Inspection on 17/06/05 for Hillside Lodge

This inspection was carried out on 17th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillside Lodge 11/09/07

Hillside Lodge 06/09/06

Hillside Lodge 30/11/05

Hillside Lodge 21/03/05

Hillside Lodge 25/08/04

Hillside Lodge 09/03/04

Hillside Lodge 17/07/03

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

CARE HOMES FOR OLDER PEOPLE Hillside Lodge Braeside Berwick upon Tweed Northumberland TD15 2BY Lead Inspector Suzanne McKean Unannounced 17 & 30 June 2005 09:30 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 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. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillside Lodge Address Braeside Berwick upon Tweed Northumberland TD15 2BY 01289 307 500 01289 308 566 hillside.lodge@fshc.co.uk Tamaris Healthcare Limited 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) Mrs Margaret Shippen CRH 50 Category(ies) of OP Old Age (50) registration, with number of places Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two named service users are under 65 years of age. Date of last inspection 21 March 2005 Brief Description of the Service: Hillside Lodge is a two-storey purpose built facility of traditional brick and tiled construction. Bedrooms and shared areas are provided on both floors and there is a lift in the center of the premisis near to the entrace. All bedrooms are single with en-suites containing a toilet and handbasin, and there are toilets situated near to the communal areas. There are showers and bathrooms situated on each of the floors and dining areas and lounges of appropriate size to meet the standards. The home is situated in a residential area of the town of Berwick. Car parking areas are provided at the front of the building giving level access to the home. There are grassed sitting areas, which are accessible to, and for the use of, residents and visitors. The surrounding area is predominantly residential. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 8½ hours over two days by one inspector, who has visited the home on a number of previous occasions and is known to many residents, their families and the staff working in the home. The manager was not on duty on the first visit although she was at the time of the second one. This allowed the examination of records which were being stored securely in line with the homes policy on confidentiality. Nineteen residents were spoken to during the visit and four relatives and the inspector also spoke to seven of the staff the in process of the inspection visits. During the inspection records examined included, 6 care plans and medication records, the training records, the fire log as well as complaints and accident records. What the service does well: The residents spoken to during the visit were positive about the care being delivered and those residents who were able to express their opinions were complementary about the staff and the way they are supported. An example of resident comments are “the staff are good and will do anything asked”. The food being served during the visit was well received by the residents of whom seven said that they enjoyed it for example “Food is really nice” “always lots to eat”. The Manager and staff have regular, meetings with the relatives of the care home residents, as well as day to day contact with them regarding general issues. All negative comments are recorded so that the Manager can anylise them for quality assurance purposes. The home is clean and well decorated and was tidy on both days of the visit although they were not planned. The home is providing extensive training opportunities for the staff which is well documented and planned, this allows the Manager to easily identify the programmed being delivered and identify any gaps or omissions. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 6 The assessment undertaken prior to admission is detailed and the staff undertaking them competent to undertake them. Each resident has a contract in place. The home is not registered for, and therefore does not provide, intermediate care. EVIDENCE: Six care plans were examined and each has comprehensive preadmission assessments, which were undertaken by the senior staff in the home. The residents also have a care management assessment, which is provided, to the home prior to admission and from these documents an individual care plan is produced. There are suitable resident contracts available in the care plans examined. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their health needs met and are being given their medication in a safe way according the prescriptions of their General practitioner. Residents are being treated with respect by the staff, who are aware of their needs and their individual rights. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment. Six care plans were examined and they were completed to a good standard. There was evidence that relevant risk assessments are available for the prevention of falls, nutrition, wound care, moving and assisting, continence promotion and mental health status. The plans showed that they are regularly reviewed and updated and that reviews are regularly held with residents and their representatives. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores, hoists and other moving and handling aids are available according to the assessed needs of the resident. The recording of the nursing action taken for wound care was satisfactory with Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 10 evaluations being dated and signed. The district nursing services provide any nursing care for residents receiving social and personal care and this is being recorded in the care plans as necessary. The home has policies and procedures in place to ensure the safe administration of medicines. The treatment room was clean and well organised. There was no over stocking of medication and minimum controlled drugs in use. A random check of the Medicine Administration Records and the Controlled Drugs found no discrepancies. The home has sight of the prescriptions and record all medicines received and disposed of with dates and signatures of staff and the pharmacist. A pharmacy audit has recently been carried out and a copy of this was provided following the inspection. Four residents were asked specifically about their level of privacy and all were satisfied that it was being maintained. Staff were seen to knock at bedroom doors prior to entering and all asked were able to describe the importance of this type of action. Bedroom, bathrooms and toilet doors have locks in place. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 15 The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. Staff are aware of the importance of a balanced diet and the way it is served. EVIDENCE: The kitchen was clean and well organised, however the recording of food, fridge, and freezer temperatures were not available for the two weeks prior to the inspection although they were available from before that period, a requirement has therefore been made to ensure that this be addressed. There was an ample supply of frozen, tinned, dried and fresh food available all of which was appropriately stored. The kitchen staff were aware of residents specialist needs including how to fortify foods for those who have poor appetites or those who have lost weight. The residents are offered a choice of three meals a day and residents spoken with said that the “food is really nice” and “there is always lots to eat”. The meal being served was ample portion size, hot and well presented. Residents were offered assistance in a discreet manner. Residents were offered second helpings and alternatives to the main and dessert course were available. A variety of cold drinks were available throughout the meal and hot, cold drinks and biscuits were available throughout the day. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16, 18 The home ensures that the residents and relatives are made aware of the complaints policy and that it is available in a variety of places. The residents are protected by ensuring that the staff are given appropriate training and ongoing support. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance as well as being displayed in the home. There is a system for managing and dealing with complaints, which makes it possible for them to be investigated and action taken to address any issues identified The records of the complaints made to the home was examined, there has been one complaint recorded and the records of this was detailed including the response to the complainant and the action taken in response to the issues raised. The Manager records all issues raised even if they are not made as formal complaints and deals with them informally if requested to do so. Three of the residents who were interviewed during the visit were asked about the way in which they would have any problems dealt with, each were able to identify the way this would be done. Protection of Vulnerable Adults training and the mechanisms for whistleblowing and reporting concerns to the Manager is in place and the records of this was examined confirming this. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The home is well decorated and is safe for the residents to live in. It is being maintained in a satisfactory way and there is a programme in place to ensure that the redecoration and maintenance is undertaken. The bedrooms are all single occupancy and are decorated and equipped in a homely and personalised way. There are suitable toilets and bathrooms which are well equipped and nicely decorated. The necessary specialist equipment is provided in the home and when required appropriate advisors are brought in to offer advice and assess residents needs e.g. Physiotherapy. EVIDENCE: A tour of the home was conducted with the Deputy manager to assess the general condition of the home. It is tidy and organised in such a way to make sure that the residents are able to use the home safely. It is purpose built and is well maintained and there is evidence of some refurbishment and redecoration-taking place as necessary. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 14 The home has a choice of outdoor areas in which to sit and there is outdoor seating provided, and some of the residents have participated in gardening projects. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff were observed to follow infection control policies throughout the day. The light and emergency call cords were all clean and all emergency cords reached skirting level. All of the on-suite bathrooms in the bedrooms have liquid soap, disposable hand towels and waste bins which reduces the risk of cross infection in the home. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 The home is staffed with appropriate numbers of staff and there are qualified nurses on duty in sufficient numbers to meet the needs of the residents. The staff are recruited and selected using a system which ensures that they are able to care for the residents and are going to offer a safe place for them to live. EVIDENCE: Staffing rotas showed that the Manager is ensuring that enough staff are on duty to meet the staffing levels set down prior to the change to the CSCI without reduction. It was noted that when sickness and staff holidays occur these occasions are usually covered by home staff. However when this is not possible agency staff are being used, late reporting does occasionally result in fewer staff being on duty for short periods. Four staff records were examined and were all complete including two references and a completed application form, the requirement to have a CRB in place is applied to all of the staff in the home. The training records maintained by the Manager to allow her to plan for training was examined, it was very clearly maintained and offered a good system. There is evidence of a significant amount of training however this standard was not fully examined at this inspection and will be looked at in more detail at the next one. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 38 The Registered Manager, Mrs Shippen, ensures that she has systems in place to make sure that the home is managed effectively taking into account the needs and wishes of the residents. She is continuing to consult the residents, staff and other interested parties to review the service provided and manage the staff in a way to improve care delivered. EVIDENCE: The Manager, Mrs Shippen has a good understanding of the client group, there are clear lines of accountability both in the home and within the company, and she has the relevant management qualification. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 17 The personal records kept in the home of residents who are receiving assistance to manage their finances were examined and are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place, and there is a small float available for the staff to access. The care plans are being stored on a shelf in an unlocked room and their confidentially could not be ensured. There is a policy for supervision, for care staff and the records to support the Managers confirmation that she attempts to ensure safe working practices for moving and handling, first aid, food hygiene and infection control were in place and, although the record needs to be brought up to date. The home has in place arrangements to ensure that persons working at the care home receive suitable training in fire prevention and by means of fire drills and training in the procedures to be followed in the case of fire. There is a monthly health and safety meeting involving a selection of home staff for which records are available. Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x 2 3 Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 19 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 OP37 Regulation 17 (1) (a) Requirement The storage of care plans must be reviewed to ensure that they are secure and offer confidentiality. The kitchen records must be maintained in such a way to be able to demonstrate safe practices are in place. Timescale for action 01.08.05 2. OP15 16 (2) (i) 01.08.05 3. 4. 5. 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. 4. 5. Refer to Standard Good Practice Recommendations Hillside Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 Lodge B53-B03 S48297 Hillside Lodge V226878 150605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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