Inspection on 23/01/06 for Hillside

This inspection was carried out on 23rd January 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillside 28/04/06

Hillside 24/11/05

Hillside 12/01/05

Hillside 15/10/04

Hillside 13/01/04

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

CARE HOME ADULTS 18-65 Hillside 45 Gainsborough Road Henley On Thames Oxfordshire RG9 1SY Lead Inspector Catherine Kane Unannounced Inspection 23rd & 24th January 2006 04:30 Hillside DS0000013217.V278462.R01.S.doc Version 5.1 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 Hillside DS0000013217.V278462.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 Adults 18-65. 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. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillside Address 45 Gainsborough Road Henley On Thames Oxfordshire RG9 1SY 01491 577169 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) Caretech Community Services Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: Hillside is a semi-detached house situated in a residential area of Henley on Thames. The home is registered for three people with a learning disability. The home has a cosy lounge, dining room, kitchen and two bathrooms. There is a small garden to the back of the house. Each resident has their own bedroom; one with some adaptations on the ground floor and two others on the first floor. The home is run and managed by CareTech Community Services Ltd, a national organisation with experience in providing services for people with a learning disability. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place during the day of Monday 23 January 2006. The manager and staff did not know the inspector was planning to visit. The inspector returned to the home on Tuesday 24 January 2006 for a follow-up visit and to meet the deputy manager. The time spent in the home was over three hours. The purpose of the visit was to see how the home is meeting National Minimum Standards. The inspector met all three residents and three staff who were on duty at the time of the visits. During the inspection she saw how staff helped residents look after and take their medicines, read notes and looked at other records kept in the home. She was also there when residents were having their evening meal. The home is still without a registered manager. The CareTech area manager has kept CSCI informed of efforts to recruit a suitable manager. The inspector would like to thank each resident for making her feel very welcome. She also thanks the deputy manager and staff on duty for their assistance during the inspection. What the service does well: 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. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed at the inspection held on 24 November 2005. EVIDENCE: Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed at the inspection held on 24 November 2005. EVIDENCE: Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: During the inspection residents and staff sat together to share their evening meal. This was freshly prepared. There was a friendly, family atmosphere with residents and staff sharing news and plans for the following days. Residents help with the planning and preparation of meals and said they were happy with the meals provided. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Some practices relating to medication could be improved. EVIDENCE: During the inspection the inspector saw how residents were helped to take their medication. Both staff on duty were confident about the system used and knew well how each resident preferred to take their medicines. Lists of staff names with their approved signatures or initials were kept and staff training assessments were kept including training by an external source with relevant knowledge of medicines. However, the inspector strongly recommends that some practices be improved. The medicines cabinet was generally in order but some residents’ medicine bottles were very sticky; care should be taken to keep residents’ medication clean following use. Medication Administration Record (MAR) sheets should be signed at the time following administration to avoid risk of error, not at the end when all residents have been given their medication. Hand written entries on MAR sheets should reflect exactly what has been written on the pharmacist’s label and signed and checked by staff trained to administer medication, again to avoid risk of error. During the inspection the deputy manager quickly became aware that one resident’s medication was not locked in the medication cabinet, as it should be. This had been taken out with the resident earlier that day but it had not been returned. A better system for Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 11 accounting for medicines that need to be taken out of the home when the resident goes out or when they go away on visits is needed. The inspector strongly recommends that guidance issued by the Royal Pharmaceutical Society of Great Britain be followed. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The complaints procedure is easy to follow. The policies and procedures that protect vulnerable people are robust. EVIDENCE: The deputy manager provided all relatives with information on how a complaint can be made. This home operates in accordance with the Oxfordshire Multi-Agency Code of Practice to protect vulnerable adults from abuse. Staff confirmed a good understanding of their ‘duty of care’ to protect vulnerable people and some staff have attended specific local training. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed at the inspection held on 24 November 2005. EVIDENCE: Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 The arrangements for the induction of staff and training are generally good with staff demonstrating a clear understanding of their roles. The systems for recruitment, selection and performance management of staff who work in this home are generally good. EVIDENCE: There is a well-established core staff team providing consistent care support to residents. Staff have a good understanding of residents’ support needs and communication methods. The relationships between staff and residents are good. The deputy manager provided details of the range of training opportunities to enable staff to do their job. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 While this home runs well, managed by the competent deputy manager, it still needs a permanent manager to provide leadership, guidance and direction to ensure residents receive consistent quality care and to develop the service further. EVIDENCE: The inspector receives copies of the proprietors’ representative’s monthly visit reports. Well maintained health, safety and welfare records are kept in the home and were made available for inspection. CareTech, who run this service, have financial and accounting systems that are subject to internal and external audits. The deputy manager shared with the inspector the outcomes from the recent internal audit that indicates this is a well organised home. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 X X 3 X Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 17 Yes 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. 1. Standard YA37 Regulation 8(1)(a) Requirement The organisation must put forward a plan to appoint a manager to register with CSCI. This was made a requirement at previous inspections. Revised timescale. Timescale for action 15/03/06 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 YA20 YA20 YA20 Good Practice Recommendations The inspector strongly recommends that storage of medicines should be improved so that medicine bottles are kept clean at all times. The inspector strongly recommends that Medication Administration Record (MAR) sheets should be signed at the time following administration to avoid risk of error. The inspector strongly recommends that a better system for accounting for medicines that need to be taken out and returned to the home should be put in place. Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Hillside DS0000013217.V278462.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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