Inspection on 30/01/06 for Hillscourt

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillscourt 19/09/06

Hillscourt 16/05/05

Hillscourt 07/01/05

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 Hillscourt The Hillscourt Nursing Home 8-10 Pennsylvania Road Exeter Devon EX4 6BH Lead Inspector Rachel Doyle Unannounced Inspection 30th January 2006 14:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 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. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillscourt Address The Hillscourt Nursing Home 8-10 Pennsylvania Road Exeter Devon EX4 6BH 01392 431662 01392 433406 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) GT Care Services Ltd. Mrs Jenny Louise Mary Harry Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Notice of Proposal to Grant Registration for staffing/environmental conditions of registration issued 7/6/94 To admit one named person outside the categories of registration as detailed in the notice dated 1st July 2005 The maximum number of persons accommodated at the home, including the named service user, will remain at 27 On the termination of the placement of the named service user, the registered person will notify the Commission in writing and the particulars and conditions of this registration will revert to those held on the 23rd June 2005 16th May 2005 Date of last inspection Brief Description of the Service: Hillscourt is a 27 bedded Home which is registered to provide nursing care for those aged over 65 years. It is an older property situated in Exeter close to amenities. There is a pavement ramp and wheelchair access. At the rear there is a level patio reached by a conservatory. The Home provides nursing care for 27 residents in individual rooms, which are divided between two floors with the upper floor split into two levels. There is a convenience store opposite, which is open 24 hours. There are no car-parking facilities but there is a multi-storey car park only 5 minutes walk from the Home and two hour parking in surrounding roads. The Home does not provide intermediate care. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Unannounced inspection took place on Friday 30th January 2005 at 14.3016.00. The inspector was welcomed by the Registered Provider and the Registered Manager. There were 24 residents at the Home, some in the lounges and conservatory and others resting in their rooms. A new resident was arriving the following day to a re-furbished room. The inspector spoke to 4 residents in depth and spent time with 4 others in the lounge, and spoke to 2 staff and the Registered Provider. The Home are devising a new care planning format and this was discussed. The Home are keen to improve carers’ input in recording and the proposed system looked comprehensive. There is now a Personal Development Manager and Secretary employed at the Home. This inspection looks only at the 5 National Minimum Standards which were not assessed during the previous report and any which were the subject of a Requirement or Recommendation. The inspector was able to tour the Home freely and had access to any relevant documents. Carers all seemed happy in their work and spoke positively about their role and their new uniforms. There was a relaxed atmosphere and good rapport was seen between residents and staff throughout the inspection. Two residents said that ‘it was all good and that they had nothing to moan about’. What the service does well: What has improved since the last inspection? Wheelchairs are being used properly by staff when mobilising residents. This topic is included in staff meetings to ensure residents’ safety. There are appropriate risk assessments. The use of lap tables has been assessed to ensure that there are no restraint issues. The staff have been made aware that tables must be placed appropriately. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 6 The administration of medication has been improved to provide a safe system, which does not place residents at risk. The Registered Provider has worked hard to set up an excellent quality assurance system at the Home. Two residents said that they did not fill out any questionnaires as they felt that it was unnecessary as the Home was good. 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. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 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 Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not judged on this occasion. EVIDENCE: Not assessed during this inspection. Please see previous inspection reports. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 9 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): 9 Medication administration systems are well managed, promoting residents’ good health. EVIDENCE: The medication system was discussed. There is a new drugs trolley and this is taken around the Home to each resident as medication is administered. Staff were seen to ensure that medication is taken by residents before being signed for by staff. MARS sheets were all correct, including any hand written transcriptions and there is photographic identification of all residents with a list of their formally used names and preferred names. Storage is well managed and all medication was in date. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 10 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): Not judged on this occasion. EVIDENCE: Not assessed during this inspection. Please see previous inspection report. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 11 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): 18 Residents are protected from harm or abuse as sound procedures are in place. EVIDENCE: Protection of Vulnerable Adults training is booked with external trainers. All staff have attended. The Practical Guide was visible in the office. The Home has reviewed the practice of using lap tables to ensure that there is not a restraint issue. Staff were aware of this and the topic of Protection of Vulnerable Adults is included regularly in staff meetings. All residents spoken to felt that they were well cared for and that they were listened to by the manager and staff. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 12 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, 22 Residents are provided with safe and comfortable surroundings giving residents an attractive and homely place to live. EVIDENCE: The standard of the environment within the Home is excellent. Residents said that they were pleased with the ongoing decoration and recent improvements and felt involved in any changes. The owner discussed in detail the ongoing maintenance and a tour of the Home confirmed this. Rooms are decorated to a high standard with clear thought as to how a resident would want the room to feel and Manual Handling issues. Each resident is given a calendar by the Home to hang in their room on arrival. A detailed written maintenance programme was seen and there is a maintenance man who works 60 hours a week. Two rooms have recently been vacated and re-furbished to a high standard. There are plans for further improvement and two extra bedrooms in the near future. Wheelchair use is monitored by the Provider and discussed in staff meetings to ensure that Manual Handling and Safety issues are adhered to. Staff meeting minutes were seen and information was handed out to all staff as good practice reminders. Reporting any maintenance needs is included Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 13 in staff job description and these are addressed in a timely way. There are good risk assessments and action plans, especially addressing the use of wheelchairs by staff. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 14 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): Not judged on this occasion. EVIDENCE: Not assessed on this occasion. Please see previous inspection reports. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 15 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): 33 There is leadership, guidance and monitoring systems in place to ensure that residents receive consistent quality care. EVIDENCE: The Home is a member of the Registered Homes Association and the Provider often uses them for advice. They have a positive attitude to inspections and have an open and transparent relationship with CSCI and timely responses to inspection reports. The Home works in partnership with Croner (employment law). The Home is also working to achieve the Investors in People Award and is awaiting the auditors. The Provider undertook the annual quality assurance survey on August 2005. Residents were able to fill out a detailed questionnaire anonymously if they wished or with help from their representatives. The results showed that there were a majority of high scores and comments included ‘this is an extremely caring and friendly environment’, I fully appreciate how well my relative is being looked after, couldn’t be better anywhere’, and ‘I am cared for with skill, politeness and patience’. Results are then analysed and any Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 16 negative comments discussed in staff meetings and an action plan followed. This is the first quality assurance audit undertaken by the current provider and was found to be very comprehensive; resident focussed and well thought out. It was suggested that the questionnaire is widened to include visiting health care professionals and a questionnaire sent separately to relatives as appropriate. CSCI will send a selection of comment cards to accompany the system as the provider sees fit. They said that they would also send a summary of their findings to CSCI as per the National Minimum Standard. Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X 3 X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? 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. Refer to Standard Good Practice Recommendations Hillscourt DS0000042993.V261793.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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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