CARE HOMES FOR OLDER PEOPLE
Hillswood Lodge 9 The Close Endon Stoke On Trent Staffordshire ST9 9JH Lead Inspector
Rachel Davis Unannounced Inspection 16th November 2005 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Hillswood Lodge Address 9 The Close Endon Stoke On Trent Staffordshire ST9 9JH 01782 504637 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) Hillswood Care Ltd Helen Josephine Sharif Sandra Dawn Seabridge Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Manager must complete the Registered Manager`s Award Date of last inspection 25/05/05 Brief Description of the Service: Hillswood Lodge is a residential care home offering 16 places for older people; four of these may be for service users with dementia over the age of 65. There were three vacancies at the time of this inspection. The home is a large detached property located in the centre of Endon situated at the top of a private drive. Local amenities are within a short walking distance and the local towns are accessible by car or public transport. Both the exterior and interior of the property are very well maintained; the home is exceptionally clean and the décor is set to a high standard. The service users are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms meet the required sizes set out by the national minimum standards and are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; one of the lounge areas has French doors opening onto a large patio area, overlooking a mature and wellkept garden. Adequate parking is available. The responsible individual for Hillswood Lodge is Mr John Howard and Sandra Seabridge is the registered manager. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 16th November 2005 at 11.00 a.m. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection amounted to four hours. What the service does well:
The manager assesses potential residents and this information is transferred into the care plans. It was clear that the manager “listens” to staff, residents, visitors and other visiting professionals to ensure an appropriate outcome for those using the service. Privacy and dignity are upheld in the home and this was confirmed by the residents and staff. The residents are encouraged to make as many choices as they are able in their daily lives. “It is better than home you are so well looked after” “ I am so happy here” were a couple of the very positive comments made A menu is available every day and those residents asked said that the food provided was very good. “ We had a beautiful dinner today”. All bedrooms have been redecorated and are equipped with good quality furnishings and fittings. Residents are encouraged to bring their personal possessions into the home with them. The residents spoke highly of the care staff team and respectful attitudes were observed. The care team and residents speak highly of the manager and her support and dedication. Staffing levels were as required, the inspector observed the staff to be delivering a high standard of care and attention to the service users. Staff were also heard offering choice and enabled the service users to make decisions and as many choices as they were able in their daily lives. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 6 The registered provider Mr Howard continues to visit the home and forwards the Regulation 26 report to the Commission for Social Care Inspection on a monthly basis. This evidences the home self audits and improves both the service delivery and environmental standards as required. What has improved since the last inspection? What they could do better:
The home has worked extremely hard to meet requirements and there are a good number of areas where the home exceeds the National Minimum Standards. Only three requirements have been made on this visit. The registered manager recognises that she must continue to review, audit and evaluate the home to ensure that the high standards set are continually being met. The home has established that they must continue to devise and develop their documentation to offer continuity and consistency in written format. No other areas of need have been identified on this occasion.
Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 7 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. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 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 Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 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): 1 and 3 The statement of purpose and service user guide provided suitable and sufficient information for permanent and prospective residents to enable them to make an informed decision about the suitability of the home. All residents who move into the home have their needs assessed and receive written confirmation from the home to say they can meet these needs. EVIDENCE: The revised Statement of Purpose and Service User Guide were examined and it was clear that work had been undertaken to provide an informative and detailed document that would assist potential service users when considering moving into the home, these documents had been reviewed in January 2005. Each service user guide also contains the latest inspection report and adequate information relating to the home. On admission, personal care, mobility and medication needs were documented along with mental state, social interests and carer/family involvement; service users relatives/representatives are also included in this procedure.
Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 10 Each resident and their relatives are fully informed prior to admission that the home can meet their needs. Evidence was seen to verify that any specialists’ needs were arranged as required; recordings provided a fair and factual account of events that had happened. Residents spoken to expressed their continued satisfaction with the home, management and the care staff. “ It is beautiful here” was one of the very positive comments made.” Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 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, 9 and 10. Care planning systems adequately reflect the aspirations of residents. The risk assessment and decision-making systems are transparent and enable service users to take responsible risks that are part of an independent lifestyle. Medication is well managed and the systems in place safeguard the service user. EVIDENCE: One fairly recently admitted residents care records were examined and the information contained within was clear and succinct. Care plans, daily records, reviews and risk assessments are of a good standard and individualised to evidence ongoing consultation with residents, families and other healthcare professionals where appropriate. The health care section of the care plan evidenced that needs were closely monitored and medical professionals contacted when necessary, suitable recording of body weight and nutritional needs were in place. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 12 A visiting professional had felt compelled to write to the home and stated: “ I write to thank you for the outstanding care you have afforded this resident, I have to say that the compassion, care and kindness shown at all times with dignity and respect was something which was a pleasure to behold.” Suitable policies on the receiving, admissions and safe handling of medications were in place. The ‘as and when required’ medication records were checked on this visit and evidenced that a safe system was now in place. Risk assessments are carried out on both a personal and environmental basis to reduce potential accidents. The registered manager undertakes an individual risk assessment for each resident so that the risk of potential accidents is either removed or reduced. The risk assessments are reviewed bi monthly, or if circumstances change, and amended if any hazards present themselves at a later date. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15 Visitors are made welcome and various avenues for encouraging residents’ choice are considered. Worthwhile activities and stimulation from residents are in place, this provides daily variation and interest for people living in the home. EVIDENCE: The home has a robust activities programme arranged over the week to meet the needs and capabilities of residents. Staff and residents spoken to confirmed that they especially enjoyed reminiscence, board games and bingo. Some residents still access the local community, they are encouraged to maintain and forge links and exercise choice and control of their lives. Visitors to the home have made very positive comments in the homes comments book one comment read: “Everything is lovely, spotlessly clean with really caring people.” A varied menu is available for residents with the recent introduction of lasagne, chicken korma, beef burgers and pizza; alternative meals are offered daily.
Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 14 Staff confirmed that a number of residents have enjoyed trying new things and like to be involved with menu planning. Residents’ meetings minutes confirmed this was a regular area for discussion. New menus are continually explored and records are kept as required. Drinks and snacks are readily available. All staff working in the kitchen have a Food Hygiene Certificate. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents felt they were listened to and that action would be taken to resolve the complaint as quickly as possible. EVIDENCE: The home has a detailed complaints procedure whish was checked and is in line with the requirements; the appropriate complaints log is also in place. The home also offers grumbles, comments and compliments book which is sited by the visitors signing in book in the main entrance hall. This has been used by visitors on a number of occasions and confirmed their happiness and ease at discussing their views with Hillswood Lodge. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 16 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): 19, 24, 25 and 26. The standard of the environment within this home is excellent providing residents with an attractive and homely place to live. EVIDENCE: A partial tour of the environment was undertaken during this inspection of all of the communal areas, some bedrooms and the kitchen. A large notice board sited in the hall offers residents and their family and friends up to date information on activities, advocacy services, a leaflet is available giving information on recognising signs of abuse, outings and church service information is also available. The home is exceptionally clean and the staff are commended on this. All areas are in a good state of repair; the manager confirmed that all bedrooms have now been redecorated. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 17 The bedrooms are provided with the required storage facilities and residents are offered a key to their bedrooms. It was noted that new flooring had been provided in one area, it must be verified that this type of flooring is considered suitable. Wardrobes must also be checked to ensure that they are all attached to the wall as required. New good quality patio furniture has been purchased, it was noted that the gardens looked very attractive were well kempt. A tour of the home evidenced that all radiators have now been audited and suitably covered for the safety of the residents. The registered care manager confirmed that some of these covers would be further improved in the near future. The home has purchased foot operated bins for the safe disposal of clinical waste. The home has the required ‘yellow bags’ and the outside clinical waste bin sited to the rear of the property now has a lock. The home has also replaced latex gloves with nitrile gloves to avoid any allergies. Communal areas contained liquid soap and paper towels, antimicrobial cleaning rub is also available. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 18 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): All staff were suitably trained to carry out their duties, the homes recruitment practices are in line with the National Minimum Standards. EVIDENCE: On the day of the inspection there were two care staff, one cook and the manager, thirteen residents were living in the home at this time. The number of staff on duty adequately met the levels expected. Two of the senior care staff have just started the National Vocational Qualification 4 (NVQ4), Sandra Seabridge has recently completed the Registered Managers Award (RMA) and is waiting for her certificate. Staff were very positive about working at Hillswood Lodge, comments included: “I love it here, I was welcomed, we all get on, the environment is really nice, it is relaxed.” “Sandra is a good manager, she is fair, she knows what we are asking of her because she has been a care worker and understands these residents needs.” Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 19 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): 31, 32, 35 and 38 The management team have a clear development plan and vision for the home, this is effectively communicated to the residents, staff, relatives and significant others. EVIDENCE: Since the last inspection the manager, Mrs Sandra Seabridge has completed the Registered Managers Award. Completing this award helps to ensure that a competent skilled manager is in place who is adept at fostering an atmosphere of openness and respect, in which residents, family, friends and staff all feel valued and that their opinions matter. Mr Howard, the proprietor, visits the home regularly and completes the required regulation 26 reports for the manager and the Commission for Social Care Inspection; these are always very open, honest and informative. The home does not deal with residents’ finances, no monies are held.
Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 20 During this inspection the manager confirmed that she was satisfied that all the required checks, assessments, maintenance and records were complete and up to date. It was noted that checks for fridge temperatures, were not as accurate and reliable as they should be, the manager was aware of this, and was in the process of implementing a new system. Overall, the health, welfare and safety of staff and residents are promoted and protected. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 21 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 X 4 X X X X 2 X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 X X 2 Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP24 OP24 Regulation 13(4)(a) 13(4)(c) Requirement The registered manager must ensure that the flooring provided is suitable. The registered manager must ensure that all wardrobes are attached to the wall for safety purposes. The registered manager must ensure that fridge and freezer temperatures records are accurate and up to date. Timescale for action 01/12/05 25/11/05 3 OP38 12(1)(a) 25/11/05 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 Refer to Standard OP9 Good Practice Recommendations The registered manger should consider offering refresher training for those administrating medications during 2006. Hillswood Lodge DS0000059811.V266886.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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