Inspection on 17/01/06 for Hilltop House

This inspection was carried out on 17th January 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilltop House 02/12/08

Hilltop House 08/12/06

Hilltop House 13/07/05

Hilltop House 03/03/05

Hilltop House 15/09/04

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

CARE HOME ADULTS 18-65 Hilltop House 30 Hilltop Road Twyford Berkshire RG10 9BN Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 17th January 2006 11:20 Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 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 Hilltop House DS0000011393.V279569.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 Adults 18-65. 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. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hilltop House Address 30 Hilltop Road Twyford Berkshire RG10 9BN 0118 934 0053 0118 934 0659 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) Mrs Janet Clarke Mrs Janet Clarke Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: Hilltop House is a care home for 8 people with mental health needs. It is registered for adults over 18 years of age and is able to accommodate both genders. It does not provide nursing care or provide care for people detained under the Mental Health Act 1983. The house is staffed throughout the 24hour period, with the night staff sleeping in. The house is owned and managed by Mrs Janet Clarke. The house is within a quiet residential area of Twyford. It is close to local shops and a bus stop is directly outside the property. Twyford has a train station, which is about 15 minutes walk from the house. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection occurring on a weekday between 11.20 and 15.05 hours. The Registered Manager was present throughout the inspection. 5 residents were spoken with and 3 members of staff. The main emphasis of the inspection was to review the key standards not inspected on the previous visit in July 2005. This report should be read in conjunction with the report published following the last inspection. This will ensure that a complete overview of the key standards is available to the reader. What the service does well: What has improved since the last inspection? What they could do better: By the Registered Managers own admission, administration tasks are not one of her strengths. She has employed an assistant (one day a week) who had commenced work prior to the last inspection, to assist her with tasks. In areas where compliance with the regulations of the Care Standards Act should be absolute and paramount (recruitment of staff) deficits were identified. These Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 6 deficits could increase risks for the residents. The Registered Manager must ensure that she protects the residents at all times. The Registered Manager also needs to ensure that she attends up-to-date training on the protection of vulnerable adults and if indicated, ensure all her members of care staff receive this training too. She must also ensure the care staff receive regular and documented supervision at least six times a year. 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. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 17 The residents in this home enjoy a good quality of life. They were all very positive about their lifestyles and the choices they are enabled to make. The resident group are also concerned and caring for each other. EVIDENCE: Of the residents spoken with they commented favourably on the level of activities and interests they take part in. The majority of the residents who live in this home enjoy quiet, relaxed lifestyles. The rapport with the members of staff was observed to be very good and comments from the residents assured that they find the staff friendly, supportive and always willing to offer assistance and advice. The home has good neighbourly relations with its local community. All of the residents spoken with commented that the choice and quality of food was very good. Individual dietary preferences are well catered for and the majority of the meals are home-made from fresh ingredients. Some of the residents commented on their enjoyment of baking cakes for everyone else to enjoy. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 This home ensures that the health care needs of the residents are assessed and responded to appropriately. EVIDENCE: Two the residents are presently in hospital. The Registered Manager and members of staff are continuing to support these residents whilst they are away from the home by visiting them regularly and facilitating visits back to the home. The members of care staff responded appropriately by seeking specialist help when it was required for these two residents. The Registered Manager is also ensuring that the home is included in any Care Programme Approach (CPA) meetings. This is good practice. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The Registered Manager has not received up to date training with regard to the protection of vulnerable adults. The home does not have an up-to-date edition of the local multi-agency procedures with regard to the protection of vulnerable adults. EVIDENCE: It was noted that the home does not have an up-to-date edition of the local multi-agency procedures with regard to the protection of vulnerable adults. The home does have its own policy to ensure that residents are protected from abuse, neglect and self-harm. However, when the home receives their up-todate copy of the local procedures it would be an opportune moment to review the homes policy to ensure compliance with the multi-agency procedures. The Registered Manager has not attended a recent training course on the protection of vulnerable adults and not all members of staff have received similar training. This indicates that an audit of all staff should be undertaken to ensure that they have received recent training in this area of care delivery. There is nothing to suggest that this home does not protect the residents from abuse but it is important that all members of staff receive regular training and the home has up-to-date procedures. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 This home provides a warm, comfortable and homely environment for residents to live within. EVIDENCE: The home is suitable for its stated purpose. It meets the residents’ individual and collective needs and is comfortable and homely. A programme of redecoration and some refurbishment has started. The residents are being included in these plans and indicating their choices and preferences. All of the residents have individual rooms. Of the residents spoken with, all were complimentary about the home they live in and the facilities available to them. The home was clean and tidy. Several of the residents commented that this is always the case. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 36 The Registered Manager has not fully complied with the regulations with regard to the recruitment of staff. A previous requirement has not been met. The Registered Manager has not ensured that all members of care staff receive regular and documented supervision at least six times a year. EVIDENCE: The recruitment records of the two most recently appointed members of staff were reviewed and found to be incomplete. For one member of staff (appointed in August 2005) there was no application form and no health declaration. For the other member of staff (appointed July 2005) they had commenced work without a Criminal Records Bureau (CRB) check having been completed or POVA first check. This person’s CRB arrived two months after the commencement of employment. This should not occur. The Registered Manager must also ensure that she can evidence her decision making when employing members of staff who have disclosed information that could influence their suitability to work in the care home. The supervision records of both these members of staff were reviewed. They had both received a supervision session each that had been recorded. This frequency does not comply with the standard that staff receive regular, Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 15 recorded supervision meetings at least six times a year. The records of other staff were reviewed and it was evidenced that they had received insufficient supervision sessions. The Registered Manager accepted that she had not complied with a previous requirement. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The Registered Manager must ensure that she demonstrates her competence to run the home in a way that ensures the protection of the residents who live in the home. The residents do feel that they are included in the review of the quality of the care delivered in the home and feel their views are listened to. The home does ensure that the health, safety and well being of the residents and members of staff are protected and promoted. EVIDENCE: The Registered Manager is qualified and experienced to run the home. On this inspection it has been evidenced that the manager had not complied fully with regulations to ensure the protection of residents. She has accepted that these deficits had occurred and accepts responsibility for them. She has stated that she will ensure the safeguards are pursued and followed in the future. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 17 The Registered Manager is not included on the rota of staff working in the home although, she assured that she visits the home most days for lengthy periods of time and is always on call to members of staff. Members of staff and the residents confirmed this. The Registered Manager should consider recording when she is present in the home and ensure that such a record is available for inspection. Of the residents spoken with all felt that their views about how well the home is run and whether it meets their needs are taken seriously. Whilst formal meetings might not take place regularly the group of residents do meet informally with the members of staff and the Registered Manager to consider whether there are alternatives they could consider to improve the quality of service they receive. It has to be said that none of the residents spoken with offered any dissenting comments about the care and attention they receive in the home. They were all extremely positive. Random samples of health and safety records were reviewed and all were found to be up-to-date. A member of the fire service declared in a report of June 2005 fire precautions in the home was satisfactory and a member of the environmental health department in September 2005 made various recommendations which have been complied with. Members of care staff do receive regular mandatory training in moving in handling; fire safety; first aid; food hygiene and infection control. Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 2 X 3 X X 3 X Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13(6) Requirement Timescale for action 31/03/06 2 YA23 13(6) 3 YA34 19 4. YA36 18(2) The Registered Manager must ensure she receives up-to-date training in the protection of vulnerable adults. The Registered Manager should 31/03/06 conduct an audit of all members of care staff to ensure that they have received up-to-date training in the protection of vulnerable adults and then provide training to those that require it. The Registered Manager must 31/01/06 ensure that she complies with the regulations with regards the recruitment of staff and not deviate from this. She must also ensure that she can evidence her decision making when employing staff who have disclosed information that could influence their suitability to work in the care home. All members of staff must 31/03/06 receive at least 6 supervision sessions each year. They should be recorded. A schedule for implementing regular supervision should be devised in the first instance. This standard was DS0000011393.V279569.R01.S.doc Version 5.1 Hilltop House Page 20 5. YA37 10 not met following the previous inspection. The Registered Manager must ensure that she demonstrates her competence to manage the home by ensuring that the regulations in place to protect residents are complied with. 31/03/06 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 Refer to Standard YA23 Good Practice Recommendations The Registered Manager should obtain an up-to-date copy of the multi agency local procedures for the protection of vulnerable adults. On receipt of this document the homes own policy and procedure with regard to this area of care should be reviewed and revised if necessary. The Registered Manager should consider recording when she is present in the home and ensure that such a record is available for inspection. 2 YA37 Hilltop House DS0000011393.V279569.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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