Inspection on 04/08/06 for Hillside

This inspection was carried out on 4th August 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillside 22/11/05

Hillside 03/08/05

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 Bijayraj Ramkhelawon Key Unannounced Inspection 4th August 2006 13:00 Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 DS0000019428.V303840.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 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 DS0000019428.V303840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Address 82 Pinner Road Oxhey Hertfordshire WD19 4EH 01923 245 466 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) Watford and District Mencap Mrs Amanda Richards Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 11 people with learning disability - 8 in Pinner Road and 3 in 4 Hillside. 22nd November 2005 Date of last inspection Brief Description of the Service: 82 Pinner Road This 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 This is a smaller mid-terrace property accommodating three service users who also live more independently. The property 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. The ‘Statement of Purpose’, ‘Service User’s Guide’ and the ‘Complaints procedure’ are available for current and prospective service users. Current fees charged is £450 per week. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on the 4th August 2006. The inspector looked at care plans pertaining to the care and welfare of the service users and other records. A partial tour of the buildings was carried out and the inspector spoke with service users and the staff on duty. What the service does well: What has improved since the last inspection? What they could do better: The ‘service user’s guide’ must be produced and a copy supplied to the Commission and each service user. Medicine bottles and containers must be dated when first opened. Hand written instructions on Medicine Record Sheets (MAR) must be signed. A record of the temperature where medicines are stored must be kept so as to ensure that sub standard medicines are not administered to service users. Badly stained carpets in the corridors and stairs must be cleaned or replaced. Badly stained shower tray must be cleaned or replaced. Loose and broken tiles in the shower room must be replaced. Badly worn and stained flooring in the bathroom must be replaced. An extractor fan must be fitted in the kitchen of 4 Hillside. Hand paper towels and liquid soap must be provided in communal bathrooms. Each staff should receive an annual appraisal. Fire drill carried out should indicate the name of staff and service users who participated and the duration of this exercise. Fire risk assessment should be carried out as recommended by Hertfordshire Fire Rescue Service. The temperature of the fridge and freezers should be checked and records kept. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 6 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 DS0000019428.V303840.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 1&2 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Adequate information was available to prospective service users. Each service had an assessment of their needs carried out. However, the ‘service user’s guide’ must be produced and a copy supplied to the Commission and each service user. EVIDENCE: The ‘service user’s guide was not available nor a copy given to each service user or the Commission. Prospective service users visit the home and ‘test drive’ it before any decisions for placement are made. Service users needs were assessed and whole life reviews were held annually. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 6,7,and 9 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. 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 guarded and individual records are securely stored. EVIDENCE: Care plans examined contained a full and comprehensive assessment of service users personal needs, goals and aspirations and these were reviewed on a regular basis. These care plan provided evidence of how the service users were being supported with an individual approach to decision making. Risk assessments were carried out to support service users to live a fulfilling and meaningful lifestyle within a risk management framework. Service users were observed taking part in domestic activities without any prompting. Good interaction between service users and staff were observed and the atmosphere was relaxed and friendly. Service users said that they were happy with the Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 10 service provision and appreciated the support they received from staff including their key workers. Information about service users was observed to be securely stored. Confidentiality is protected; training in confidentiality was in place and a recognised induction process was also in place. Data protection policies and procedures were accessible in the office. Each service user has a yearly whole life review. Comprehensive, regularly reviewed care plans are in place and in a format appreciated by the service users; it is easily evidenced on reading through these that they are live documents and that individual’s assessed needs were being met. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16 & 17 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. The service promotes personal development and the service users take part in age, peer and culturally appropriate activities and leisure activities both at home and in the local community. Personal, family and other relationships are supported. Rights and responsibilities were recognised and respected in the service users daily lives. A healthy diet was promoted and enjoyed in comfort. EVIDENCE: Care plans and individual’s progress records showed that service users were provided with a wide variety of activities both at home and in the local community as well as further afield including short break and holidays. Service users were supported to exercise their rights and be respectful of others; the “my time” sessions provided an excellent tool for supporting the ongoing development. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 12 Service users are able to choose from a varied and healthy menu. The dining area of the home was comfortable and reasonably spacious. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 18,19 and 20 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Personal support was provided in accordance with the individuals’ needs and preference. Service users are supported to retain and administer their own medication wherever possible; policies, procedures and protocols were in place. However, minor shortfalls in the recording and management of medicines were identified and these must be addressed so that service users are not put at risk. EVIDENCE: Service users said that they were supported to be as independent as possible and to have control over their own lives. Interaction between staff and service users was seen to be warm and appropriate. Service users said that staff respected their privacy and dignity and that they were able to see other professionals, friends and relatives in private. Care plans were detailed and comprehensive. These showed how identified needs were being met. ‘My Health’ folders, were extensive profiles of the service users individual health status and needs which formed part of the care plan. These were reviewed on a regular basis. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 14 One service user self medicates and another receives some assistance from staff. The administration of medicines was kept in good order. However, it was noted that medicine bottles and containers were not dated when first opened; hand written instructions on MAR sheets were not signed and there were no records kept of the temperature where medicines were stored. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 22 & 23 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Service users do feel that their views are listened to and acted on and they are protected from all forms of abuse, neglect and self-harm. EVIDENCE: Service users said that their views were listened to and acted on. They were actively encouraged to air their views during the one to one “My Time” sessions with their individual key workers. There had been no complaints received since the last inspection. Staff training in abuse awareness, policies and procedures and health and safety protocols were all in place to provide safeguards. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 the following standard(s): 24 & 30 The quality outcome in this area is poor. This judgement has been made using all available evidence including a visit to this service. The individual style of each of the bedrooms helps to promote service user independence and good communal facilities help to meet their needs. However, the general décor, floorings and repair works in some areas must be carried out so as to maintain a clean and homely environment. An extractor fan or similar condensation extracting device must be fitted so that the wet and slippery kitchen floor remain dry and safe. Hand paper towels and liquid soap must be provided in communal bathrooms so as to control the spread of infection. EVIDENCE: Service users’ bedrooms were personalised with individual’s belongings. Staff encouraged service users to bring and/or choose their own furniture and can decorate and personalise their rooms, subject to fire and safety regulations. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 17 Recent internal works have been carried out and damp proofing course applied. Due to this work there have been areas where the carpets have been badly stained. However, there were loose and broken tiles in the shower room, badly stained shower tray, badly worn and stained flooring in the bathroom and areas of badly stained carpets in the corridors and stairs. The kitchen in 4 Hillside was wet and slippery due to condensation. There were no hand paper towels and liquid soap provided in the communal bathrooms. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 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 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 & 35 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. The skills and experience of staff were varied. There was an enthusiastic, dedicated and caring staff team. Adequate numbers of staff were rostered on duty, ensuring that service users personal care needs can be met in a manner to suit service users, protecting their dignity. However, each staff should receive an annual appraisal so care staff are supported in maintaining a good standard of care and safe practices. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. Staff files examined did not have had all the relevant documents required by this Standard. The manager said that these were kept at the head office. Staff spoken to confirmed that they have received appropriate training, this included statutory training. They also said that they receive regular supervision but not an annual appraisal. They said they have been given a copy of the General Social Care Council Code of Conduct. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 19 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): 37,39 & 42 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Service users benefit from a well run home that has a good ethos and leadership; the registered manager’s approach is good. The service users have a strong sense of ownership and know that their views underpin the reviews and developments of the home. However, record keeping for health and safety and fire safety regulations must be kept in good order so that service users and staff are not put at risk. EVIDENCE: Staff confirmed that the registered manager operated an open door policy to staff, service users and to their representatives. Good professional interaction between staff and service users was observed. Staff confirmed that they had undertaken all the mandatory training. Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 20 All statutory records were available for inspection and maintained in accordance with legislation. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of service users. However, it was noted that a risk assessment as recommended by Hertfordshire Fire and Rescue Service was also not carried out. Fire drills carried out did not indicate the name of staff and service users who participated and the duration of these exercises. The temperature of the fridge and freezers were not checked nor any records kept. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents. A valid insurance certificate (expires on 29/11/06) was displayed in the office and this offered cover of no less than £5 million. Hillside DS0000019428.V303840.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 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 2 2 3 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 1 25 x 26 X 27 X 28 X 29 x 30 2 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 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Hillside DS0000019428.V303840.R01.S.doc Version 5.2 Page 22 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 YA1 Regulation 5 (1) & (2) 13 (2) Requirement The ‘service user’s guide’ must be produced and a copy supplied to the Commission and each service user. a) Medicine bottles and containers must be dated when first opened. b) Hand written instructions on MAR sheets must be signed. c) A record of the temperature where medicines are stored must be kept. a) Badly stained carpets in the corridors and stairs must be cleaned or replaced. b) Badly stained shower tray must be cleaned or replaced. c) Loose and broken tiles in the shower room must be replaced. d) Badly worn and stained flooring in the bathroom must be replaced. e) An extractor fan must be fitted in the kitchen of 4 Hillside. DS0000019428.V303840.R01.S.doc Timescale for action 07/10/06 2. YA20 07/10/06 3. YA24 23 (2) (b) 07/10/06 Hillside Version 5.2 Page 23 4. YA30 13 (3) Hand paper towels and liquid soap must be provided in communal bathrooms. 07/10/06 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. Refer to Standard YA36 YA42 Good Practice Recommendations Each staff should receive an annual appraisal. a) Fire drills carried out should indicate the name of staff and service users who participated and the duration of these exercises. b) Fire risk assessment should be carried out as recommended by Hertfordshire Fire Rescue Service. The temperature of the fridge and freezers should be checked and with records kept. 3. 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