Inspection on 15/11/05 for Hillview

This inspection was carried out on 15th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillview 27/08/08

Hillview 15/10/07

Hillview 23/01/07

Hillview 30/07/06

Hillview 19/05/05

Hillview 07/12/04

Hillview 07/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hillview 17 Collett Road Ware Hertfordshire SG12 7LY Lead Inspector Jeffrey Orange Unannounced Inspection 15th November 2005 08:20 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 Hillview DS0000019430.V265542.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. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillview Address 17 Collett Road Ware Hertfordshire SG12 7LY 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) 01920 469428 01920 469428 angelacsi@aol.com Colley Care Limited (Trading as B & M Care) Angela Page Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 Brief Description of the Service: Hillview is owned and operated by B&M Investments Limited, of Three Gables, Corner Hall, Lawn Lane, Hemel Hempstead, Hertfordshire HP3 9HN. 01442236020, and is registered to provide accommodation and care for up to 36 older people. Hillview is a large house, which has been converted and equipped for use as a residential care home for older people. The accommodation is arranged over three floors and is, with one exception, in single rooms. There is a passenger lift to all floors and the home is adapted for wheelchair use. There are gardens to the front and rear of the home, with car parking provided at the rear. A wooden decking area has been created at the front of the home, to provide an additional communal sitting area. Hillview is situated in a residential area of Ware, close to the town centre, with easy access to bus and rail services. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours, commencing at 8.20 am, which provided an opportunity to observe the morning routine of the home. Overall it was a positive inspection, with progress having been made to meet requirements and recommendations made following the previous inspection of the 19th May 2005. Where key standards were assessed during the inspection of the 19th May 2005 these have not all been assessed again on this occasion and reference should be made to the report of that inspection for details. This inspection focussed in particular on how choices for residents are offered and recorded. This was discussed with the manager and key staff and could usefully be considered by the home over the next six months to explore possible ways to expand staff’s understanding of the principles behind it and practical ways of improving it. What the service does well: What has improved since the last inspection? What they could do better: Some requirements will be made in respect of medication practice, although this has improved in general. Some recruitment and recording issues need addressing and choices offered to residents need to be better formalised and recorded. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 6 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. Hillview DS0000019430.V265542.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 Hillview DS0000019430.V265542.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): 1 Hillview makes available the necessary information for those people who are considering it as a home for themselves, or for someone they care for, in order that they are able to make an informed decision. EVIDENCE: The Statement of Purpose, Service User’s Guide and other associated documentation has been seen and provides the required information. It is important that this is kept under review and revised as appropriate. Hillview DS0000019430.V265542.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): 7,9 Those care plans seen were generally satisfactory. However, as stated on previous occasions, whilst the care plan format in use is quite comprehensive and detailed, the full benefit of it will only be obtained when there is a consistently thorough standard of completion of all parts in each case. Medication practice has improved in many respects since the last inspection. The cleanliness and tidiness of the medication trolley was found to be of a high standard on this occasion. There were some specific areas that need attention and they were discussed with the senior care worker responsible and with the manager. (See requirements and recommendations) EVIDENCE: Care plans for resident’s that had recently been admitted were examined. One example of where completion was not adequate was in respect of a care plan where the list of personal belongings and social history details had not been recorded adequately. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 10 Returned medication is still not being recorded at the time it becomes surplus and some control drugs had not been recorded when they were transferred out of the home with a resident. The medication trolley cannot be secured appropriately. The temperature of the new storage facility for medication should be monitored and recorded. Hillview DS0000019430.V265542.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): 12,14,15 The activities programme is now more structured and based upon individual preferences. The catering staff devise menus on the basis of known resident preferences, although this is not always formally recorded. “I always have plenty to eat” was one comment made by a resident. Formal consultation in order to discuss choices with residents is sporadic and infrequent, the manager and staff appear to rely on informal consultation and “knowing” what residents like. EVIDENCE: The inspector spoke at length with the activities organiser who has recently been appointed and discussed future developments and resources available. Records of individual activity programmes and resident activity survey sheet were seen. Menus were seen and discussions held with the Cook and Manager. Records of residents meetings were seen, these had been held in July and December 2004 and October 2005. Lunch was observed and appeared to be attractive and nutritious and was served in an appropriate way in the dining area or resident’s own rooms Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 12 according to choice. “ I can have my breakfast whenever I like” one resident informed the inspector. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 13 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): 16,17 A complaint received by the CSCI in respect of food hygiene was appropriately dealt with and recorded. It has previously been established that residents are assisted to take part in elections, most usually by way of postal voting. Age Concern Advocacy services are also publicised in the home. EVIDENCE: Please see the published report of the additional visit in respect of this complaint, which took place on the 21st July 2005. Information about advocacy services available is displayed in the home. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 14 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): 25,26 Hillview is an older building, which has been well adapted to meet the needs of its residents and is kept well decorated and furnished. Storage facilities, private space for consultations with health professionals visiting the home and staff rest accommodation has all been markedly improved since the previous inspection. One incidence of inappropriate storage of cleaning materials was found and brought to the attention of the manager. EVIDENCE: A room for health consultations has been provided, staff restroom accommodation has been enhanced and storage for wheelchairs etc is being completed. Improved medication storage has also been provided. Cleaning materials were found in one bathroom during the inspection. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 15 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): 29 Recruitment policies and procedures, when followed in full, should provide residents with confidence that only those fit to be so are employed by the home. References should always make clear who is providing the reference. EVIDENCE: Staff files for two recently recruited staff were seen, in one case it was not clear who had actually provided the references contained and files did not always include a recent photograph of the member of staff. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 16 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): 31,32,33,34,37 The management of the home provides an approachable and quite informal atmosphere. As detailed elsewhere, it is not always clear from records held how service users and staff are able to affect the way that the service is organised and delivered. Quality assurance is not formalised into a coherent strategy, although various elements are present and the manager has sought to put in place surveys of residents and health and social care professionals. EVIDENCE: Staff and residents were seen to feel able to approach the manager and discuss issues affecting care and the running of the home. Staff meetings and residents meetings are not held regularly or frequently. Residents’ views are obtained informally on a day-to-day basis, with occasional more formal surveys undertaken. Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x X X X X X X 2 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 X X 2 X Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The record of medication awaiting return to the pharmacist must enable the home to audit what is being held for return at any time, not just on a monthly or periodic basis. This requirement has been brought forward again. The detailed requirement was clarified with the Senior Care Worker responsible for medication under the Manager. The medication trolley must be adequately secured at all times when not being moved during the administration of medication. Where controlled drugs or any medication is transferred out of the home, this must be fully recorded at the time. All materials covered by the COSHH regulations(1988) should be locked away when not in use Timescale for action 15/11/05 2 OP9 13(2) 15/11/05 3 OP9 13(2) 15/11/05 4 OP38 13(3) 19/05/05 Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 19 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 OP1 Good Practice Recommendations The format and content of the home’s Statement of Purpose and Service User’s Guide should be kept under review, and revised as necessary, to take account of any changes in the service and to ensure that they fully comply with the requirements of the National Minimum Standards and Care Homes Regulations. In order to get the maximum benefit from the care plan documentation in use in the home, all parts should be fully completed. The temperature of the medication storage cupboard should be monitored and recorded to ensure that it is within recommended levels for the medication contained e.g. in respect of Lactulose 20°C The home should investigate current best practice in the provision of activities for older people in residential care settings to inform future planning and provision for residents at Hillview. The home should consider how choice for residents can be exercised and recorded and should consider the frequency and nature of routine regular consultation with residents, individually and collectively to see if it is adequate. The manager and staff should discuss what factors might limit the ability of residents to express choice freely and to take steps to address this wherever possible. Any specific dietary requirements for individual residents should be clearly recorded and available to all staff concerned with the provision and preparation of food at any time, particularly in the event of the absence of the usual catering staff. It should always be clear in staff records held who has provided the required references during the recruitment process. Staff files should include a recent photograph of the member of staff in each case. The new treatment room should be provided with a lock in order to ensure that records held in it remain confidential. DS0000019430.V265542.R01.S.doc Version 5.0 Page 20 2 3 OP7 OP9 4 OP12 5 OP33OP14 6 OP15 7 8 9 OP29 OP29 OP37 Hillview Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Hillview DS0000019430.V265542.R01.S.doc Version 5.0 Page 21 - 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. 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