Inspection on 14/11/06 for Hilltop Manor

This inspection was carried out on 14th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hilltop Manor 15/12/05

Hilltop Manor 02/08/05

Hilltop Manor 01/03/05

Hilltop Manor 07/09/04

Hilltop Manor 16/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Hilltop Manor 15 Finkle Hill Sherburn In Elmet Leeds North Yorkshire LS25 6EB Lead Inspector Mrs Irene Ward Key Unannounced Inspection 14th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hilltop Manor DS0000007652.V318212.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. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilltop Manor Address 15 Finkle Hill Sherburn In Elmet Leeds North Yorkshire LS25 6EB 01977 683898 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 Alison Jayne Green Mr Allen Williams, Mrs Claire Louise Buckle Mrs Alison Jayne Green Care Home 35 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 35 (OP) and up to 35 (DE(E)) up to a maximum of 35 Service Users. 15th December 2005 Date of last inspection Brief Description of the Service: Hilltop Manor is registered to provide residential personal and social care for up to 35 people over 65 years of age who suffer from dementia. The property is a two-storey building, which has been extended and adapted for its present use. There are two passenger lifts providing access between the two floors and a pleasant secure garden at the rear of the property. The home is located in the village of Sherburn-in-Elmet, and is close to local services and amenities. The registered providers are Mrs Alison Green, Mr Allen Williams, and Mrs Claire Buckle. The registered manager is Mrs Alison Green. The weekly fees on 14th November 2006 range from £349 to £395. This information was supplied to the Commission For Social Care Inspection via the pre-inspection questionnaire received on the 15th September 2006. Service users/relatives and other interested parties are able to have access to inspection reports as they are displayed in the reception area of the home. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit carried out on the 14th November 2006. This visit was carried out by one Regulation Inspector and started at 09.30 hrs and finished at 15.45 hrs with 3 hours preparation time. The inspection process included information provided by the home prior to inspection. Surveys were also sent to relatives and friends and health and social care professionals. Twenty surveys had been sent and thirteen surveys have been returned to the Commission for Social Care Inspection. All of which were very positive about the overall care provided by the home. The site visit comprised of a full inspection of the premises, which included some service users private accommodation. The care records of four service users were looked, which included service users assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent observing activity in the home and interaction between service users and staff, talking and listening to service users, friends and relatives visiting the home. Time was also spent talking to members of staff. There was also opportunity to speak with a visiting District Nurse. The focus of the inspection was a number of key standards, inspecting the case records of service users in detail to establish if they corresponded with service users experiences in the home. The registered manager, the deputy manager and one of the registered providers were all available throughout the day. There were no requirements outstanding from previous inspections. There were no requirements or recommendations made at this inspection. The last unannounced inspection was carried out on the 15th December 2005. What the service does well: The staff provide a clean, warm and comfortable home for service user to live in. The home provides good care for service users and supports them to maintain their independence. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 6 Members of staff were observed to provide appropriate care when supporting service users in maintaining their independence in daily tasks. One service user said, “I would not swap it for Buckingham Palace”. Comments from relatives/visitors and a visiting health care professional were all positive. Relatives made comments such as “the home is very good and staff are friendly”. A visiting health care professional said, “The staff are helpful and will always assist”. Service users confirmed that they could see visitors at anytime enabling them to maintain relationships with their family and friends. What has improved since the last inspection? 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. Hilltop Manor DS0000007652.V318212.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 Hilltop Manor DS0000007652.V318212.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): 3 and 6. Quality in this outcome area is good. Service users needs are properly assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that a service user guide is sent to all service users/relatives when making an enquiry about the home. The Statement of Purpose and the Service User Guide has been reviewed and updated. Pre-admission assessments are in place and held on service users individual files. A care needs assessment from local authorities was also in place where necessary. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 9 Four service users files were looked at. All files held initial assessments, care plans and risk assessments. Contracts/terms and conditions of residency seen had been signed and agreed with service users or their representatives. When one service user was asked how she chose the home, she said that she had heard good reports about the home as it has a good reputation in the community; this had helped her choose Hilltop Manor. The home does not provide intermediate care. Hilltop Manor DS0000007652.V318212.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. Quality in this outcome area is good. The care provided to service users was good, and all identified needs are translated into individual plans of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users are well cared for and some made comments about the care they received. One service user said “Life is good here, there is nothing to criticise” and another said, “Staff are very friendly ”. Another service user said, “Staff are very good here, they lean over backwards for you”, whilst another commented, “they look after me”. Service users commented that they treated with respect by the staff at all times. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 11 Evidence showed that all identified needs that were assessed are recognised by care planning. The case records of four service users were looked at. All four care records had detailed risk assessments including reducing risks of falls. Care plans were comprehensive in detail about service users needs and how they were to be met by care staff. Daily records were detailed and gave a clear picture how both day and night care staff, meet service users care needs. Visits by GPs and other health and social care professionals were recorded. A visiting District Nurse to the home was spoken to and said, “the home is very good, staff are helpful and residents are well looked after”. A comment card received from a GP said, ”Excellent home, residents always well cared for & their needs & wishes respected”. Service users records confirmed that appointments are made for the dentist and optician. A private chiropodist calls approximately every six weeks to the home. The medication system and facilities were inspected. The home has introduced a new medication system and now operates a monitored dosage system. Proper procedures were in place for the administration and storage of medication and a random check of medication supplies tallied with records. The medication administration records were up to date. Controlled drugs held by the home were stored securely and appropriately and records were maintained in line with the recommended guidance. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is excellent. Daily routines enable service users to have control over their lives. Activities in the home are good and meets the social needs of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an activities organiser who is carer. Various activities are organised such as crafts, games and quizzes, various entertainers, such as Barber Shop Choir, events such as a Harvest Festival, Halloween Party and Bonfire night. The home produces a quarterly newsletter, which details forthcoming events such as Christmas shopping at the White Rose Centre and the forthcoming Christmas party for service users and their relatives. The home ensures that religious services are held for those service users who wish to attend. Regular visits are made from the local church and services and communion are performed. The hairdresser visits the home regularly. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 13 Service users all confirmed that they are able to get up and go to bed as they wish and that visitors are able to visit them at anytime. All service users said that the food at the home was very good. One service user said, “the food is good here”. Another service user said, “The food is very good here, like you would do at home”. Another service user said, “They always provide you with an alternative”. Menus provided detail of variety and choice. The daily menu is displayed on a board in the dinning room. There is a four weekly rotating menu that the cook works to. The menu is changed to take account of the foods in season. Special diets are catered for such as diabetics. The home demonstrated how they support service users to exercise choice. One of the service users whose first language is not English was making it clear that they wanted to remain in this country whilst family members wanted the service user to move abroad. The home held a review, which included the service users solicitor, interpreter and members of the family. A video interview took place in agreement with the service user and solicitor. Following the review and video interview the service user was made a ward of the Court of Protection. Therefore remaining in the country that has been home for many a year. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. Service users are confident that their complaints and concerns will be dealt with and are safe living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hilltop Manor continues to have a comprehensive complaints procedure in place. The home records all complaints they receive. No complaints have been made either to the home or the Commission For Social Care Inspection. Service users said that they were aware of how to raise any concerns. They said they would approach care staff or manager and they were confident that they would put things right. Comprehensive policies and procedures on the protection of vulnerable adults were seen including the local multi-agency agreement. Staff have received training on abuse awareness. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. People live in a safe, clean and comfortable environment that is suitable for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the site visit the home was warm, bright and clean. There were no offensive odours in any areas of the home. Bedrooms and communal areas were clean and tidy and furniture and fittings were well maintained. Several service users were able to show the inspector their rooms. Service users rooms had all been personalised with their personal belongings including pieces of furniture. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 16 Assisted bathrooms and toilets were situated near to service users bedrooms and communal areas. Service users accommodation is over two floors, which can be accessed by a passenger lift or staircase. There is level access to the home. This meant that any service users who had difficulty with mobility or used a wheelchair had access to all parts of the home. Relatives and visitors to the home said that the home was always kept “very clean”. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. Staffing levels are sufficient in meeting the assessed needs of service users. Service users are protected by the home’s vigorous recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota showed that there is usually a minimum of five care staff on duty each morning, and four on an afternoon and evening this does not include management or ancillary hours. There is the registered manager and a deputy manager. At night there are two waking night staff. Service users said that they felt that their care needs were being met and that staff are easily accessible. The home had a call bell system and service users said that the call bell requests were always attended to quickly. The staff records of three staff including a recently appointed member of staff were looked at. All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. A POVA first check had also been carried out. 57 staff holds NVQ Level 2 and 2 staff are completing NVQ Level 3. Training such as Fire safety, Health and Safety, First Aid, Dementia, Challenging Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 18 Behaviour, Medication-Safe Handling of Medicines, Pressure Care, Continence are just some of the training that has been completed by staff. The home has both a training development plan and a training analysis plan in place for the staff team. This identifies what kind of training all the staff have had and what they may need in the future to make sure that the home has a qualified and competent staff team and that the quality of care in the home continues to be good. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The service users and staff benefit from the ethos and leadership of the management team who safeguard service users interests and ensure their safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided from the pre-inspection questionnaire and the examination of selected health and safety documents show that regular checks to hot water delivery, electricity and gas and fire safety equipment are regularly undertaken. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 20 The ethos of the home is open and positive. Service users, relatives/visitors and health and social care professionals all commented highly about the home. Service users finances were not checked at this site visit, however information supplied by the pre-inspection questionnaire and historical evidence from previous reports gives evidence that service users financial interests are safeguarded. Staff supervision records were seen at the site visit. Staff confirmed that staff supervision and annual appraisals is carried out regular. Quality Assurance systems are in place at the home and a quarterly newsletter is published for service users and their families. The newsletter is full of information about forthcoming events, birthdays, deaths, new staff, training that staff have completed and so on. Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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. Extracts may not be used or reproduced without the express permission of CSCI Hilltop Manor DS0000007652.V318212.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!