior to the visit the inspection record for the service that includes all of the contact with the home in the last 12 months was looked at, together with the information contained in four service user survey forms, nine relatives’ comment cards and comment cards received from a GP and a District Nurse. Two relatives were also contacted by telephone to follow up on some comments that they had made in the returned forms. The majority of the service users in the home were spoken to at the visit, and three of these residents were happy to have a longer chat about the care that they receive at the home. Two staff were interviewed, and discussions were held with the manager, a senior carer and the cook. What the service does well: All of the service users spoken to said that they were very happy living in the home and that the staff treated them well and had a good understanding of their needs. ‘The staff are pleasant and helpful and always there as needed.’ ‘Nothing is too much trouble.’ The residents were very happy with the activities that are on offer at the home, and it was clear that the home is always looking to provide more and different activities to make life more fulfilling for the people living at the home. A recent example is the introduction of a film evening every two weeks. One resident said: ‘Its just like going to the pictures.’ Everyone said that the home is very good at responding to any health problems that they may experience, and quickly alert the doctor or community nursing staff to their needs. A GP also praised the home about this: ‘Helpful, caring staff who always have good knowledge of their patients, who always appear well cared for.’ Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 6 All of the service users said that the home allows them to make their own choices in how they live each day, including being flexible in their routines for getting up and going to bed when they wish, and where they have their meals. This was very much appreciated. The home has an excellent record in training staff in National Vocational Qualifications. 14 out of 16 care staff have these qualifications. What has improved since the last inspection? The home has been very good in the past at responding to any requirements made at an inspection, and the majority of the improvements required in December 2005 have been put in place. Risk assessments have been undertaken about how people with any mobility problems need to be supported to keep them safe. These have been developed with the involvement of each person so that they have had a say in how they can best be helped. The home did not have liquid soap or paper towels in the bathrooms and toilets. This meant that procedures to stop the spread of infection were not as good as they could be. This has been addressed and these are now in place wherever necessary. A menu board has been put up in the dining room so that everyone can see what the meals are for the day. This also tells the residents that an alternative can be provided if they do not like what is on offer. Some of the records that need to be in place and were previously missing have been improved upon. These include items such as better recording about fire drills and examination of accident records. They are important to ensure the safety of all of the residents. The examination of the accident records has resulted in some equipment, known as a pressure pad being purchased that is fitted in front of chairs or beds to detect movement and alert staff that someone is getting up. This means that some people who were having a lot of falls due to their poor mobility and dementia are now quickly attended to, and the number of falls recorded by the home have fallen. The home needs to improve the accommodation in a number of areas to make it safer for service users. They have commenced work on this by fitting low surface temperature radiators throughout the home to protect everyone from burns. The old type radiators became very hot to the touch in the winter and had someone fallen against them a serious accident could have resulted. Some of the bedrooms have been decorated and new carpets fitted. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 7 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. Hillesden House DS0000063416.V296358.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.V296358.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with information about the home and have an assessment of their needs undertaken before moving in. This means that they can feel confident that the home is able to provide them with the care that they need. EVIDENCE: A copy of the Statement of Purpose and Service User Guide had been provided to the Commission prior to the unannounced visit. The previous documents had one or two omissions but the revised documents contain all of the required information as set out in the standards and regulations. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 10 One service user indicated in a returned questionnaire that prior to admission not enough information was given about the home and what could be expected from living there, but other completed service user questionnaires and discussions on the day with the residents were positive in this respect. The manager confirmed that the documents were provided to each resident. Previous inspections have shown steady improvement in the needs assessment information available for each service user. At this visit four service user files were inspected and each had a full assessment of need in place from which a service user plan had been developed. There were also comprehensive admission details in place, referring to next of kin, GP etc. The manager confirmed that the Social Services Department care management assessment and care plan was always obtained for all individuals referred through the local authority. A discussion with a newer resident evidenced that a needs assessment had been completed with her prior to her admission to the home. Intermediate care is not provided in this home and therefore this standard was not inspected. Hillesden House DS0000063416.V296358.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Care plans have improved and medication procedures are appropriate. Service users feel they are treated with respect and value the attention to their healthcare needs that the home provides. However, there needs to be greater attention to the risks that present for service users and detail on how those risks will be minimised to ensure their health and safety. EVIDENCE: The care plans of four service users were inspected. The care plans, like the needs assessment documentation have showed steady improvement over the last two inspections that was pleasing to note. In the four records sampled there was sufficiently detailed information for care staff to understand the needs of each person and how they should be supported. The manager is recommended, however, to undertake an audit of the paperwork and the numbering system used to ensure that it is readily understandable by staff and the service users when their care is being reviewed. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 12 There was evidence that a monthly review of each care plan had been completed by a senior member of staff, with the involvement of the service users where possible. Each care plan showed that a full moving and handling risk assessment had been completed. However, the plans would benefit from a more extensive review of any risks presenting for each service user, such as for smoking, for those who wander due to dementia, etc. This aspect of the care plan has been discussed previously and has been a requirement of previous reports. It is again a requirement that full attention to the individual risks presenting for each service user is given, and that such risks are recorded, together with the strategy in place to minimise the risk as far as possible. The Commission will expect to see this issue addressed. The plans showed very good responses to individual’s health needs and the action taken when any health problems were experienced, i.e. full involvement of the GP and District Nurse, hospital appointments, dental, ophthalmic etc. All of the service users spoken with said that the home were very alert to their health needs and there was never any hesitation in calling a GP should this be required. For one service user with poor mobility there was evidence of the involvement of the community physiotherapy service that had been visiting the service user on a fortnightly basis. This particular service user had a pro-pad cushion and mattress fitted to aid tissue viability. Good practice was evidenced in the use of pressure pads for three people who had dementia and needed to be monitored for their health and safety. Discussion evidenced that their individual needs were well understood and the pads used accordingly. The manager reported that the use of the pressure pads had allowed better care to be provided to these three people. This showed a good response by the home to ensure that the diverse needs of service users who have dementia are being addressed by the home. A District Nurse and a G.P. both returned comment cards about the service that were positive. The G.P. said: ‘Helpful, caring staff who always have good knowledge of their patients, who always appear well cared for.’ The home has appropriate policies and procedures in place related to medication. Medication receipt, handling, storage and return are appropriate. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 13 Part of the lunchtime medication round was seen and there was good practice displayed, including discreet observation of the medication being taken, and clear recording. The MAR (Medication Administration Record) charts were examined for the four service users whose care was being followed and there were no gaps in recording or any other obvious anomalies. One issue discussed was the provision of their inhalers to two service users whilst they were in the dining room when other residents were present, which did not seem to be very good practice. Discussion with a senior staff member and the service users evidenced however that they had in the past been offered their inhalers in the privacy of their room, but that they preferred the routine of having it straight after their lunch before moving on to other activities. They indicated that they did not mind being in view of others. The home is reminded to always check with each service user about what routine they would prefer, and if it is a time issue to explore alternative ways of ensuring that the inhalers are provided in a timely and discrete manner. The four service user comment cards that were returned were positive about the staff and the support that they receive from them. The four people who were spoken to in some depth all said that the staff treated them very well. ‘The staff are pleasant and helpful and always there as needed.’ ‘Nothing is too much trouble.’ This was also the general response from everyone spoken to, who all said that the staff treated them with respect and cared about their privacy and dignity. The nine comment cards received from relatives were all positive about the care received. Two relatives were contacted by telephone and both said that they were very satisfied with the way that their relatives were treated. Hillesden House DS0000063416.V296358.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff work hard to continually develop a wider range of activities, and are flexible in the routines of the home to meet the residents’ needs and wishes. Some further discussion is needed about meals to ensure that they are enjoyed by all service users. EVIDENCE: Previous inspections have evidenced that a range of activities are provided by the home, including fun mobility, art and craft sessions, bingo, board games, visiting entertainers etc. Religious services are also held by clergy of various denominations to suit the faiths of the current residents. The pre inspection questionnaire received from the home highlighted that these activities continue and that the home has also extended the range of activities to include a gentleman who visits with a range of videos about gardens, and the home now has twice monthly film nights. One of the residents spoke about the film nights and said that there was a big screen and that they had a drink and food – ‘its just like going to the pictures.’ Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 15 A fun mobility session took place on the morning of the visit and residents were observed taking part and clearly enjoying themselves. All of the people spoken to said that there is a good range of activities which they join in as they please. The home keeps a record of all of the activities that each person takes part in. Two of the returned service user questionnaires replied ‘usually’ to the question ‘are there activities arranged that you can take part in?’ Although the evidence shows that the home strive to provide a range of activities, they are reminded to liaise with all residents to see if there are any further additions required to meet a wider range of needs. Service users were asked about their wider day to day lives within the home and each confirmed that they made their own choices in all areas of daily living. Residents spoken with confirmed that their visitors were made welcome in the home at any reasonable time, and they decided whether to see them in private or in a communal area. The nine relative comment cards that were returned all responded positively that they were made welcome in the home at any time. Service users said that they were allowed to bring personal possessions with them when they moved into the home. A number of people invited a viewing of their bedroom and in each case it was personalised to the individual’s taste. The home does not deal with the financial affairs of any of the residents. The service users who were asked were unclear about their rights to look at their personal records, although they all said that they were sure that if they asked to do so there would not be a problem. The home is recommended to discuss this with each resident at their monthly review so that they can make an informed choice about whether to do so. This could also be added to the Service User Guide. The kitchen was inspected and a discussion held with the cook. The Environmental Health Officer has visited the home and required a refurbishment of the kitchen, which is planned but not yet started (this is more completely addressed later in the report). Records were seen for ‘fridge, freezer and cooked food temperatures and these were appropriate. The weekly order forms for fresh and frozen foods were seen and the food seemed suitable in variety and amounts. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 16 The home operates a four week rolling menu that does not change in line with the seasons. The cook has recorded individual service users likes and dislikes and discusses with them an alternative choice if she knows there is something on the menu that they will not like. A menu board is available in the dining room showing the meal of the day. This does not show a choice but advises residents to say if they do not want what is on offer. It would be helpful if a stated alternative is shown on the menu board, and this is a recommendation of this report. The manager and cook advised that at the residents meeting held in March the service users were asked if they would like a change to the menu but this was declined. However, from the four service user questionnaires returned there seemed to be mixed views about the meals. ‘x is a very good cook,’ was stated in one form, but two said the food was usually good, and one said sometimes. (The form allowed them to state whether the food was ‘always, usually, sometimes or never good). Additionally in discussion with the service users there was mixed views as to how much the meals in the home were enjoyed, with the need for more fresh fruit also being mentioned. A relative spoken with also said that there did not seem to be the variety of food on offer that would be expected. It is appreciated that individuals living at the home will have different preferences and views about what meals are enjoyable, but as there is some dissatisfaction being expressed the home is required to have another look at the menus and what is on offer and discuss some alternatives with the residents. This should also explore the availability of fresh fruit in between meals. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 17 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the complaints procedure could be simplified, service users and their relatives know that if they raise an issue it will be acted upon. Appropriate policies are in place regarding the protection of the service users from abuse but staff training has been slow, resulting in a lack of confidence when discussing adult protection issues. Service users, however, state that they feel safe in the home. EVIDENCE: The home has a Complaints Procedure that directs the service users to complain through a hierarchical structure, first to the care assistant, then senior carer, then manager and then proprietor. While it would be expected that some service users would complain to a member of staff initially it would seem less cumbersome if the care assistant could then pass the complaint on for them. In discussion with the service users they all said that they would complain directly to the manager if they had any concerns, and this would seem a more simple and clear process to be followed. In addition to this confusion, information displayed in the reception area about how to complain is unclear, as it talks variously about the National Care Standards Commission (this Commission’s predecessor), the local authority and the Commission as bodies to whom to make a complaint, and this is misleading. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 18 The home is required to review its complaints procedure to ensure that it is clear for service users and their relatives. The home has a complaints log but no complaints had been received since the last inspection. The Commission has not received any complaints directly about this service. It would be good practice, and it is recommended, that a record is kept of any more minor grumbles, for quality assurance purposes, and also to record any compliments. The home has appropriate policies and procedures in place for responding to suspicion or evidence of abuse or neglect to promote the safety and protection of service users. They also have a copy of the Department of Health guidance entitled ‘No Secrets’ and a copy of the local authority /multi-disciplinary procedures for adult protection. The manager is recommended to apply to attend a course that is provided by the local authority periodically about the above, and the appropriate referral procedures. A member of staff was questioned about a fictitious abuse scenario and how she would respond. The response showed some gaps in her knowledge. The manager reported that she was undertaking abuse training with the staff team in July, which would be by way of a purchased video with accompanying course material. Understanding of the course would be formally tested. The home is required to ensure that all of the staff receive the abuse training in the timescale that the manager has indicated, i.e. July 2006. The home provides safe storage for money and valuables for each service user. The policies and procedures of the home clearly prevent the involvement of staff in assisting in the making of or benefit from a service users’ will. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. Areas of the environment are unsafe and the home has slowed in its actions to rectify these issues, which means that the risk to service users is high. EVIDENCE: A considerable number of environmental improvements were required of the new owners of the home when they took over in February 2005. An action plan was received from them prior to their registration setting out how the improvements would be addressed, with timescales. This was a requirement of the Commission. During the earlier part of last year pleasing progress had been made against the action plan, but since then completion of the required works has slowed. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 20 Work completed includes the fitting of low surface temperature radiators, a ramp to an outside balcony has been made safe, some carpets have been replaced, wash basins have been fitted to the three bedrooms formerly without basins, and some bedrooms have been refurbished. There are several areas of work that need addressing to ensure the health and safety of the service users including: - safety work to ensure the swimming pool is either filled in or a fence provided to make the area safe. Concern at the visit was heightened, as it is understood that one service user who has dementia is prone to wandering outside unescorted. - water temperature regulators or other engineering control to sinks where a risk assessment of each service user shows that this is needed. Recent testing of the water from sink taps showed that water was being discharged at 58 degrees centigrade. The recommended temperature is 43 degrees centigrade. It was disappointing to find that the above work has not been completed, in spite of reassurances earlier this year that these issues would be addressed. A letter of serious concern has been sent to the proprietor regarding the swimming pool and the hot water issues with a requirement that an action plan is provided to the Commission setting out how this will be addressed and within what timescale. A complete refurbishment of the kitchen has been required by the Environmental Health Department of the local authority. This work has not yet been addressed. Other areas of work still required are the fitting of locks to bedroom doors, further carpet renewal and extensive redecoration of the premises. One of the comment cards returned by a relative stated: ‘Parts of the home look shabby and could do with some decorating to give a better impression to visitors.’ The Commission intends to meet with the proprietors to discuss these requirements and how these will be addressed to the Commission’s satisfaction. All areas of the home were found clean. Staff were observed following appropriate procedures to prevent the spread of infection, i.e. wearing of protective clothing, washing hands, dealing with laundry etc. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 21 It was pleasing to note that paper towels have now been provided in the bathrooms and toilets to prevent the spread of infection. A relative who was contacted made mention of the cleanliness of the home, with clean towels always available. The laundry was visited and appropriate washing facilities were in place. The home had a copy of the ‘Guidelines for Infection Control in Care Homes in Staffordshire’ that was recently produced by the Health Protection Unit and it was pleasing to note that this was being looked at with the home actively seeking to make improvements in their approach to infection control as indicated by the document. The manager was undertaking a training course with staff on infection control on the afternoon of the inspection, with a repeat course the following week for the remainder of the staff. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. While the majority of staff are qualified to NVQ 2 or above which is commendable, other mandatory training and recruitment procedures require some improvements. Service users, however, feel that they are well supported by a knowledgeable team of staff. EVIDENCE: The staffing rotas were looked at. These showed that there are three staff available on each shift, which includes a senior carer. A relative who was spoken with said that the staffing levels could be improved, but the overall care provided was satisfactory. The home currently has 14 residents out of a possible 22 and have continued with their normal staffing levels for 22 residents, and it was considered at the visit that the staffing levels are appropriate to meet the needs of the current residents. There were sufficient catering and cleaning staff available to meet the needs of the home. There are two cooks and two cleaners employed. The home has a good record of enrolling staff on NVQ courses and at the time of the visit 14 out of a total of 16 staff were in possession of NVQ 2 or above (87.5 ). This was pleasing to note. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 23 The home has an appropriate recruitment procedure based on equal opportunities. However, the home’s own policy was not followed appropriately on every occasion, evidenced in missing information in four staff files sampled. This included a new member of staff having no CRB and no references. In another file there was only one reference and proof of identity and a photograph were also missing. All staff receive a copy of the General Social Care Council’s Code of Practice and a statement of terms and conditions. The home is required to obtain a CRB (or initially POVA First clearance if necessary) before any staff commences working at the home. The home is required to obtain two written references before appointing a member of staff. The home is also required to maintain all of the information contained in Schedule 2 ‘Information and documents in respect of persons carrying on, managing or working at a care home.’ A copy of the staff training schedule was provided and staff training was also discussed with the manager. This showed that moving and handling training was up to date, training in infection control was in progress and all relevant staff had received medication training (senior staff). Further more advanced training was also planned for these staff, and the basic training was as well going to be provided to care staff who do not administer medication, which was seen as good practice. 10 staff out of 16 have a current first aid certificate. Other training that is still required includes Fire Safety (advised as planned for the end of June), abuse training (planned for July), and dementia awareness, currently planned for August. However, there are no firm dates planned for the latter two topics as yet. The home was granted registration of an additional two places in the dementia category on the condition that staff received the appropriate training. It was noted that Basic Food Hygiene training is in place and in date for half of the staff. It is a requirement of this report that the home ensures that all mandatory training and any specialist training that is required is up to date for all staff. It is recommended that all staff who serve food receive Basic Food Hygiene training. It was evidenced that staff receive induction and foundation training to Skills for Care requirements within the appropriate timescales. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The general running of the home is such that appropriate personal care is provided to residents. However, the lack of safety of the environment and the unavailability of risk assessments to manage these risks is of concern. EVIDENCE: The current manager has been the manager at the home for a number of years now and also has considerable additional experience in care. She has her NVQ Level 3 qualification. She has yet to undertake her NVQ 4 and Registered Managers Award qualifications due to the lack of a course in her local area. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 25 This training is becoming pressing and the manager agreed that she would enrol onto a course within the next three months. This is a requirement of this report. The service users spoken with all said that the manager has a good understanding of their needs and is very approachable and helpful. She has undertaken additional training to update her knowledge, and holds a Training for Trainers award to equip her to undertake moving and handling training with the staff. There are clear lines of accountability within the home and the manager reported a good relationship existed with the proprietors. There has been a little progress linked to quality assurance of the service. The home sends out a questionnaire to relatives each month to seek their views on the way that the home is run. Whilst a report has not yet been produced to analyse all of the information, there was clear evidence to show that any issues raised are considered by the home and appropriate action to improve is taken. For example, a relative highlighted an issue with the laundry procedures and prompt action was taken to rectify this to everyone’s satisfaction. While a residents meeting was held in March, when activities and food was discussed, the home does not otherwise formally meet with residents to gain their views about the home, except for their monthly review of their care plan. This must be addressed and the findings published and made available to the residents and prospective service users and other interested parties, including the Commission. It is important that the views of other stakeholders, such as GP’s, chiropodists, nurses, staff etc. are also sought so that all of these views are used to inform the planning and review of the services provided in the home. This consultation is a requirement of this report. The home does not retain responsibility for any service user monies, and the manager understands that other family members assist a number of residents in their financial affairs. The home does keep some possessions for safe keeping for service users and these are appropriately stored in a locked safe and records are kept of all transactions. Every room has also recently had a lockable facility fitted for the safeguarding of items that service users want to keep with them but ensure added security, and it is pleasing to note that this action has been taken. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 26 The home employs an outside contractor to provide all health and safety advice, including the provision of written policies, risk assessments for all safe working practice topics, and associated written records of risk assessments for the environment. The home is recommended to audit these policies and discuss them with staff to ensure that the provision of the information is not just a paper exercise. COSHH (Control of Substances Hazardous to Health) requirements were met in terms of safe storage and the information available for staff. As stated previously in this report, and also found at previous inspections, there is a lack of written risk assessments in place related to areas of individual need, although those for safe moving and handling have been added since the last inspection. The home must review each service user’s care and identify and record any individual risks presenting for each service user and how the risk will be managed. This must include individual risk assessments for the hot water, for the swimming pool and any other relevant environmental hazards as well as those relating to personal care needs. The serious concerns letters have highlighted that these must be addressed with urgency. Evidence was seen that staff receive induction and foundation training to Skills for Care specification. A requirement has been made regarding mandatory training. Evidence was seen that fire drills are undertaken and there was a record maintained. The pre inspection questionnaire completed by the manager showed that fire equipment had been recently checked. It was highlighted to the manager that a member of staff who was questioned did not know where the nearest fire extinguisher was on the upstairs landing. It was discussed with the manager that the home does not have a full fire risk assessment in place that considers all areas of the home and the reduction of risk from fire as far as practicable. Areas for consideration include prevention of fire, escape from fire, communication, suppression of fire etc. This list is not exhaustive. The undertaking of a full fire risk assessment is required, to include individual risk assessment for each service user and how the risk will be managed for individuals, including those with hearing impairment, poor mobility etc. An emergency plan is also needed in the event of the home needing to be evacuated because of fire or other emergency. Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 27 On the day of the visit the home was updating training and acting on advice from the local Health Protection Agency to ensure further understanding and practice of measures to prevent the spread of infection and communicable diseases. The previous visit had shown a high level of falls as recorded in the Accident Book. The home were recommended to analyse the falls to see if there were any patterns emerging. It was pleasing to see that this had been undertaken and following this analysis the home had invested in two pressure pads to be used for the residents who were most vulnerable to falls as they tried to immobilise unaided. A wider discussion was held with the manager about addressing equality and diversity in the service. Evidence was available at the visit as highlighted above that the home tries to consider the meeting of individual needs and ensure that no-one’s care is compromised due to their different needs. The home invites representatives of different faiths into the home to hold religious services for the various denominations. The manager is going to give some thought about how information can be recorded to show their progress across the wider range of considering race, gender, sexuality etc. This will be discussed again at the next inspection. The pre inspection questionnaire evidenced that the hoist, adaptations, lift and emergency lighting had all been tested within the appropriate timescales. There had been a recent test undertaken for Legionella and the home were awaiting the report. The Environmental Health Department has required the home to completely refurbish the kitchen. This work has not yet been completed and is required. All accidents, illnesses and incidents are appropriately recorded and reported. Hillesden House DS0000063416.V296358.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 2 X 3 X X X 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 13(4) b Requirement Ensure that any areas of risk relating to each individual service user are appropriately assessed and recorded. (This was a previous requirement and has not been appropriately met) Revisit the menus and discuss some alternative proposals for meals with the residents Review the complaints procedure to ensure that it is clear for service users and their relatives. Provide the abuse training to all staff to the timescale indicated by the manager Make the swimming pool area safe (This was an immediate requirement and has been a previous requirement that has not been met) Undertake individual risk assessments for all service users for all of the hot water taps, and ensure a means of controlling the discharge temperatures where this is indicated as DS0000063416.V296358.R01.S.doc Timescale for action 08/07/06 2. 3. OP15 OP16 12(3) 22(2) 08/08/06 08/08/06 4. 5 OP18 OP19 13(6) 13(4) (a) (c) and 23(2) o 31/07/06 08/06/06 6 OP19 13(4) a and c 08/06/06 Hillesden House Version 5.2 Page 30 7 OP19 13(4) and 23 8 OP29 19 and Schedule 2 required by the risk assessments (This was an immediate requirement and risk assessments have previously been required). Provide the Commission with an action plan to show when the kitchen will be refurbished and the other outstanding work on the home and grounds will be completed. (An action plan has been provided previously but the schedule is now out of date). The home is required to obtain a CRB (or initially POVA First clearance if necessary) before any staff commence working at the home. 15/07/06 30/06/06 9 10 OP29 OP29 19 and Schedule 2 19 and Schedule 2 The home is required to obtain 30/06/06 two written references before appointing a member of staff. The home is required to maintain 30/06/06 all of the information contained in Schedule 2 ‘Information and documents in respect of persons carrying on, managing or working at a care home.’ All mandatory and specialist training must be up to date for all staff The manager must take steps to enrol on NVQ 4 and Registered Managers Award Ensure that consultation is undertaken with service users and other relevant groups to inform the development of the service. Undertake a fire risk assessment. Provide an emergency plan for the home 31/08/06 18 (1) c 11 12 OP30 OP31 9(2)(b)(i) 24 13 OP33 30/09/06 31/08/06 13(4) 14 15 OP38 OP38 13(4) 31/07/06 31/07/06 Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 31 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 OP15 5 6 OP18 Refer to Standard OP7 OP9 Good Practice Recommendations Undertake an audit of the care plan paperwork and the numbering system used to ensure that it is readily understandable by staff Hold another discussion with service users who have inhalers to ensure that it is provided at a time and a place convenient to them. Further consult with service users to discover any additional activities that would be enjoyed. Discuss with the service users in an overt way their right to access their personal records Consider showing the alternative meal choice on the menu board The manager is recommended to attend a course regarding the inter agency procedures for the Protection of Vulnerable Adults Provide Basic Food Hygiene training for all staff that serve food. It is recommended that the home’s health and safety policies are audited and discussed with staff. Keep a record of minor grumbles and compliments made about the home. OP12 OP14 OP30 7 OP38 8 OP16 9 Hillesden House DS0000063416.V296358.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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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