Inspection on 30/11/05 for Hillside Lodge

This inspection was carried out on 30th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillside Lodge 11/09/07

Hillside Lodge 06/09/06

Hillside Lodge 17/06/05

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 Inspection 30th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000048297.V258149.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000048297.V258149.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillside Lodge Address Braeside Berwick Upon Tweed Northumberland TD15 2BY 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) 01289 307500 01289 308566 hillside.lodge@fshc.co.uk Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Margaret Shippen Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places DS0000048297.V258149.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users are under 65 years of age. The Commission for Social Care Inspection must be notified immediately should this service user leave the home so that this condition can be removed. 17th June 2005 Date of last inspection 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 centre of the premises near to the entrance. All bedrooms are single with en-suites containing a toilet and hand basin, 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. DS0000048297.V258149.R01.S.doc Version 5.0 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 4 hours on one day 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 this visit. This is the second unannounced inspection the home has had in this year and all of the core standards have been examined over the inspections so both reports should be looked at for the full picture. Ten residents were spoken to during the visit and four relatives and the inspector also spoke to five of the staff the in process of the inspection visits. During the inspection records examined included, 4 care plans and medication records, the training records, the fire log as well as complaints and accident records. At the last inspection two requirements and no recommendations were made both of which have been met. What the service does well: What has improved since the last inspection? Since the last inspection the home has completed the work to make the nurses stations on the corridors able to be locked so that the care plans can be stored safely ensuring confidentiality. The kitchen records are now detailed and were up to date. DS0000048297.V258149.R01.S.doc Version 5.0 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. DS0000048297.V258149.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000048297.V258149.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The assessment undertaken prior to admission is detailed and the staff involved are 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. DS0000048297.V258149.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Individual care planning is undertaken and the care is being delivered in line with these plans. EVIDENCE: All residents have an individual plan of care, based on the admission assessment. Four 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. They showed that they are regularly reviewed and updated and that reviews are regularly held with residents and their representatives. Residents have access to all NHS services and facilities. There is 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 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. DS0000048297.V258149.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their cultural, social, religious and recreational interests and needs. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. EVIDENCE: The staff in the home confirmed on discussion that residents are encouraged to take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. Residents confirmed that they are able to make choices about how they spend their day and said they were satisfied with the activities available. Some organised activities are available and staff said that residents are able to choose whether or not they are involved, residents confirmed this. There are a number of activities going on in the home particular to the time of the year. The recording of the social activity is not in great detail and could be developed further to show the spectrum of things going on the in the home. DS0000048297.V258149.R01.S.doc Version 5.0 Page 11 The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Four relatives spoken to on the day and through returned questionnaires confirmed that they are welcomed to the home. Relatives are given information within the residents’ guide about visiting arrangements. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. 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. Staff are preparing pureed meals in a small blender which puts pressure on them at a time when they are their most busy, purchase of a large food processor would make it easier to achieve to a high standard. DS0000048297.V258149.R01.S.doc Version 5.0 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 the following standard(s): 16 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. 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 were 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. DS0000048297.V258149.R01.S.doc Version 5.0 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 the following standard(s): 26 The home is clean and well organised and the staff are knowledgeable regarding the ways to prevent the risk of cross infection in the home. Equipment and facilities are available to support the staff in doing this. EVIDENCE: A tour of the home was conducted both with staff and alone however these standards were examined in detail at the last unannounced inspection and were not repeated on this one. The home is clean and was odour free on the day. The residents’ who were asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. The bathroom and toilet areas were tidy and clean. 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 and appropriate equipment was available. The light and emergency call cords were all clean and all emergency cords reached skirting level. DS0000048297.V258149.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 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. 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 home staff usually covers these occasions. 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. DS0000048297.V258149.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The home has in place effective health and safety systems including staff training and risk assessments. EVIDENCE: There is a system in place to review health and safety in the home involving the staff for which records are available. Training records are in place and are up to date. Records were examined of the staff meetings which take place regularly and the contents of these suggest that there a broad spectrum of relevant issues discussed. The Manager also facilitates meetings with the relatives and residents as appropriate as well as having an open door policy. Residents and relatives spoken to felt that they could raise issues with the staff as necessary. DS0000048297.V258149.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 DS0000048297.V258149.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP15 Good Practice Recommendations The record of social activity could be completed in greater detail to show the variety of things going on in the home and who is involved. It is recommended that the home purchase a large food processor to allow kitchen staff to prepare “pureed diets” more easily. DS0000048297.V258149.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Cramlington Area Office 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 DS0000048297.V258149.R01.S.doc Version 5.0 Page 19 - 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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