Inspection on 13/03/06 for Hillside Residential Home

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillside Residential Home 14/10/08

Hillside Residential Home 03/10/07

Hillside Residential Home 09/11/06

Hillside Residential Home 21/11/05

Hillside Residential Home 21/03/05

Hillside Residential Home 03/08/04

Hillside Residential Home 21/01/04

Hillside Residential Home 23/06/03

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

CARE HOMES FOR OLDER PEOPLE Hillside Residential Home Alcester Road Hollywood Birmingham West Midlands B47 5NS Lead Inspector N Andrews Unannounced Inspection 09:30 13 and 15 March 2006 th th 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 Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillside Residential Home Address Alcester Road Hollywood Birmingham West Midlands B47 5NS 0121 430 2126 0121 430 6306 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) Mr Christopher Michael Higgins Angela Christine Griffiths Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may also accommodate 2 named people with a dementia illness. 21st November 2005 Date of last inspection Brief Description of the Service: Hillside is a detached, purpose-built property situated in a secluded, semi-rural position on the outskirts of Birmingham. The property stands in its own grounds surrounded by lawns and set well back from the main road at the end of a driveway. The registered provider lives in his own separate, first floor accommodation adjoining the premises. There are car-parking facilities at the front of the premises. The property is registered as a care home providing residential i.e. personal, care for a maximum of 17 older people above the age of 65 years who may also have a physical disability. The home may also accommodate two named people with a dementia illness. The home is a single storey building. All of the service users are accommodated on the ground floor in 15 single bedrooms and 1 double bedroom. All of the single bedrooms, except one, have an en suite facility. At the time of the inspection one of the double bedrooms was being used as a single room. There were 16 service users and one vacancy. The home’s main aim is to provide a warm, homely environment for the service users and to provide individual care. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection that was carried out over two days. The inspection included a tour of the premises. Time was also spent with the registered manager assessing the progress made by the home in implementing the requirements and recommendations arising from previous inspections. Various records that the home is required to keep and several policies and procedures were inspected. Individual discussions were held with five service users. It was pleasing to note that significant progress had been made by the home since the previous inspection in addressing the outstanding requirements and recommendations. This was mainly due to the continuing commitment and work of the registered manager and staff. The number of requirements and recommendations had fallen since the previous inspection from 27 to 9 and from 16 to 12, respectively. Seven of the 9 outstanding requirements were requirements that had been identified in previous inspections. The number of requirements and recommendations still needed to be reduced to a more acceptable level. It was a matter of concern, in particular, that the requirements in regard to fire safety precautions had still not been fully implemented. These issues must be satisfactorily addressed in the near future. The home was inspected against 15 of the National Minimum Standards. Eight of the Standards were met, six of the Standards were nearly met and one was not met. The service users with whom discussions were held spoke positively about the home and the care that they received from the staff. The five service users confirmed that the staff were kind and described them variously as patient, helpful and polite. One service user described the staff as ‘excellent’ and said ‘the staff do all they can for me, they’re most helpful’. One service user stated ‘the staff respond quickly to the alarm’ and another service user said ‘they always come when I call them’. The service users also said that the staff treated them with respect and confirmed that they always knocked the door before entering their bedrooms. The service users felt confident about raising any concerns that they may have with the staff and said that they would receive a quick and appropriate response. They also confirmed that the routines were flexible i.e. that they could get up and go to bed when they wished and eat their meals in their own rooms if they preferred to do so. One service user said, ‘On the whole I’m quite happy here. They’re very considerate. There is always enough staff on duty. The staff are marvellous’. Another service user confirmed that she was given a copy of the service users’ guide when she was admitted. She stated that her visitors were always made welcome. Another service user said that she had been able to make a visit to the home prior to admission. Three service users felt that the social activities were adequate. Three of the service users expressed their satisfaction with Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 6 the food. One service user said, ‘I enjoy the food and I’m putting on weight’. However, two of the service users made less complimentary comments about the food. One service user said that the food was ‘mediocre’ and that she would ‘like to think that it was better than it is’. Another service user said ‘The food is a bit hit and miss. The trouble is the meat, you can’t cut it, the knives have got no edge on them’. The registered manager is asked to consider the comments made by the service users in regard to the food provided and to take appropriate remedial action to address the concerns expressed. What the service does well: What has improved since the last inspection? What they could do better: The service users’ care plans and the contents of some of the home’s policies and procedures were in need of improvement. There was also a need to improve some aspects of the environment, including fire safety precautions, and to develop the home’s systems for monitoring the quality of the service. The registered manager said that further work was needed to improve the decoration e.g. curtains and bed linen, and for continuous improvement all round. Please contact the provider for advice of actions taken in response to this Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 8 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 Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 9 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 An assessment of the needs of prospective service users was carried out prior to admission. EVIDENCE: The home’s response to the two requirements that were made in regard to Standard 1 as a result of previous inspections was assessed. The first requirement was that the statement of purpose must be amended in accordance with the guidance given in this (i.e. the previous) report in order to include all the information detailed in Regulation 4 and Schedule 1. A copy of the home’s statement of purpose was made available for inspection. It was pleasing to note that the requirement had been implemented. The second requirement was that the service users’ guide must be amended in accordance with the guidance given in this (i.e. the previous) report in order to include all the information detailed in Regulation 5 and Standard 1 and copies given to all current, and any prospective, service user. A copy of the service users’ guide was made available for inspection. It was pleasing to note that the requirement had been implemented. The registered manager confirmed that the majority of the service users had been admitted to the home following a community care assessment. In Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 10 addition, most of the service users had also undergone a care needs assessment by the home. It was confirmed that the home’s policy was to carry out an assessment of the care needs of all prospective service users prior to admission. The assessment form used by the home for assessing the care needs of prospective service users referred to all of the aspects of care listed in Standard 3.3. The registered manager was aware of the importance of carrying out an accurate and detailed assessment of the service users’ needs prior to admission i.e. in order to ensure that the needs of any person subsequently admitted to the home could be met and also to ensure that the home continued to operate within the conditions of registration. The home’s response to the recommendation that was made in regard to Standard 5 as a result of the previous inspection was assessed. The recommendation was that a clear statement regarding the home’s policy on pre-admission visits and the four week trial period following admission should be included in the service users’ guide. It was noted that the service users’ guide contained a reference to ‘offering a four week trial period’. However, there was no reference to the home’s policy on pre-admission visits. Therefore, this aspect of the recommendation still stands. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 11 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, 8 and 9 All of the service users had an individual care plan. However, the contents of the care plans needed to be improved. The staff worked well with other professionals in order to ensure that the service users’ health care needs were met. The home’s policy and procedures for the safe storage and administration of medication were satisfactory. EVIDENCE: The registered manager confirmed that all of the service users had an individual care plan. Since the last inspection, the two forms that had previously been used as a care plan had been combined into one form. It was confirmed that all of the service users’ plans had been reviewed within the past month. The home’s response to the three requirements that were made in regard to Standard 7 as a result of the previous inspection was assessed. The first requirement was that a service user plan that covers all aspects of care as set out in Standards 7.2 and 3.3 must be drawn up with each service user in accordance with Regulation 15. The home had a care plan that consisted of two separate forms. Improvements to the contents of the forms were discussed. In order to avoid any possible confusion and to ensure that the care plans covered all aspects of care, the registered manager agreed to combine the two forms, insert consecutive page and paragraph numbers and add headings covering ‘History of Falls’, ‘Personal Safety and Risk’ and ‘Social Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 12 Interests’. The care plans must be completed by the staff and signed by the service user whenever capable and/or representative. In the meantime, the requirement still stands. The second requirement was that clear, specific and detailed guidance must be included in the service users’ plans to ensure the appropriate delivery of care. The plans must include the action to be taken to ensure that all aspects of the service users’ needs are met. The care plans in respect of a small number of service users were inspected. There had been a noticeable improvement in the standard of recording since the previous inspection. However, there was still scope for further improvement in order to ensure that the guidance to staff was clear and specific. The care plans in respect of two service users that had recently been admitted to the home did not include any details of their medication. In addition, the section headed ‘Maintaining Links with Family’ required more details about the way in which this would be facilitated by the staff. Some recording was not as specific as it should be e.g. phrases such as ‘assist where necessary’ were still being used. Therefore, the requirement still stands. The third requirement was that the home’s policy on ‘Dealing with Aggression Towards Staff’ must state that all incidents involving physical restraint must be reported to the CSCI without delay in accordance with Regulation 37. The requirement had been implemented. The registered manager confirmed that the staff supported the service users’ ability to self-care whenever possible/appropriate. One service user had developed a pressure sore during her stay in hospital. The district nurse was attending to her daily. Pressure relieving mattresses and seat pads were provided when necessary. The district nurse also provided advice in regard to continence management. The medication for one service user that was thought to be developing Alzheimer’s disease was being monitored. The service users were encouraged to walk and to remain physically active for as long as possible/appropriate. The home held a ‘fitness and fun’ session every week. The registered manager stated that the service users were assessed in respect of food preferences, special diets and allergies. All of the service users were registered with one of two local GP surgeries. The dentist visited the home when necessary. The chiropodist visited the home every six to eight weeks. An optician visited the home at least once a year to check the eyesight of all the service users. The service users were referred to the hearing clinic by the GP to undergo hearing tests whenever it was considered necessary. The service users had their ears syringed by the district nurse, if necessary. The home used the Nomad monitored dosage system for the administration of medication. The registered manager stated that the home had a positive relationship with the local Lloyds pharmacy. There was a weekly delivery of medication. The home had a satisfactory policy and procedure for the administration of medication. The home had an up to date list of the names of all the staff that were involved in the administration of medication and their signatures. Two service users were in receipt of Controlled Drugs. The Controlled Drugs were kept in an appropriate lockable facility. The other Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 13 medication was held in a lockable medication trolley that was kept in a lockable store. One service user self-administered her medication. The home’s response to the requirement that was made in regard to Standard 9 as a result of the previous inspection was assessed. The requirement was that a risk assessment must be carried out and recorded in respect of any service user who self-medicates and the service user asked to sign an appropriately worded consent form. The requirement had been implemented. The Medication Administration Records (MAR) Charts were inspected and were complete and up to date. However, the annotation of the recommencement of the medication administered to one service user was not being recorded on the MAR Chart from the date of recommencement. In order to avoid any possible errors or confusion, when medication is recommenced the notation of the administration of the medication must be recorded on the MAR Chart on the date that the medication is recommenced (rather than on the date that the MAR Chart begins). It was confirmed that all of the staff that were involved in the administration of medication had undergone relevant training in the safe handling of medicines. The home’s response to the recommendation that was made in regard to Standard 10 as a result of the previous inspection was assessed. The recommendation was that a mobile handset should be provided to enable the service users to make and receive telephone calls in private. The recommendation had not been implemented and still stands. The home’s response to the two recommendations that were made in regard to Standard 11 as a result of the previous inspection was assessed. The first recommendation was that the service users’ wishes regarding terminal care and the arrangements after death should be included in their care plans. The recommendation had not been fully implemented and still stands. The second recommendation was that the out of date reference to the NCSC in the home’s policy on dying and death should be replaced with a reference to the CSCI. The recommendation had not been implemented and still stands. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 14 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): 15 The majority of service users were satisfied with the food provided. However, continuing efforts must be made to ensure that a satisfactory standard of food is maintained for all of the service users. EVIDENCE: The home’s response to the recommendation that was made in regard to Standard 12 as a result of the previous inspection was assessed. The recommendation was that a daily record of the social and leisure activities provided by the home and the names of the service users that participated should be maintained and a notice board on which information about such activities can be displayed should be introduced. The registered manager confirmed that the home had begun to maintain a record of the social and leisure activities on 14 February 2006. It was also confirmed that a notice board had been introduced. Therefore, the recommendation had been implemented. It was suggested that the notice board could be placed in a more prominent position. However, the registered manager gave an assurance that the notice board had been placed in the most suitable place for the service users. The home’s response to the recommendation that was made in regard to Standard 13 as a result of the previous inspection was assessed. The recommendation was that relatives, friends and representatives of service users should be given written information, preferably in the service users’ Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 15 guide, about the home’s policy on maintaining relatives and friend’s involvement with service users at the time of an admission to the home. The service users’ guide contained a brief reference to the home’s policy on this matter. Therefore, the requirement was regarded as having been implemented. The home’s response to the requirement and recommendation that was made in regard to Standard 14 as a result of the previous inspection was assessed. The requirement was that information regarding the service users’ right of access to the records held about them by the home must be given to the service users, preferably in the service users’ guide. The requirement had been implemented. The recommendation was that service users and their relatives and friends should be informed, preferably in the service users’ guide, of how to contact external agents, including advocates, who will act in their best interests. The recommendation had been implemented. The registered manager stated that a procedure for obtaining the views of the service users about the food provided had been introduced on 13 February 2006. The service users were asked each day after lunch what they thought about the food and their comments were recorded. The registered manager stated that no adverse comments had been received apart from one service user who felt there were ‘too many vegetables’. However, two of the five service users with whom discussions were held during the inspection felt that the standard of food provided could be improved. A choice of food was available for breakfast and for teatime meals. Breakfast was served in the service users’ bedrooms. If any service user did not like the food on offer at lunch times an alternative meal was provided. The home had a four-week menu. The registered manager stated that more fresh fruit had been provided recently and more jellies. It was also stated that the home had been without a permanent cook since December 2005. An attempt had been made by the home to recruit a temporary replacement without success. Normally, at the present time, one of three members of staff shared the responsibility for the cooking. Two of the three staff had previous catering experience and all three had a food hygiene certificate. None of the current service users had any special dietary requirements. The diabetic needs of three service users were controlled by medication. One service user required staff assistance with eating. No special equipment was needed by any of the service users. Overall, the Standard on food was regarded as having been met. However, the registered manager should continue to obtain the service users’ responses in regard to the meals provided in order to ensure that the quality of the food is maintained at a high standard. If the permanent cook is unable to return to work in the very near future renewed efforts must be made to find a temporary replacement as quickly as possible. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 16 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): 18 The home had procedures in place to help ensure that the service users were protected from abuse. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 16 as a result of the previous inspection was assessed. The requirement was that all references to the home’s complaints procedure must include the full address and telephone number of the Worcester office of the CSCI. The requirement had been implemented. The registered manager confirmed that no allegations or suspicions of abuse had been reported to her or otherwise come to her attention since the previous inspection. She also confirmed that she had not had to refer any member of staff who may be unsuitable to work with vulnerable adults for consideration for inclusion on the POVA register. The home had a policy on ‘Dealing with Aggression Towards Staff’. The requirement that was made in regard to the amendments to the policy as a result of the previous inspection had been implemented. (See ‘Health and Personal Care’–Standard 7 Service User Plan above). The home’s response to the two requirements and two recommendations that were made in regard to Standard 18 as a result of the previous inspection was assessed. The first requirement was that the home’s ‘Adult Protection and Prevention of Abuse’ policy must be amended to include information for referring all allegations of abuse to the Adult Protection Coordinator and to the CSCI. The home’s policy had been amended and included new information. However, the registered manager was recommended to verify the address and telephone number of the Adult Protection Coordinator and to correct the details in the policy, if necessary. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 17 The requirement was regarded as having been implemented. The second requirement was that the home’s whistle blowing policy must be amended in line with the Public Interest Disclosure Act 1998 to allow referral of concerns to the CSCI without exhausting internal mechanisms first. The requirement had been implemented. The first recommendation was that a copy of the Department of Health Guidance ‘No Secrets’ and information about the Worcestershire policy and procedure for the protection of vulnerable adults should be kept at the home. The home had obtained a copy of ‘No Secrets’ and information about the Worcestershire policy and procedure was obtained during the inspection. The recommendation, therefore, had been implemented. The second recommendation was that the home’s policy regarding the service users’ money and financial affairs should be amended so that it includes a reference to ensuring service users’ access to their personal financial records, consultation on finances in private, advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. The reference to the NCSC should be replaced by a reference to the CSCI. The recommendation had been implemented. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 18 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): 21 and 24 The service users had sufficient and suitable bathroom and toilet facilities. The service users bedrooms were comfortable and personalised. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 19 as a result of the previous inspection was assessed. The requirement was that written evidence must be provided to show that the home complies with the requirements of the local fire service. A similar requirement was made in regard to fire safety precautions in Standard 38 under ‘Management and Administration’. Therefore, both requirements are considered together under this heading latter in this report. The home had two bathrooms, both of which had a toilet, and two separate toilets. In addition, all of the bedrooms except one had an en suite facility. All of the communal bathrooms and toilets had paper towel and liquid soap dispensers. Both of the bathrooms had a hoist and both of the hoists had recently been serviced. Five service users required the use of a wheelchair for transferring from their bedrooms to the dining room and for outside use i.e. long distances. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 19 The home’s response to the requirement and recommendation that were made in regard to Standard 22 as a result of the previous inspection was assessed. The requirement was that all the recommendations made by the occupational therapist as a result of the visit to the home on 29/08/05 must be implemented. The registered manager stated that the bath hoists had been serviced 23 February 2006. The requirement had been implemented. The recommendation was that adequate storage space for storing wheelchairs and other equipment should be provided. The recommendation had not been implemented and still stands. The registered manager stated that all of the items of bedroom furniture listed in Standard 24.2 had been provided except for a table in bedroom 1. It was confirmed that a table had been ordered. The home’s response to the two requirements that were made in regard to Standard 24 as a result of the previous inspection was assessed. The first requirement was that all of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users, in accordance with the guidance given in this (i.e. the previous) report. It was noted that bedroom 15 had been provided with a lockable storage and that in bedroom 8 the radiator had been repaired and a lock had been fitted to the bedroom door. The requirement had, therefore, been implemented. The second requirement was that the floors in bedrooms 6 and 7 must be carpeted or provided with an acceptable equivalent floor covering. The requirement had not been implemented and still stands. The absence of a floor covering with a non-slip surface in the bedrooms of service users that may be incontinent, in particular, poses a potential safety hazard. The home’s response to the requirement and recommendation that were made in regard to Standard 25 as a result of the previous inspection was assessed. The requirement was that the temperature of the hot water from the hot water outlet in bedroom 12 must be reduced, regulated and maintained at 43 degrees C in order to prevent the risk of scalding. The requirement had been implemented. The recommendation was that the lighting levels in the home should be tested in order to ensure that they meet recognised standards i.e. lux 150. The recommendation was implemented on 13 March 2006 during the inspection. The home’s response to the recommendation that was made in regard to Standard 26 as a result of the previous inspection was assessed. The recommendation was that the home’s Infection Control Policy should be amended in accordance with the guidance given in this (i.e. the previous) report. A copy of the home’s Infection Control Policy was made available for inspection. Changes to the wording of the policy were discussed with and agreed by the registered manager. The recommendation was regarded as having been implemented. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 20 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 and 30 The staffing arrangements were satisfactory and sufficient to meet the needs of the service users. Arrangements were in place to ensure that the staff received appropriate training. EVIDENCE: In addition to the registered manager, the home employed two assistant managers for a total of 70 hours per week, four senior care assistants for a total of 140 hours per week, five care assistant for a total of 133 hors per week and five night care assistants for a total of 140 hours per week i.e. two night care assistants on waking duty per night. A cook was normally employed for 30 hours per week. However, the cook had been and was still on sick leave. Therefore, at the time of the inspection, members of the care staff were responsible for undertaking all of the catering duties. A member of staff was employed for 20 hours per week to undertake all of the cleaning and domestic duties. The registered manager stated that the care staff undertook some of the cleaning duties at weekends and that the night care assistants were also responsible for some of the domestic duties. None of the staff were below the age of 20 years. The staffing levels and the arrangements made for the deployment of staff were satisfactory. The home’s response to the three requirements that were made in regard to Standard 29 as a result of the previous inspection was assessed. The first requirement was that all applicants for employment at the home, including staff employed since 29 July 2005, must be asked to provide a full employment history. The registered manager confirmed that the requirement had been implemented. The second requirement was that two relevant, written Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 21 references, one of which must be from the applicant’s current or most recent employer, must be obtained in respect of all prospective staff prior to their appointment. The registered manager confirmed that no new members of staff had been appointed since the previous inspection. The registered manager also stated that she had attempted to obtain written references in respect of three existing members of staff that did not already have two written references. The registered manager had obtained two written references in respect of one member of staff, one written reference in respect of another member of staff and none in respect of the third member of staff. The registered manager was advised that two written references must always be obtained in respect of all prospective staff prior to their appointment. The registered manager was also advised that, if written references cannot be obtained in regard to existing staff, verbal references must be obtained and recorded. If any referee fails to respond to the requests for a reference the applicant must be asked to provide the name and address of a suitable alternative referee. The requirement was regarded as having been implemented. The third requirement was that disclosure checks from the CRB must be obtained for all new staff prior to their appointments. The registered manager stated that, although no new staff had been appointed since the previous inspection, a disclosure check had been obtained from the CRB in respect of all the existing staff. The requirement was regarded as having been implemented. However, it is important that the registered manager continues to follow the correct staff recruitment procedures including obtaining two written references and a disclosure check from the CRB prior to the appointment of all new staff. Standard 29 will be inspected fully during the next inspection of the home. The registered manager confirmed that the home provided an induction for new staff based on TOPSS (Skills for Care) standards. The TOPSS documents had been provided by the NVQ Assessor. However, none of the staff were undertaking the induction training at the present time. The registered manager confirmed that all the staff had received a minimum of three paid days training during the past year. It was noted that all the staff had an ‘Individual Record of Staff Training’ that contains the details of the training undertaken and the dates of completion. The home also had a training matrix that contained the details of the core training undertaken by the staff and the gaps in training. The registered manager was advised to include in the ‘Individual Record of Staff Training’ details of all the identified training needs of each member of staff and the way in which these will be met. The home’s response to the recommendation that was made in regard to Standard 30 as a result of the previous inspection was assessed. The recommendation was that the advice and guidance of the NVQ tutor should be obtained in writing regarding the need for staff that are placed on NVQ level 2 training to undergo TOPSS foundation training. A copy of a letter to the registered manager from the Director/Internal Verifier regarding induction training was made available for inspection. Unfortunately, the letter made no reference to foundation training. However, it was confirmed that all newly appointed staff undertake Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 22 induction training. Following the induction training the staff undertake further training that is provided by Omega. The training includes issues relating to health and safety, abuse awareness and communication etc. The registered manager stated that, following the successful completion of this training, the staff are issued with a Technical Certificate. The members of staff that have undergone both forms of training are enrolled on NVQ level 2 courses. Therefore, the recommendation was no longer regarded as relevant and has been deleted. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 23 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): 32, 33, 34, 35 and 38 The service users benefited from the leadership and management approach of the home. However, the systems for monitoring the quality of the service needed to be improved. Evidence should also be provided to show that the service users are safeguarded by the home’s financial procedures. The service users’ own financial interests were safeguarded. The service users’ health and welfare were promoted. EVIDENCE: The home’s response to the requirement and recommendation that were made in regard to Standard 31 as a result of the previous inspection was assessed. The requirement was that the registered manager must undertake appropriate training in health and safety and the protection of vulnerable adults from abuse. The registered manager confirmed that training in health and safety had been arranged for 20 March 2006 at Solihull College. However, no arrangements had yet been made for the registered manager to undertake training in the protection of vulnerable adults from abuse. Therefore, the requirement had not been fully implemented and still stands. Information to Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 24 enable the registered manager to access suitable training was sent to the registered manager following the inspection. The recommendation was that the registered manager should be provided with a job description that enables her to take responsibility for fulfilling her duties. The recommendation had not been implemented and still stands. The management approach of the home was positive and inclusive. It was stated that staff meetings were held approximately every three months and that service user meetings were held approximately every month. The last service user meeting was held in January 2006. The home had a complaints procedure and had used questionnaires to obtain feedback from the service users and their relatives. The home also operated a key worker system. However, there was no evidence to show that management planning and practice encouraged innovation, creativity and development. There was evidence to show that the home is committed to equal opportunities. It was confirmed that a copy of the Code of Practice published by the General Social Care Council had been issued to all of the staff. The home’s response to the requirement and recommendation that were made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The home did not have a full quality assurance system in operation. Therefore, the requirement had not been implemented and still stands. The recommendation was that the results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. It was pleasing to note that work had been carried out by one of the assistant managers to introduce questionnaires as part of a quality assurance system. Six questionnaires had been completed by the service users’ relatives/visitors in February 2006. During the same month, eleven service users and ten members of staff had also completed questionnaires. It was stated that the results of the service user surveys would be published shortly in a newsletter. The recommendation had been implemented. Questionnaires should continue to be used to obtain the views of service users, relatives, stakeholders and staff members at least every twelve months. The home did not have an annual development plan. There was no evidence available to demonstrate the home’s commitment to lifelong learning and development for each service user. The registered manager had reviewed and amended some of the home’s policies and procedures in the light of the National Minimum Standards and the requirements arising from CSCI inspection reports. Although it was pleasing to note that a significant number of requirements identified in CSCI inspection reports had been implemented within the agreed timescales, there were still some requirements outstanding. The home displayed a copy of the Employers’ Liability Insurance Certificate provided by Ansvar that was for a minimum of £5m and valid until 10 April Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 25 2006. It was confirmed that records were kept of all the transactions entered into by the registered provider. However, a business and financial plan for the home was not available for inspection. The home’s response to the requirement that was made in regard to Standard 35 as a result of the previous inspection was assessed. The requirement was that a record of all money held by the home for safekeeping on behalf of service users must be kept in accordance with the guidance given in this (i.e. the previous) report. The registered manager confirmed that the home no longer held any money for safekeeping on behalf of any of the service users. The relatives of the service users are invoiced each month for any expenses incurred by the service users. The requirement was, therefore, no longer relevant and has been deleted. The home maintained individual records of the personal expenses incurred by service users e.g. hairdressing, chiropody etc. The registered manager confirmed that neither she nor any other person connected with the running of the home acted as an agent or appointee on behalf of any service user. The home had a safe in which any money or valuables belonging to the service users could be held for safekeeping. However, the registered manager stated that no items were currently held on behalf of any service user. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that the home’s complaints procedure and the procedures to be followed in the event of accidents or a service user becoming missing must be amended in accordance with the guidance given in this (i.e. the previous) report. A copy of the home’s complaints procedure was made available for inspection. The complaints procedure had been amended and now contained the name, address and telephone number of the CSCI. This aspect of the requirement had been implemented. A copy of the home’s ‘Accident/Incident Procedure’ was made available for inspection. It was noted that the procedure had been amended and that it now included the name, address and telephone number of the CSCI. It also included a statement that ‘any accident or incident that adversely affects the wellbeing or safety of any resident’ must be reported to the CSCI without delay in accordance with Regulation 37. Therefore, this aspect of the requirement had also been implemented. However, the ‘Accident/Incident Procedure’ must also include a statement that the relatives of service users should be informed of any serious accident or incident. A copy of the procedure to be followed in the event of a service user becoming missing was made available for inspection. The procedure had been amended and now included a statement that ‘any accident or any event that adversely affects the wellbeing or safety of any service user must be reported to the CSCI without delay in accordance with Regulation 37’. The same procedure also included a statement that the ‘relatives of the missing person must be informed without delay’. Therefore, this aspect of the requirement had been implemented. However, it was noted that the procedure did not include the full address and telephone number of the CSCI. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 26 The home’s response to the five requirements and one recommendation that were made in regard to Standard 38 as a result of the previous inspection was assessed. The first requirement was that a copy of the Fire Safety Officer’s letter containing details of fire safety precautions must be obtained and the recommendations fully and satisfactorily implemented. A copy of the Fire Safety Officer’s letter dated 16 May 2002 had been sent to the CSCI on 5 December 2005. The registered manager confirmed that all the matters referred to in the letter had been addressed except for the provision of intumescent strips and smoke seals to a number of fire resisting doors. This part of the requirement, therefore, had not been implemented and still stands. A Notice of Immediate Requirement was issued at the conclusion of the inspection in regard to this matter. The second requirement was that fire doors must be kept closed and not wedged open. Appropriate devices must be fitted to doors if they are to remain open. The registered manager stated that automatic self-closing devices i.e. dorgards, had been fitted to the bedroom doors of six of the service users. The registered manager was waiting for a further ten automatic self-closing devices to be delivered and fitted. Therefore, the requirement had not been fully implemented and still stands. The third requirement was that there must be at least one member of staff on duty at all times, day and night, who is trained in first aid to at least the level of an Appointed Person. The registered manager confirmed that all the staff, including the night care assistants, had undertaken first aid training on 23 February 2006. It was stated that all the staff had a valid first aid certificate. Therefore, the requirement had been implemented. The fourth requirement was that training in food hygiene, dementia-care and risk assessment must be provided for all the staff. The registered manager confirmed that training had been provided in food hygiene, dementia-care and risk assessment on 22 November 2005 and 24 and 22 February 2006, respectively. The requirement had, therefore, been implemented. The fifth requirement was that risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3, including security of premises, moving and handling and maintenance of a safe environment, including kitchen equipment and laundry. The requirement had been implemented. However, the registered manager was advised to include further control measures in the risk assessments e.g. staff training and security lighting etc, in order to enhance the safety of the service users and staff. The registered manager was also advised to review all of the risk assessments at every twelve months and more frequently, if necessary. The recommendation was that the service user that refuses to have footplates attached to her wheelchair should be asked to sign and date an appropriately worded form confirming her decision and this should be kept on her personal file. The registered manager confirmed that the recommendation had been implemented. The registered manager also confirmed that all the staff had received training in fire safety on 14 November 2005 and updated training in infection control and moving and handling on 23 November 2005. It was stated that health and safety training had been arranged for 20 March 2006. The registered manager confirmed that all Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 27 hazardous substances were kept in a lockable cupboard. It was also confirmed that Gasforce serviced the boilers and the central heating system annually contract. The next full service is due in June 2006. However, a visit had been made to the home on 8 December 2005 in order to repair a fault. PAT testing had been carried out on 16 January 2006. Thermostatically controlled mixer valves had been fitted to all of the hot water outlets used by the service users. The temperature of the water was checked every week and recorded. The water had been tested for bacteria on 12 May 2005. Water samples had also been collected for testing on 13 March 2006. The results of the tests were not known at the time of the inspection. However, a copy of the results was subsequently forwarded to the CSCI and this stated that no species of Legionella bacteria were isolated from the samples analysed. The home had a coded door entry system. The registered manager confirmed that individual risk assessments had been carried out on all of the service users. Written documentation was made available to show that both of the bath hoists had been serviced on 23 February 2006. It was confirmed that the home had a health and safety policy and all of the necessary COSHH and RIDDOR documentation. The home had an accident book. Accident forms were kept in the service users’ individual files. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 28 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 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 X X 2 X X STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 1 2 3 X X 2 Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 29 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement A service user plan that covers all aspects of care as set out in Standards 7.2 and 3.3 must be drawn up with and signed by each service user whenever capable and/or representative in accordance with Regulation 15. (Previous timescale 31/01/06 not met). Clear, specific and detailed guidance must be included in the service users’ plans to ensure the appropriate delivery of care. The plans must include the action to be taken to ensure that all aspects of the service users’ needs are met. (Previous timescale 31/01/06 not met). The notation of the administration of medication must be recorded on the MAR Charts on the date that the medication is commenced. The floors in bedrooms 6 and 7 must be carpeted or provided with an acceptable equivalent floor covering. (Previous timescale of 31/01/06 not met). The registered manager must DS0000018507.V286428.R01.S.doc Timescale for action 31/05/06 2 OP7 15 31/05/06 3 OP9 13 15/03/06 4 OP24 16 30/04/06 5 OP31 9,18 30/06/06 Page 30 Hillside Residential Home Version 5.1 6 OP33 24 7 OP37 17 8 OP38 12 9 OP38 23 undertake appropriate training in the protection of vulnerable adults from abuse. (Previous timescale 31/03/06 not met). A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/01/06 not met). The home’s ‘Accident/Incident Procedure’ must include a statement that the relatives of a service user must be informed without delay of any serious accident/incident in which the service user is involved. The procedure to be followed in the event of a service user becoming missing must include the full address and telephone number of the CSCI. Intumescent strips and smoke seals must be fitted to all fire resisting doors. (Previous timescale 31/01/06 not met). Fire doors must be kept closed and not wedged open. Appropriate devices must be fitted to doors if they are to remain open. (Previous timescale 24/11/05 not met). 30/06/06 30/04/06 12/04/06 30/04/06 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 OP5 OP10 Good Practice Recommendations A clear statement regarding the home’s policy on preadmission visits should be included in the service users’ guide. A mobile handset should be provided to enable the service DS0000018507.V286428.R01.S.doc Version 5.1 Page 31 Hillside Residential Home 3 4 5 OP11 OP11 OP18 6 7 OP22 OP30 8 9 10 11 OP31 OP32 OP33 OP33 12 OP34 users to make and receive telephone calls in private. The service users’ wishes regarding terminal care and the arrangements after death should be included in their care plans. The out of date reference to the NCSC in the home’s policy on dying and death should be replaced with a reference to the CSCI. Action should be taken to ensure that the home’s policy on ‘Adult Protection and Prevention of Abuse’ contains the correct address and telephone number of the Adult Protection Coordinator. Adequate storage space for storing wheelchairs and other equipment should be provided. The individual staff training and development assessments and profiles i.e. ‘Individual Record of Staff Training’ should be developed in accordance with the guidance given in this report. The registered manager should be provided with a job description that enables her to take responsibility for fulfilling her duties. Evidence should be provided to show that management planning and practice encourage innovation, creativity and development. There should be an annual development plan for the home based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Written evidence should be provided to demonstrate the home’s commitment to lifelong learning and development for each service user linked to the implementation of their individual care plans. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. Hillside Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Residential Home DS0000018507.V286428.R01.S.doc Version 5.1 Page 33 - 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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