Inspection on 09/11/06 for Hillside Residential Home

This inspection was carried out on 9th November 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 13/03/06

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 09:20 9 and 14 November 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.V317783.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V317783.R01.S.doc Version 5.2 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 Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (17) Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate 5 named people with a dementia illness. Date of last inspection 13 March 2006 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 five 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. The double bedroom has been used as a single bedroom. All of the single bedrooms, except one, have an en suite facility. At the time of the inspection there were 15 service users and two vacancies. The home’s main aim is to provide a warm, homely environment for the service users and to provide individual care. The fees ranged from £1800.00 per month for a single room to £2,200.00 per month for a large single room to £3,600.00 per person per month for double occupancy for a double room. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over the course of two days. The home was inspected against the key National Minimum Standards and time was spent with the registered manager assessing the home’s response to the requirements and recommendations that were made as a result of the previous inspection. Various records and a number of policies and procedures that the home is required to maintain were inspected. A tour of the premises was also made. Individual discussions were held with three service users and three members of staff. As part of the inspection ‘Comment Cards’ were issued to the relatives/visitors of the service users. Five Comment Cards were completed and returned. The majority of the responses to the questions that were asked were positive. The comments contained in the Comment Cards are reflected in this report. What the service does well: What has improved since the last inspection? The registered manager felt that, since the previous inspection, the confidence of the staff had increased and the range of social and leisure activities had improved. One bedroom had been redecorated, new bedding i.e. duvets and pillows, and two new bedside lights had been provided and the staff had undertaken training in health and safety and the protection of vulnerable adults from abuse. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 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 Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. Prospective service users were provided with the information they needed to make an informed choice about the home. They were given the opportunity to make visits to the home and their care needs were assessed prior to admission. Following admission, service users were given a written contract and their relatives and other visitors were encouraged to maintain contact. EVIDENCE: A copy of the home’s statement of purpose was made available for inspection. The statement of purpose contained relevant information and was produced in large, clear print. However, the fire policy and procedure that was referred to as being ‘found at Annex A’ and the home’s complaints policy and procedure that was referred to as being ‘found at Annex B’ were missing from the document. A copy of the home’s service users’ guide was also made available. The service users’ guide contained all the required information and was produced in large, clear print. The registered manager stated that all of the service users had been issued with a statement of terms and conditions of residence (contract). However, one of the files that were inspected contained no evidence to show that a Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 9 contract had been issued. A copy of the service users’ contracts must be kept on each of the service users’ individual files. One of the three service users with whom discussions were held confirmed that he had been issued with a contract following his recent admission to the home. A copy of one of the contracts that was made available for inspection was signed and dated. The contents were satisfactory apart from an incorrect reference to the Registered Homes Act 1984 in paragraph 16. The incorrect reference should be deleted and replaced with a reference to the Care Standards Act 2000. The registered manager confirmed that prospective service users were assessed prior to admission. A copy of the form that was used to carry out the assessment of the service users’ care needs was made available for inspection. The assessment form contained a reference to all of the aspects of care referred to in Standard 3.3. The registered manager stated that she carried out the assessments of prospective service users at their own home or in hospital. However, she preferred to conduct the assessments during the prospective service users’ pre-admission visits to the home. The registered manager stated that prospective service users were encouraged to make visits to the home prior to admission and that during the visits they were introduced to existing service users and staff and offered a meal. Prospective service users were also encouraged to spend time in the vacant bedroom in order to familiarise themselves with the home environment. One of the service users with whom discussions were held and who had recently been admitted to the home confirmed that he had visited the home prior to admission. The service user also said that during the visit he had viewed his bedroom and had been provided with lunch. A recommendation was made as a result of the previous inspection that a clear statement regarding the home’s policy on pre-admission visits should be included in the service users’ guide. The recommendation had been implemented. The service users’ guide included a reference to ‘offering a pre-admission visit and a four-week trial period’. The service users’ contract also contained a reference to a four-week trial period following admission. It was stated that emergency admissions to the home did not normally take place. The statement of purpose stated, ‘No emergency admissions’. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The service users felt that they were treated with dignity and respect. However, the care plans did not include all of the relevant information to ensure that all of the service users’ social and healthcare needs would be met. EVIDENCE: The registered manager confirmed that all of the service users had a care plan. Since the previous inspection, the care plans had been amended to include a reference to all of the aspects of care referred to in Standards 3.3 and 7.2. Therefore, the first requirement that was made in regard to care plans as a result of the previous inspection had been implemented. However, the care plans that were inspected did not include a reference to all of the service users’ needs or state clearly how the needs would be met. One file contained no evidence to show that nutritional screening or risk assessments on nutrition had been undertaken. A risk assessment on smoking in respect of the same service user had also not been carried out. An Immediate Requirement Notice was issued in regard to this matter at the conclusion of the inspection. Written confirmation was subsequently provided to show that this requirement had been implemented. The recording in the service user’s care plan in regard to the action to be taken by staff was not in sufficient detail. For example, in regard to diet the care plan stated, ‘To help with the diet and by giving the Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 11 correct food’. The care plan did not state specifically what help must be given and what the ‘correct food’ was. The care plan also stated, ‘To have regular reviews of medication’. However, there was no specific indication of how frequently the reviews should be held or who was responsible for ensuring that the reviews would be carried out. The care plan did not state how the service users’ interest in reading and crosswords was to be maintained or encouraged. The care plan in respect of another service user had not been reviewed since 30 August 2006. In addition, the care plan did not include any reference to nutritional screening or to pressure sores. Therefore, the second requirement that was made in regard to care plans as a result of the previous inspection had not been implemented and still stands. The service users with whom discussions were held felt that their healthcare needs were being met. One service user that had pressure sores had been provided with an appropriate mattress and cushion. The district nurse visited the home twice a week to attend to her needs. The continence adviser also visited the home when necessary. One service user that had recently been admitted was receiving appropriate weekly support from the physiotherapist. All the service users were registered with one of two local GP surgeries. The chiropodist visited every six to eight weeks and the service users’ eyesight was checked every six months. Hearing and dental checks were carried out as and when necessary. It was noted that service users were being transported in wheelchairs without footrests being used. An Immediate Requirement Notice was issued during the inspection in regard to this matter. The requirement was implemented before the conclusion of the inspection. It was also noted that a risk assessment had not been carried out in respect of three service users for whom bed rails had been provided. The registered manager was given information regarding the use of bed rails and advised to discuss the provision of bumpers, if bed rails were used, with the district nurse in order to protect the service users from possible harm. An Immediate Requirement Notice was also issued in regard to this matter at the conclusion of the inspection. Written confirmation was subsequently provided to show that this requirement had also been implemented. The blood-sugar tests that were carried out by staff in respect of one service user were not referred to in the care plan. The registered manager confirmed that the staff had been instructed on the correct procedure to be followed when carrying out bloodsugar tests by the district nurse. The staff had been advised to carry out a test only if it appeared to be necessary, to record the date, time and outcome of the test and to alert the service users’ GP if the result was significantly above or below a reading of six. The registered manager was asked to ensure that all of the relevant information and guidance regarding the blood-sugar tests was recorded in the service user’s individual care plan. The registered manager stated that most of the staff had undertaken training on diabetes by a nurse specialising in the care of people with diabetes. The home had a satisfactory policy and procedure for the administration of medication, a copy of which was made available for inspection. The Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 12 medication administration records (MAR) charts were checked in respect of a number of service users. The records showed that several omissions, all of which had occurred on 8 November 2006, had been made. An Immediate Requirement Notice was issued in regard to this matter and the requirement was implemented before the conclusion of the inspection. Where the prescribed dose was for one or two tablets the staff were recording the specific amount on the MAR charts. Controlled drugs were signed for on the MAR charts by two staff. When medication is written on the MAR charts it should also be signed for by two staff. Returns were documented in the MAR charts. The medication was stored securely in a lockable trolley that was kept in a lockable store. The dates of opening were recorded on the outside of the medicine containers. The home had a lockable cabinet that was used for the storage of controlled drugs. The cabinet was not a controlled drug cabinet and, therefore, did not meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973. The administration of controlled drugs was signed for in the register by two staff. The balances of the medication were checked and these were correct. A risk assessment had been carried out and recorded in respect of one service user that self-administered her medication. Access to medication was restricted to five members of staff, all of whom had undertaken accredited training in the administration of medication. Two other members of staff were currently undertaking similar training. One service user had all her medication administered covertly. The registered manager confirmed that this action was being taken at the request of the service user’s relative and with the consent of the GP. The decision to administer medication covertly must be recorded in the service user’s care plan and kept under regular review. The requirement that was made as a result of the previous inspection that the notation of the administration of medication must be recorded on the MAR charts on the date that the medication is commenced had been implemented. The home did not have a refrigerator for storing medicines that required cold storage. The staff with whom discussions were held were aware of the good care practices that helped to ensure that the service users’ privacy and dignity were upheld. It was confirmed that service users were seen in private by visiting professionals. Eight of the service users had their own telephone. In addition, a mobile handset had been provided in response to a recommendation that was made as a result of the previous inspection. The service users with whom discussions were held confirmed that they were treated with respect by the staff, that their right to privacy was upheld and that they always wore their own clothes. They said that the staff always knocked the door before entering their bedrooms and that the staff referred to them using their preferred term of address. None of the current service users had to share their bedroom accommodation. Standard 11 was not fully assessed during this inspection. However, the home’s response to the two recommendations that were made as a result of the previous inspection was assessed. The first recommendation was that the Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 13 service users’ wishes regarding terminal care and the arrangements after death should be included in their care plans. 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. It was confirmed that both recommendations had been implemented. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities was provided within a flexible routine. The service users were able to maintain contact with their relatives and friends and to exercise choice and control over their lives. The service users were provided with a wholesome and balanced diet. EVIDENCE: The daily routines were responsive to the service users’ needs. Different social and leisure activities were provided including television, music, Bingo and other board games. A hairdresser visited the home every Tuesday morning, a fitness and fun session was held every Tuesday afternoon and the service users received a manicure every Thursday. A Halloween party had recently been held. The service users’ birthdays and other special occasions were celebrated. A minister from the Anglican Church visited the home once a month to conduct a service. Other activities included art and craft sessions, karaoke and cake making. Two service users had recently been taken out for lunch and shopping afterwards. A fete had been held in the summer and the money raised had been used to fund a day outing to Blackpool in September. Five service users had spent a long weekend at Butlins’ in Minehead in April 2006. A Christmas party was planned for 15 December 2006. One of the service users with whom a discussion was held said that there was ‘no entertainment in the evenings’. The same service user said that she would like to see more armchairs in the conservatory and the height of the television in Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 15 the conservatory lowered to a more appropriate level. Another service user ‘missed having other service users to talk to’. The three service users said that they could get up and go to bed when they wished to and eat their meals in their bedrooms if they so wished. One of the Comment Cards received from the relatives/visitors stated, ‘The entertainment and outings that are organised are very good’. There were no unnecessary restrictions in regard to visiting. The service users with whom discussions were held confirmed that their visitors were made welcome and that they were able to see their visitors in private. One service user said, ‘They’re always given a cup of tea’. One of the five Comment Cards that were received from the service users’ relatives/visitors stated, ‘My family and I have always been made to feel very welcome by the staff’. The statement of purpose and service users’ guide contained relevant information governing the principles and practices of the home in regard to visitors and the arrangements for visiting. The service users with whom discussions were held confirmed that they were able to exercise personal autonomy and choice. They also confirmed that they were able to bring personal possessions with them when they were admitted to the home. The service users’ guide stated, ‘You are more than welcome to bring some of your cherished belongings to make your room more homely and personal’. The service users’ guide also contained details of the local advocacy service, social services and the telephone number of a local solicitor. The statement of purpose and service users’ guide contained information regarding the service users’ right of access to the records held about them by the home. The service users with whom discussions were held were satisfied with the quality and quantity of the food provided. They confirmed that mealtimes were unhurried. The record of the food provided indicated that the service users received a balanced and wholesome diet. The meals that were observed being served during the inspection were attractively presented. The home operated a four-week menu. Meals were served at regular intervals throughout the day and drinks and biscuits were served between meals. Lunch is the main, cooked meal of the day. There is always a choice of dessert and an alternative meal is provided if the service users do not like the meal on offer. The service users were offered a choice of food for breakfast and for the teatime meal. The registered manager confirmed that a member of staff was always present during mealtimes. Three service users required staff assistance with feeding. The staff were observed giving help in a discreet manner to the service users that needed assistance with eating. The registered manager felt that a suitable heated food trolley should be provided to encourage the service users to exercise greater independence and choice at meal times. Each day, after the midday meal, the service users were asked if they had enjoyed their lunch and their responses were recorded. The menu was displayed in the main corridor. All the service users had breakfast served to them in their bedrooms. Two service users had all their meals in their Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 16 bedrooms. The dining room was clean and pleasantly decorated. There was a cleaning schedule in the kitchen. A record of the temperatures of the two fridges and three freezers was maintained. The kitchen equipment included a food probe, a fire blanket and a fire extinguisher. The cook had undertaken food hygiene and infection control training. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The home had a clear, simple complaints procedure and the service users felt confident about making complaints. The home’s policies and procedures for the protection of service users from abuse needed to be reviewed and amended in order to fully ensure the safety of the service users. EVIDENCE: The home had a satisfactory complaints procedure that was referred to in the statement of purpose and service users’ guide. The home also maintained a folder in which the details of all the complaints made against the home were kept. No complaints had been made against the home since the previous inspection. A complaint had been made prior to the last inspection. The registered manager confirmed that all of the issues arising from the complaint had been dealt with appropriately and that there were no residual concerns to be resolved. The service users’ files that were inspected contained a copy of the complaints procedure. However, it was noted that these copies included an out of date reference to the former County Inspectorate. The out of date complaints procedures should be replaced with an amended copy containing the correct information and a copy displayed in the home. The service users with whom discussions were held felt confident about making a complaint and that any complaint that was made would be responded to quickly and appropriately. The registered manager confirmed that no incidents of suspected or alleged abuse had occurred within the home or had otherwise come to her attention since the previous inspection. The registered manager also confirmed that that she had had no reason to be concerned about the way in which any of the Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 18 service users had been cared for or any reason to refer any member of staff for consideration for inclusion on the POVA register. The home had policies on ‘Adult Protection and Prevention of Abuse’, ‘Whistle Blowing’, ‘Abuse’, ‘Dealing with Aggression Towards Staff’ and ‘Management of Service Users Money and Financial Affairs’. Copies of all these policies were made available for inspection. The Abuse Policy contained a reference to the ‘absence of consent’. The safety and protection of the service users must not be compromised. Therefore, any reference in the home’s Abuse Policy that implies or suggests that appropriate action to investigate a suspected or alleged incident of abuse cannot proceed should be deleted. The home’s Abuse Policy and the policy on ‘Adult Protection and Prevention of Abuse’ should be reviewed and brought together into one single, clear and comprehensive policy. The contents of the other policies were satisfactory. However, none of the above policies had been signed or dated. A recommendation was made as a result of the previous inspection that 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. The policy contained the address of County Hall and the telephone number of the Access Centre but not the address and telephone number of the Adult Protection Coordinator. Therefore, the recommendation had not been implemented. In order to avoid any unnecessary delays in contacting the Adult Protection Coordinator, should it be necessary to do so, it is advisable that the relevant information is included in the policy. The recommendation still stands. It was pleasing to note that all the senior staff and several members of the care staff had undertaken training on the protection of vulnerable adults from abuse on 18 May 2006. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users lived in a clean, safe, comfortable and well-maintained environment. EVIDENCE: The home was purpose built and all of the accommodation was provided on the ground floor. All of the bedrooms except one had an en suite facility. The premises were safe, accessible and well maintained. Protective covers had been fitted to the radiators and handrails had been installed in the two main corridors. The gardens were tidy. The home had enlisted the help of a maintenance man and a gardener. A maintenance book was kept in which all of the items that had been repaired or replaced had been recorded. The home did not have a programme of routine maintenance and renewal of the fabric and decoration of the premises. The registered manager stated that the home had not had a recent visit from the Fire Safety Officer. The most recent visit by the Environmental Health Officer had resulted in action being taken by the home to ensure that the lid was kept on the waste bin in the kitchen and that eggs were stored in the fridge. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 20 A recommendation was made in regard to Standard 22 as a result of the previous inspection that adequate storage space for storing wheelchairs and other equipment should be provided. The recommendation had not been implemented and still stands. A requirement was made in regard to Standard 24 as a result of the previous inspection 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. The registered manager confirmed that the relatives of the service users who occupied bedrooms 6 and 7 had provided written statements that they did not wish to have carpets provided in the bedrooms. The requirement has, therefore, been deleted. However, when the service users that currently occupy these bedrooms leave the home or otherwise vacate the bedrooms, carpets must be provided. The home had a satisfactory laundry that was appropriately sited and contained a washing machine and a tumble dryer. The washing machine had a sluicing facility. The laundry contained a wash hand basin. The laundry floor finishes were impermeable and these and the wall finishes were readily cleanable. The home had a satisfactory policy and procedure on the control of infection. The premises were clean. The service users with whom discussions were held stated that they were satisfied with the standard of cleanliness of the home and with their own personal clothing. All of the service users appeared clean and well dressed. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The quality outcome in this area was good. This judgement has been made using available evidence including a visit to this service. The service users felt that their care needs were being met. The home was committed to providing a well-trained workforce. However, the staff recruitment procedures did not fully protect the service users. EVIDENCE: A copy of the staff duty rota and details of the home’s staffing arrangements were provided. In addition to the registered manager the home employed a deputy manager for 35 hours per week, a team leader for 35 hours per week, two senior care assistants for a total of 70 hours per week and five care assistants (days) for a total of 135 hours per week. There were two night care assistants on waking duty at night. In addition, the home employed a cook for 30 hours per week and a domestic assistant for 20 hours per week. It was confirmed that the care staff were also expected to carry out some of the catering duties. The registered manager confirmed that all the staff who carried out catering duties had undertaken the food hygiene and infection control training. The service users with whom discussions were held spoke positively about the staff. One service user felt that there were always enough staff on duty and said, ‘They are all quite good’. Another service user described the staff as ‘kind and helpful’ and said ‘They work hard’. Another service user described the staff as ‘dedicated’ and said, ‘I can’t fault them. There are times when they’re pressured but on the whole they cope very well’. It was pleasing to note that the deputy manager had undertaken NVQ level 3 training and that eight of the thirteen members of care staff i.e. day and night staff, that were currently employed (excluding those on maternity leave) had undertaken the NVQ level 2 training. This exceeds the target of 50 of the Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 22 number of care staff with NVQ level 2 as laid down in the National Minimum Standards. In addition, three other members of care staff were undertaking NVQ level 2 training and three staff were undertaking NVQ level 3 training. The files of four members of staff were made available for inspection. The contents of three of the files were satisfactory. However, the file in respect of one member of staff contained only one reference. It was also noted that the two references provided in respect of another member of staff were from the same previous employing organisation. The reference provided in respect of one member of staff had been written on a compliment slip. Another reference was in the form of a testimonial. The home’s practice in regard to this aspect of the staff recruitment process needed to be improved. There was evidence to show that the staff had been issued with a copy of their contracts and job descriptions. The registered manager also confirmed that all the staff had been issued with a copy of the code of conduct and practice set by the General Social Care Council. The home had its own staff induction programme for newly appointed members of staff. The registered manager also confirmed that the staff covered the key skills in induction prior to commencing NVQ level 2 training. One new member of staff who was not eligible for funding for NVQ level 2 training but who was hoping to commence the training in the near future had not yet undertaken the induction training. The registered manager was exploring the possibility of providing induction training for the new member of staff. The training had commenced with a workbook provided by the Birmingham Care Development Agency. However, the Skills for Care training will take over when the registered manager has had the opportunity to familiarise herself with its contents. The recommendation that was made in regard to Standard 30 as a result of the previous inspection that 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 (the previous) report had not been fully implemented and still stands. The information contained in the training records needed to be updated. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The quality outcome in this area was adequate. This judgement has been made using available evidence including a visit to this service. The home had a competent and experienced manager and the home was being run in the best interests of the service users. However, the systems for monitoring the quality of the service did not fully promote the service users’ safety and welfare. EVIDENCE: The registered manager was competent and experienced and displayed the appropriate values to manage the home. The service users with whom discussions were held stated that the registered manager was approachable. It was confirmed that the registered manager had completed the NVQ level 4 training in Health and Social Care (Adults) in July 2006. It was also confirmed that the registered manager had commenced the Registered Managers’ Award (RMA) training at Solihull College. However, the RMA training had not yet been completed. The registered manager commenced the A1 Assessors Course two years previously and hoped to complete this training by the end of December 2006. The registered manager was keen to promote the new Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 24 induction training that was freely available to new staff below the age of 25 years. It was confirmed that the requirement that was made as a result of the previous inspection that the registered manager must undertake appropriate training in the protection of vulnerable adults from abuse (POVA) had been implemented. The registered manager and several members of staff had undertaken POVA training on 18 May 2006. It was also confirmed that the recommendation that was made as a result of the previous inspection, that the registered manager should be provided with a job description that enables her to take responsibility for fulfilling her duties, had been implemented. Standard 32 was not fully assessed during this inspection. However, the home’s response to the recommendation that was made in regard to Standard 32 as a result of the previous inspection was assessed. The recommendation was that evidence should be provided to show that management planning and practice encourage innovation, creativity and development. The recommendation had not been implemented and still stands. The one requirement and two recommendations that were made in regard to Standard 33 as a result of the previous inspection had not been implemented and still stand. The home was still without a comprehensive quality assurance system. However, the registered manager stated that advice was being sought on the development of a quality assurance system for the home. It was pleasing to note the work that had been undertaken by the deputy manager to obtain feedback from service users, visitors and staff on the quality of the service provided by the home. Questionnaires had been issued during September 2006 to all three groups. The information provided in the responses had been collated but not yet issued to those taking part in the exercise. The deputy manager was advised to extend the work to obtain feedback on the quality of the service by issuing questionnaires to other stakeholders in the community in accordance with Standard 33.7. Standard 34 was not fully assessed during this inspection. However, the home’s response to the recommendation that was made in regard to Standard 34 as a result of the previous inspection was assessed. The recommendation was that a business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. The recommendation had not been implemented and still stands. The registered manager stated that the home did not normally handle any of the service users’ finances and that no one connected with the running of the home acted as an agent or appointee on behalf of any of the service users. However, one service user had recently handed money over to the home for safekeeping. The money was kept in an envelope in a bag together with the home’s petty cash. A record of the service users’ money was being maintained. However, the arrangements for the safekeeping of both the service users’ money and the home’s petty cash were unsafe and unsatisfactory and also placed staff at risk. Secure facilities must be provided Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 25 for the safe keeping of money held by the home on behalf of service users. The registered manager stated that the home did not hold any valuables on behalf of service users. Standard 37 was not fully assessed during this inspection. However, 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 concerned amendments to the written procedures to be followed in the event of an accident and in the event of a service user becoming missing. The requirement had been implemented. Two requirements were made in regard to Standard 38 as a result of the previous inspection. The first requirement was that intumescent strips and smoke seals must be fitted to all fire resisting doors. The requirement had not been implemented and still stands. 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. This requirement had been implemented. Risk assessments had been undertaken in regard to several safe working practice topics. However, the risk assessments did not include the safe storage and disposal of hazardous substances. The home held relevant information on COSHH. The boilers had been serviced on 29 November 2005 and were shortly due for the next annual service. The home had a health and safety policy. Water samples were tested for Legionella bacteria on 14 March 2006. The outcome of the tests dated 29 March 2006 was satisfactory and stated ‘No bacteria were isolated from the samples analysed’. PAT tests had been carried out on 16 January 2006. The majority of staff had undertaken training in most of the core areas. However, some staff, including three newly appointed members of staff, had not undertaken all of the core training. The records of the fire safety checks were inspected. The record of the monthly check on the fire extinguishers had not been maintained since the 8 September 2006. An Immediate Requirement Notice was issued during inspection in regard to this matter and the requirement was implemented before the conclusion of the inspection. It was noted that one of the five named people with a dementia illness referred to in the Certificate of Registration was no longer residing at the home. Therefore, arrangements will be made by the CSCI for a new amended Certificate of Registration to be issued to the home. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 26 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X X 2 Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 27 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 2 Standard OP2 Regulation 5 15 Requirement A copy of the service users’ contracts must be kept in their individual files. A risk assessment in regard to nutrition must be carried out and recorded in respect of all service users and, where necessary, risk assessments on pressure sores, and included in the service users’ individual care plans. Clear, specific and detailed guidance must be included in the service users’ care plans to ensure the appropriate delivery of care. The care plans must include the action to be taken to ensure that all aspects of the service users’ needs are met. (Previous timescale 31/05/06 not met). The service users’ care plans must be reviewed at least once a month by the staff. The decision to administer medication covertly must be supported in writing by a person duly authorised to consent, recorded in the service user’s care plan and kept under regular DS0000018507.V317783.R01.S.doc Timescale for action 31/12/06 31/12/06 OP7 3 OP7 15 31/12/06 4 5 OP7 OP9 15 13 31/12/06 31/12/06 Hillside Residential Home Version 5.2 Page 28 6 OP9 13 7 OP18 12,13 8 OP29 19 9 OP31 9,18 10 OP33 24 11 OP35 16 12 OP38 12 13 OP38 13 14 OP38 12,18 review. A suitable dedicated refrigerator for storing medication that requires cold storage must be provided. All of the home’s policies and procedures, including the policy and procedure on the protection of service users, must be reviewed, amended where necessary, signed and dated by the registered manager in accordance with the guidance given in this report. Two relevant, written references must be obtained before appointing any member of staff and any gaps in employment records must be explored. The registered manager must continue to pursue the training necessary to achieve the Registered Managers’ Award. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 30/06/06 not met). A secure lockable facility must be provided for the safe keeping of any money or valuables held by the home on behalf of the service users. Intumescent strips and smoke seals must be fitted to all fire resisting doors. (Previous timescale 12/04/06 not met). Risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3 including the safe storage and disposal of hazardous substances. Arrangements must be made for all the staff to undertake training in all of the core areas. DS0000018507.V317783.R01.S.doc 31/12/06 31/12/06 07/12/06 31/12/07 31/01/07 07/12/06 31/12/06 31/12/06 28/02/07 Hillside Residential Home Version 5.2 Page 29 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 OP1 OP2 Good Practice Recommendations Action should be taken to ensure that all of the information contained in the statement of purpose is produced in full. The incorrect reference in the statement of terms and conditions of residence (contract) to the Registered Homes Act 1984 should be deleted and replaced by a reference to the Care Standards Act 2000. When medication is written on to the MAR charts by hand it should be checked signed for as being correct by two members of staff. A metal cabinet that complies with the Misuse of Drugs (Safe Custody) Regulations 1973 should be provided for the storage and safekeeping of controlled drugs. Appropriate action should be taken to address the matters raised by the service users referred to in Standard 12 of this report. A suitable heated food trolley should be provided in order to encourage service users to exercise greater independence and choice at mealtimes. All of the out of date copies of the home’s complaints procedure, including those on the service users’ files, should be replaced with an up to date copy and a copy of the complaints procedure should be displayed in the home. 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. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be introduced and implemented with records kept. 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 the report dated March 2006 and kept up to date. DS0000018507.V317783.R01.S.doc Version 5.2 Page 30 3 4 5 6 7 OP9 OP9 OP12 OP15 OP16 8 OP18 9 10 11 OP19 OP22 OP30 Hillside Residential Home 12 13 14 OP32 OP33 OP33 15 OP33 16 OP34 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. The results of service user surveys should be published and made available to current and prospective users, their representatives and other interested parties, including the CSCI. A business and financial plan for the establishment should be drawn up, made open to inspection and reviewed annually. Hillside Residential Home DS0000018507.V317783.R01.S.doc Version 5.2 Page 31 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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