Inspection on 16/04/08 for Hillsborough Residential Home

This inspection was carried out on 16th April 2008.

CSCI found this care home to be providing an Good 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

Hillsborough Residential Home 24/03/10

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Hillsborough Residential Home Southern Road Callington Cornwall PL17 7ER Lead Inspector Mandy Norton Unannounced Inspection 16th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillsborough Residential Home DS0000070506.V362144.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. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillsborough Residential Home Address Southern Road Callington Cornwall PL17 7ER 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) 01579 383138 01579 383621 hillsborough@tiscali.co.uk Hillsborough Residential Home Ltd Mrs Eileen Marie Danvers Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Hillsborough Residential Home DS0000070506.V362144.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 either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 22. Date of last inspection Brief Description of the Service: Hillsborough Residential Home is a converted property on the outskirts of Callington. Care is provided to a maximum of 22 people of either gender who require personal care only. The accommodation is on 2 floors with access to the first floor via 2 stair-lifts. Communal space consists of a dining room and 2 lounges all on the ground floor. People have access to the mature gardens, where seating is provided. The provider/manager has owned and run the home for many years and likes to provide care in a friendly and homely environment. Social and recreational activities are provided. The food is home cooked and locally sourced with choices for each meal time. The fees range from £300 – 330 per week. Each person is issued with a contract once a settling in period has been achieved. The provider/manager was reminded to display a copy of the previous inspection report at the front entrance. Hillsborough Residential Home DS0000070506.V362144.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place from 10.45 am until 3 pm on the14th April 2008. inspection was conducted with the provider/manager. A tour of the home was carried out some of the people living in the home were spoken to and observed during the visit. This report also contains information taken from the completed annual quality assurance assessment (a document that is completed annually detailing ongoing improvements and achievements) and discussion with staff on duty on the day of the inspection. There were 19 people living in the home at the time of the inspection. What the service does well: The home is homely, comfortable and clean and hygienic. The staff are friendly and work well together to deliver good quality care to the people living in the home. People living in the home like the provider/managers dog coming to work with her and enjoy the 3 cats the home has. Staffing levels are designed to meet peoples needs throughout the day and night and recent changes in shift patterns means that there are sufficient staff on duty at peak times. The care plans are up to date and have a lot of relevant information about peoples assessed needs meaning the care is based on individual need. Communication between the provider/manager, care staff and people living in the home is good meaning that there are very few complaints or concerns. The provider/manager spends time with the people who live in the home to ensure their needs are being met. The maintenance records and risk assessments are comprehensive and up to date, meaning people are safe living in the home. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: The provider/manager said that the Statement of Purpose was updated following last inspection and needs to be again once the current refurbishments are complete. Information provided to people prior to admission describes the home and what the service can offer. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 9 She said she visits people to assess them prior to them moving into the home unless they are admitted under the ‘rapid assessment scheme’ then she has information form the care manager and the care plan they have prepared prior to admission. Two people spoken to said they had chosen to live at the home as they knew of its reputation beforehand. During a tour of the home the inspection somebody came to look around the home, a staff member was able to show them around and they were given a brochure before they left. The Annual Quality Assurance Assessment states that following a period of settling in the person and the manager assess if the placement is meeting their needs. Once this has been achieved a contract is issued. The provider/manager was advised that she should display the last inspection report at the main entrance. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practice regarding the planning and delivery of care means that people can be sure that their health and personal care needs will be always be fully met. EVIDENCE: Care plans examined had information about the individual and their health and personal care needs. They are up to date and had been regularly reviewed. Each person has a named diary into which the staff write about the persons day to day activities and support required 3 times a day. A District Nurse visited during the inspection and the provider/manager said that they have a good relationship with local health care professionals. Blister packs are stored in a locked trolley kept in the dining room and taken around the house on a tray with any as required medicines and bottles of liquids. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 11 The provider/manager said that training in administration of medicines is done by Boots who supply the blister packs. Certificates to confirm this were seen when looking at staff files. There is no designated medicines fridge but there are only 2 items that need to be stored in a fridge that are in use at the moment. They are stored in door of the domestic fridge the provider/manager was advised to put them in another container inside the fridge door. The creams and lotions seen in individual rooms all had prescription labels on them. The provider/manager was advised to write the opening date on each pot/tube. One person is self medicating and has been assessed as being able to do this safely. Staff were heard interacting with people living in the home appropriately and providing support and help in a discreet manner. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the home and community meaning the people have a range of opportunities to participate in stimulating and motivating activities. Meals and mealtimes are not rushed making them an enjoyable, social occasion for people. EVIDENCE: The provider/manager said that entertainment such as a sing along session is bought in and that most of the people living in the home join in when this happens. Care staff are able to spend time with people during quiet periods talking or taking them out into the garden when the weather is nice. There are links with the local community and 2 of the local churches visit the home regularly. The Annual Quality Assurance Assessment states that there are areas in the home that people can meet with their friends and relatives without being disturbed. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 13 One lounge has a TV and one doesn’t, most people also have a TV in their own room. One person spoken to enjoys knitting baby clothes that are then taken to the local hospital and another person goes out for a walk each day sometimes meeting up with a relative in the local town. The provider/manager brings her young dog into the home on a daily basis and the home has 3 cats, the people spoken to really like having the animals in the house and are pleased when the cats sit on their lap or sleep on their beds (it was noted that small blankets were on the beds that the cats sleep on the protect the bedding). The garden is spacious and full of a variety of plants for people to enjoy. There is easy access and seating for people to use. The provider/manager and her staff are currently cooking the meals as they are advertising for a cook. The people spoken to said that the meals are good when the staff cook and that they can have an alternative if they don’t like the main meal option. Snacks and drinks are available 24 hours a day. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Formal complaints and reporting of abuse policies and procedures are in place. They are available to all staff at all times. People feel their concerns are listened to and acted upon meaning that they raise concerns or make complaints when they should meaning people don’t accept a service if it doesn’t meet their needs. EVIDENCE: The complaints procedure is in the Service Users Guide, the provider/manager was advised that this should also be displayed at the main entrance. The Annual Quality Assurance Assessment states that the home has had no complaints in the last 12 months and the Commission have had no complaints about the service in the last 12 months. Staff files examined showed that staff have attended adult protection (safeguarding) training. The provider/manager said that staff are aware of the changing needs of the people living in the home and that at times they can become more vulnerable. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment has improvements ongoing at the time of the inspection meaning that people have a more homely, comfortable and safe environment in which to live. EVIDENCE: The home presents as welcoming and homely. At the time of the inspection the home was undergoing rewiring and upgrading of some fire doors, emergency lighting and heat detectors. The provider/manager said that redecoration of some areas of the home would take place once the work is completed. People spoken to did not feel affected by the ongoing work. Individual rooms seen were personalised with furniture, ornaments and photographs that people had bought in with them. People spoken to said they liked their rooms and felt comfortable. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 16 Communal space consists of a dining room and 2 lounges, one with a TV and one without. People spoken to said they enjoyed spending time in the lounge as they can chat with other people and enjoy views of the garden. On the day of the inspection most people were having their meal at the dining room table and this was treated like a social occasion. There are toilets and bathrooms, with adaptations to meet the needs of the current residents, throughout the home accessible to everybody. A number of rooms have en-suite facilities. The garden is accessible to people and seating is provided. The home was clean and tidy despite the ongoing refurbishment work. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provider/manager shows a responsible attitude and is implementing changes and improvements in order to keep improving quality and outcomes for people living in the home. The staffing levels ensure people’s needs are being met at all times. EVIDENCE: The provider/manager said that she achieved a RMA in 2007.On the day of the inspection there were the provider/manager, 2 care staff and a domestic on duty in the morning and afternoon to look after 19 people, some of whom are quite independent. Overnight there is one waking staff member and one sleeping. The manager said that this works as most people settle and sleep well overnight. The atmosphere in the home was calm and organised. People spoken to said that the staff don’t rush them and they can get help when they need it. Four staff files were examined and contained all the information required including 2 written references and a clear CRB check. The files also included evidence of appraisals and supervision, the provider/manager said that she knows that some people are now due to have them done again. All files Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 18 contained induction programmes, contracts of employment and training certificates for numerous courses and study days including; health and safety, infection control, fire safety and medicines handling. The provider/manager said that earlier that week some staff attended a deaf awareness training session, which proved to be very interesting. She said that 3 staff members are currently studying for an National Vocational Qualification 3 in care and at least 4 staff members are going to be starting studying for an National Vocational Qualification 2 in the near future. No records were seen for any manual handling training or updates. The provider/manager was reminded that staff should be updated/trained annually. Staff spoken to said that they enjoyed working at the home and because it is small more attention can be paid to people. The Annual Quality Assurance Assessment states that all staff have a job description (which was seen in staff files) and a handbook, that has recently been updated. The provider/manager has a secretary who works part time to help with filing and organisation of files. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 The procedures the provider/manager has in place are designed to meet the needs of the service, and to continually improve the service the home offers to meet the needs of the people that live there EVIDENCE: The provider/manager has had the home for many years and finds she works well with a small staff group. This enables her to get to know them well and ensure they are well supported and trained to be able to care for the people who live at the home. As she works in the home she also knows the Service Users and their visitors well and is always available to speak to people if they have concerns or worries. She feels this ‘open door’ approach lets people talk about their concerns when they arise instead of them building up and becoming worse. She also has satisfaction surveys given out to Service Users Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 20 and/or their representatives from time to time. She said once the ongoing work is completed these will be due to be distributed again. Minutes of a recent night staff meeting were seen and the provider/manager said that she also has meetings with day staff and that she is planning a relatives/residents meeting in the near future. The provider/manager said that they do not deal with people’s personal finances. They provide receipts for hairdressing for example and invoice the person responsible for managing the personal allowance. Records of expenditure and receipts are kept to confirm what has been spent. People are encouraged to manage their own finances if possible to retain a level of independence. The provider/manager described the procedures she has in place for people’s safety during the ongoing refurbishment within the home. She has also put up a notice at the front entrance to inform visitors about the potential risks. When floorboards are being lifted upstairs people are asked to use the downstairs lounges and the ongoing work is not able to start until personal care is complete and all the rooms are vacated. Some personal risk assessments were seen in care plans, these were up to date. The current detailed fire risk assessment was seen (the provider/manager said she is aware this will need updating once the ongoing work is completed). Most of the windows on the first floor have restrictors fitted, the provider/manager should make sure that the small number of windows in the upstairs annexe are also restricted. A free- standing radiator was seen in a persons room, the provider/manager was reminded that a risk assessment should be carried out on such items. Staff were seen wearing gloves and aprons at appropriate times and hand washing sinks were seen in various locations in the home. The microwave in the kitchen is placed on top of a tall fridge, when asked if this was too high for staff to reach, a staff member demonstrated how they use it and said it was not a problem for anybody and it is not often used. The fire log- book was up to date and a number of routine maintenance of equipment records were seen to confirm the information supplied in the Annual Quality Assurance Assessment. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP16 OP30 OP38 Good Practice Recommendations The complaints procedure included in the Service Users Guide should also be displayed at the main entrance. Care staff should attend annual lifting and handling training/updating. All windows on the first floor should have window restrictors fitted. Any free standing radiators in use should have an up to date risk assessment in place. Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillsborough Residential Home DS0000070506.V362144.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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