Inspection on 03/08/05 for Hillside

This inspection was carried out on 3rd August 2005.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillside 04/08/06

Hillside 22/11/05

Hillside 21/12/04

Hillside 03/08/04

Hillside 07/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Hillside 82 Pinner Road Oxhey Hertfordshire WD19 4EH Lead Inspector Hazel Wynn Unannounced 03.08.05 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 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 Stationary 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 I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillside Address 82 Pinner Road Oxhey Hertfordshire WD19 4EH 01923 245466 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Watford and District Mencap Mrs Amanda Richards Care Home 11 Category(ies) of LD LD Learning disability 11 registration, with number of places Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for 11 people with learning disability - 8 in Pinner Road and 3 in 4 Hillside. Date of last inspection 21.12.04 Brief Description of the Service: 82 Pinner Road is a detached building providing personal care and accommodation for eight people who have a learning disability. Three of the service users live a more independent life in a self-contained flat that is situated on the first floor of the building. All other service users have single occupancy bedrooms in a purpose-built extension on the ground floor. The property has a small frontage with steps leading to the front door. At the rear of the property, the garden is mainly laid to patio. 4 Hillside Crescent is a smaller mid-terrace property accommodating three service users who also live more independently. The property is in close proximity to 82 Hillside Road and has a small rear garden. Both properties are managed and staffed by one staff team and is known collectively as Hillside. The home was first registered with Hertfordshire County Council in 1993. It is located close to Watford Town Centre that offers numerous amenities including Watford Town football stadium, theatres, a multi-screen cinema and a large undercover shopping mall. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 3rd August 2005. The inspector looked at records relating to the care and welfare of the service users and Health and Safety records. A tour of the buildings was carried out and the inspector spoke with service users and the staff on duty. The inspector found that most of the National Minimum Standards had been met. A requirement was made for Regulation 26 reports (reports of visits made by the proprietor or his representative) to be forwarded to the Commission for Social Care Inspection. Two recommendations were made: 1). To show the date of review on Risk Assessments. 2). To correct the title of the Inspecting body on the Statement of Purpose which had been updated with an error. The staff were professional, friendly and supportive of the inspection and the service users were observed to be relaxed, content and well cared for. The environment was clean, fresh, homely and comfortable. This report covers both 82 Pinner Road and 4 Hillside Crescent in close proximity to the main house at No. 82; any reference that applies to one of houses only will be clearly stated as to which one the inspector is referring but in the main the report stands for both homes. What the service does well: What has improved since the last inspection? New health records have been introduced and these provide a complete record of changing needs and how these are being addressed; providing reliable tracking of health and progress. Areas of the home have been re-carpeted and redecorated to provide a homely, attractive environment for service users. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 6 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 I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 8 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 standard(s) 1 - 5 Prospective service users are supported to make an informed choice about where to live. All needs are fully assessed by a competent person in conjunction with the service user and all significant others. The home will not admit service users for whom they do not have the capacity to meet their needs. EVIDENCE: The service users have each been given an updated user friendly Service User Guide (this needs a correction to the title of the Commission for Social Care Inspection) as does the Statement of Purpose (which has been updated with the error). Where a vacancy arises, the current service users would be consulted regarding the suitability of a prospective service user living with them; the prospective service user would make frequent visits to the home (including overnight/weekend stays) as part of the assessment and transition process. Service users have a full and comprehensive assessment in place on their individual files. Service Users have a copy of the Agreement on their individual files which keyworkers have supported them to work through. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 9 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 standard(s) 6 -10 Service users are fully involved with care planning, reviews and they are supported to make their own decisions. The service users participate in all aspect of their life in the home and are supported to take risks. Confidentiality is protected and individual records are securely stored. EVIDENCE: The care plans seen contain a full and comprehensive assessment of service users personal needs, goals and aspirations and these are kept reviewed. The records show that the service user is present at his or her review and notes are maintained regarding their involvement in their reviews. The care plan folders provided evidence of how the service users are supported with an individual approach to make decisions. Service users influence how the home is run; each month the service users have structured time known as ‘My Time’ during this time their views are explored and action is taken; these meetings are recorded and copies were seen on the files. Risk Assessments are carried out to support service users to live lifestyles within a risk management framework. Service users were observed taking part in domestic activities, interacting with staff in a relaxed and friendly manner. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 10 Information about service users was seen to be securely stored. Confidentiality is protected; training in confidentiality is in place (the induction process notes seen provided evidence of this) and data protection policies and procedures were accessible in the office. Staff are inducted with all policies and procedures so have a good awareness of the organizations expectations. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 11 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 standard(s) 11-17 Personal development is well supported and age, peer, culturally appropriate activity opportunities are provided both in the home and in the local community for personal development and leisure time. Relationships are fully supported. Rights are respected and responsibilities recognised. Healthy eating is encouraged and the service users enjoy their meals. EVIDENCE: Three of the service users were on a holiday of their choice and the records showed that there are ample opportunities provided for personal development and this is tracked monthly. The activities that take place in the home and local community appeared to be age, peer and culturally appropriate with a variety and choice to suit the individual. When three service users were asked by the inspector if they are happy with life in the home, they replied that they were; one of the service users replied teasingly “sometimes” and then laughed as she joked with one of the staff. All of the service users went on to say that they liked the staff and the support that they get and wouldn’t want to change anything. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 12 The care plans and progress notes seen by the inspector showed that there are ample leisure activities provided both in the home and in the local community; the service users frequent there local community with great regularity and have done so for some time and know many of the people in their local area. The records provided evidence that rights are respected and responsibilities recognised. During the ‘My Time’ meetings service users are encouraged to air their views and these will be appropriately acted on to support the service user to achieve their aim, examples of these records were seen by the inspector. Service users also have service user meeting and access to advocacy. Relationships with family and friends are very much supported and relatives/friends play a large role in the service user’s lives; the records provided evidence to this effect. Policies and procedures are in place to ensure the service users rights and responsibilities are acknowledged and respected. The menu reflected a healthy and well balanced diet and service users were observed to be enjoying their evening meal taken with staff. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 13 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 standard(s) 18 -21 Personal support is provided according to the service user’s preference. Physical and emotional needs are met. Where appropriate, service users are able to retain and administer their own medication. Ageing, illness and death would be handled with respect and in accordance with the individual’s wishes. EVIDENCE: The care plans seen contained guidance to staff in how to manage personal care needs according to the service users preference. Likes and dislikes/preferences were clearly recorded. Generally a service user will attend the GP surgery for consultation but if the GP needs to be called out he will visit them in their own room and a member of the homes Care Staff Team will support the service user. All appointments are recorded and outcomes of appointments are documented, which aids consistency in following up. A new Health Record folder has been introduced very recently and the one that had been completed provided detailed and up to date progress in health and will provide very good future tracking of health needs and outcomes. The inspector also observed the meeting of the emotional needs of three service users as staff were working alongside them. The care plans seen also Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 14 recorded the emotional needs assessed with instructions to staff for meeting the needs. One of the service users in the home self-administers their own medication, this is monitored and kept reviewed and a record of the review was seen; in this, the risk assessment had been revisited recently and there was no change but the actual risk assessment document had no date to show it was current and a recommendation was made for dates to be shown to ensure that an old risk assessment couldn’t be confused with an updated one. Medication was safely stored and the medication administration records had no gaps in the recording. A record is maintained of all medication returned to pharmacy and a receipt book was observed to be maintained. The pharmacist support the home with regular checks and the reports of these visits were accessible to the inspector. Policies and procedures were in place regarding ageing, illness and death to ensure a sensitive and supportive approach is provided to service users as changes in life and health status arise. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 15 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 standard(s) 22 -23 Service users views are listened to and acted on. Service users are protected from all forms of abuse, neglect and self-harm. EVIDENCE: There is a clear user-friendly complaints procedure in place and this has been updated; however there was an error in the address of the inspecting body and this needs amending to show it as Commission for Social Care Inspection. Service users meet with their keyworker on a regular basis and this structured time is called ‘My Time’ and a record is maintained of that meeting. Records of the meetings held provided evidence of service users being encouraged to air their views and share anything that is worrying to them and the action that is then taken; this is a good example of supportive methods of protecting vulnerable adults. Training records show that all staff are inducted with abuse awareness and attend regular updates; these sessions are designed to keep staff reminded on what signs to look out for and how to respond to any suspicion of abuse. To further protect vulnerable adults the home has policies and procedures in place. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 16 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 standard(s) 24 - 30 The home is maintained in a comfortable, homely, clean, hygienic and safe manner with personalised and comfortable bedrooms. Toilets and bathrooms meet individual needs and there is sufficient shared and individual space. Independence is promoted by the use of specialist equipment. EVIDENCE: The inspector observed the home to be comfortable and homely, clean and hygienic (both at No.4 Hillside Crescent and 82 Pinner Road). There were no mal odours and the home was clean and tidy. Risk assessments have been carried out on the environment and are kept under review. A safe environment is maintained with sufficient safe and fully accessible shared space for activities; health and safety records including care plans, fire safety records, incidents/accident records, medication and COSHH (control of substances hazardous to health) records and storage, water and fridge temperature records, seen by the inspector, provided seen by the inspector this evidence. The inspector also carried out a visual check of the environment and was satisfied that Health and Safety protocols were observed. The inspector observed that the service users bedrooms were pleasant, comfortable and personalised. Service users help to maintain the domestic Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 17 standards of their own room and are supported to do as much as possible themselves; the service users said the staff help them and the care plans show how the support is to be given to maintain independence and development of self help skills. The inspector observed that both shared and individual space was adequate and that grab rails are in place to promote independence. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 36 Staff know their roles and responsibilities to the benefit of the service users. The service users are supported, with their joint and individual needs being met, by a staff team that is competent, effective and qualified for role. Recruitment is robust to protect service users. The support and supervision given to the staff benefits the service users. EVIDENCE: Induction records seen by the inspector showed that staff are provided with a job description that describes their role and responsibilities. Units of the Learning Disability Framework Award are worked through during induction of staff to ensure that they have the skills and are qualified for their role. Staff on duty stated that several of the staff team are currently working towards levels 2 and 3 NVQ; this is evidence of how service users and those concerned with their welfare can be assured that there is a competent, effective and qualified staff team meeting the joint and individual needs of service users. Records seen also provided evidence of the staffs’ competence and effectiveness in both their style of recording and actions taken by them in meeting needs. No new staff have been recruited since the last inspection, when staff files were seen by the inspector and provided evidence that robust recruitment policies and procedures had been adhered to. The staff files seen at the last Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 19 inspection had CRB, references and employment histories in place; all future CRB checks will also include POVA checks (Protection of Vulnerable Adults check); these were introduced in July 2004 to further protect service users in the recruitment of staff. Staff stated that they receive regular formal supervision and this is documented; they further stated that they feel well supported and are happy working in the home. Formal supervision includes appraising how the staff support an individual service user and the group as a whole; it also looks at any needs the staff have in relation to carrying out their role, which ensures that the service users are supported by a motivated and supported team. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 - 43 The home is well run to the benefit of the service users. There is a strong and healthy ethos, leadership and management approach in place, which ensures that service users views underpin self-monitoring, review and developments by the home. The home’s policies, procedures and record keeping safeguard Service users rights and best interests. The competent and accountable management approach of the service benefits the service users. The health, safety and welfare of the service users is promoted and protected. EVIDENCE: The registered manager is qualified for post and has been the manager for many years at Hillside and has consistently proved that she has the ability to run the home in the best interests of the service users. Speaking to staff, service users and looking at records provided evidence that there is a strong ethos, leadership and management approach that benefits both service users and staff in respect of their health, safety and welfare. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 21 Records show how involved the service users are in the developments and decision making of the home and that their views underpin the homes direction. The inspector looked at care plans and progress notes, environmental and individual risk assessments, fire safety records, finance records, medication records, accident/incident and complaints books, COSHH records (Control of Substances Hazardous to Health) water and fridge temperature recording. The records seen were satisfactorily maintained and storage arrangement for medication and COSHH were in place. A recommendation was made that the date of review of risk assessments be added to it (although this information is in the whole life review, the date on the actual risk assessment document would rule out any possible confusion). All of the other records examined were detailed and maintained to a good standard. Staff training records confirmed that’s staff continue to update their knowledge and skills. Policies, procedures and protocols are in place to promote and protect the health, safety and welfare of the service users and staff; records showed that the policies, procedures and protocols are adhered to. The reports from the proprietors monthly visit (regulation 26) have not been forwarded to the Commission for Social Care Inspection since January 2005 and a requirement was made in this respect. The purpose of the proprietor’s monthly visit is to provide self-monitoring of the service provided and to ensure the service users needs are being met on an ongoing basis, in accordance with the Statement of Purpose. The Insurance Certificate was on display and is current. The registration certificate is prominently displayed and the details of the management and who can be accommodated in the home were correct. The service users spoken with stated that they were well cared for and the inspector was satisfied from the outcomes of the inspection, that this home is being run in the best interests of the service users. Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hillside Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 23 No 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 YA39 Regulation 26(5)(a) Requirement The proprietors visit reports must be forward to the Commission for Social Care Inspection. Timescale for action 30/08/05 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. Refer to Standard YA1 Good Practice Recommendations Correct the title of the inspecting body on the Statement of Purpose, Service User Guide and Complaints Procedure as the Commission for Social Care Inspection (not The National Care Standards as written). Risk Assessments should be dated when reviewed to indicate that it is still current. 2. YA20 Hillside I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 I52_s19428 Hillside v228421 030805 stage 4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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