CARE HOMES FOR OLDER PEOPLE
Hilltop Manor 15 Finkle Hill Sherburn In Elmet Leeds North Yorkshire LS25 6EB Lead Inspector
Denise Rouse Unannounced Inspection 15th December 2005 10.20 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.V269836.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. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 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.V269836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include up tp 35 (OP) and up to 35 (DE(E)) up to a maximum of 35 Service Users. 1st August 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. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced Inspection took place over two hours and was carried out by one Inspector, following half a day’s preparation. The registered manager Mrs Green and Mrs Buckle were present and assisted in the Inspection process. A tour of the premises was undertaken, which included both bedroom and communal areas. A number of service users and staff were spoken with as well as one relative. Some records were inspected for several service users, these including pre admission assessments, care plans; risk assessments, weight charts and GP visit sheets. Maintenance records pertaining to water temperatures were also examined. The inspection concluded with a feedback session, involving Mrs Green and Mrs Buckle with Denise Rouse, Regulatory Inspector. What the service does well: What has improved since the last inspection?
More training for care staff in the National Vocational Qualification in Care at level 2 has occurred. There will be 50 of staff at the home with this qualification once three outstanding certificates have been received. A proportion of water temperatures within service users bedrooms are taken and recorded weekly, this helps to ensure safety for service users. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 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. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 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.V269836.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None inspection at this visit. EVIDENCE: Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 9 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): Standards 7 Service users care plans and risk assessments were not all reviewed monthly, or as the service users needs changed. This may place service users at risk. EVIDENCE: A selection of service user files were inspected, some contained very detailed information, which would ensure that excellent care could be given to the service user by care staff. Unfortunately some other service user profiles were not reviewed monthly or as the service users needs changed. This may put individual service users at risk of not receiving the relevant and appropriate care or intervention. The registered manager was informed of the shortfalls and will implement an audit system to ensure that all service users care profiles are current and up to date, especially care plans and risk assessments. One service user who has experienced weight loss appeared not to have had her care plan reviewed or their weight recorded on a monthly basis. The registered manager discussed this with the care staff and informed the inspector that this was because the service user had refused to be weighed.
Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 10 If service users refuse to be weighed, this must be recorded appropriately within the care records, or it may be perceived that this intervention has not been offered by the care staff. Service users who have the ability and relatives also need to be asked to take part in the review process for care plans and risk assessments. There was evidence that one service user and on relative had taken part in this process, this needs to be developed within the home. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 11 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): None inspected at this visit. EVIDENCE: Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 12 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): None inspected at this visit. EVIDENCE: Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 13 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): None inspected at this visit. EVIDENCE: Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 14 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): Standard 28 Service users needs are met by trained and competent staff. EVIDENCE: More care staff have completed the National Qualification in Care Level 2, this ensures that the home will achieved the requirement that 50 of care staff hold this qualification by the end of 2005. Three staff were awaiting their certificates, it was confirmed by phoning the verifier that these candidates would be successful in gaining this qualification. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 15 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): Standard 38 Service users health and welfare is protected by the homes policies and procedures. However service users may be placed at risk if water temperatures are all taken and recorded on one day of the month. EVIDENCE: The maintenance man takes and records the temperatures of the hot water supplies within the homes bathrooms and service users bedrooms. A proportion are tested and recorded on a weekly basis. All the temperatures are recorded throughout the month. The documentation was inspected and three water temperatures re checked by the inspector, two were found to be slightly over 43.0 degree centigrade. This was pointed out to the registered manager who immediately notified the maintenance man and the valves were adjusted whilst the inspection was taking place. In view of this, the practice of taking and recording a proportion of water temperatures weekly should be continued.
Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 17 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 Standard OP7 Regulation 15 (1) (2) Requirement The Registered Manager must; • Ensure that service users care plans and risk assessments are updated at least monthly and as the individual service users needs change. • Service users who are capable or relatives are involved in the care plan and risk assessment reviews. Timescale for action 15/12/05 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 OP38 Good Practice Recommendations Hot water temperatures should be taken and recorded on a weekly basis, for a proportion of the building. All temperatures must be recorded monthly. Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hilltop Manor DS0000007652.V269836.R01.S.doc Version 5.0 Page 19 - 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!
