Inspection on 02/05/06 for House On The Hill

This inspection was carried out on 2nd May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

House On The Hill 23/06/08

House On The Hill 03/12/07

House On The Hill 12/12/06

House On The Hill 17/01/06

House On The Hill 01/12/04

House On The Hill 12/09/04

House On The Hill 25/02/04

House On The Hill 06/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE House On The Hill 61 Rosemary Hill Road Little Aston Sutton Coldfield West Midlands B74 4HJ Lead Inspector Mrs Mandy Brassington Unannounced Inspection 2 May 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 House On The Hill DS0000005119.V293059.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 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. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service House On The Hill Address 61 Rosemary Hill Road Little Aston Sutton Coldfield West Midlands B74 4HJ 0121 353 0464 0121 3530464 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) Bonehill Limited Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13), Physical disability over 65 years of age (3) of places House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: House on the Hill is a residential home that provides a service for older people. The home is registered to provide care for three people who have a physical disability. The home is an attractive building located in a residential area within Little Aston. Two lounges provide an area for service users to relax in. Communal areas are comfortable and personalised by the service users. All the bedrooms are located on the ground floor, each one for single occupancy; six of the bedrooms have an en-suite facility. Individuals are able to furnish their rooms. Bathing facilities are located at each end of the home. There is a small laundry and storage room used for hairdressing. Located off the dining room is a wellappointed kitchen; all of the meals are prepared and served from the kitchen. Parking for visitors and staff is available at the front of the home on the gravel drive. The front entrance has steps and a ramp and there is a secure mature garden to the rear with a seating area. The demography of the local community reflects the service users living in the home. The registered provider is Bonehill Ltd who has overall responsibility for the home; the home has not had a registered manager since 2004; a new manager was appointed to the home in April 2006 and is to complete the Fit Person process for registration. A manager from within the Bonehill Ltd Company informed the Commission for Social Care Inspection on 9 May 2006 that the fee level for House on the Hill is between £420 and £470 per week. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 8 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. Prior to the inspection visit, survey information has been obtained from service users and their relatives. Four comment cards were received back from service users and three comment cards were received from relatives. Feedback has been included within this report. A tour of the home was undertaken. The inspection included an examination of records, indirect observation, discussions with six service users, the manager, and the staff on duty. Case tracking of three care plans was undertaken. Four staff records were examined and observation of daily activities took place. The inspector ate lunch with the service users and observed the staff administer medication. An Immediate requirement notice was issued on the day of the inspection for three requirements and a further thirty-one requirements and one recommendation was made as a result of this visit. Nine requirements have been carried over from the last inspection. The home is currently failing to meet the National Minimum Standards and the Care Homes Regulations. Due to the concerns identified, the home will be subject to additional monitoring visits to ensure compliance with statutory requirements. This was considered to be a poor inspection. What the service does well: Care staff provide sensitive support to service users. The service users enjoyed the company of staff and appeared relaxed in their presence. The service users commented that staff are very helpful and thoughtful. Three comment cards received from relatives praised the staff and the care provided. Service users reported that the food in the home was good and they were given a choice of meals. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home is consistently failing to address statutory requirements and to improve the service provided to meet the National Minimum Standards. Care plans and risk assessments were not satisfactory in relation to the care needs of the individual and the support required. There was no evidence of appropriate stimulation or social activities and discussions with service users confirmed that they were reliant on their friends and families to take them out. The home is to consult with service users and provide suitable activities in the home and the community, a review of staffing needs to demonstrate how the home intends to achieve this requirement. The home also needs to improve the way in which it carries out risk assessments and manages risk. Environmental risks assessments have been completed and identified areas of risk; work has not been completed to reduce the risk and therefore service users have been placed at risk. Subsequent reviews have not taken place. The Fire system’s emergency lighting does not meet the needs of the home and safe evacuation has been furthered hindered due to inappropriate locking devices on the front door. Lighting had been identified and work had not been completed in line with the risk assessment. Immediate requirements were issued to address these concerns. The home needs to ensure it has robust recruitment procedures. Not all staff have two written references, and a long-standing requirement for appropriate work permits has not been addressed. Poor recruitment practices could leave service users vulnerable and at risk. The home needs to provide staff with a comprehensive induction programme and annual training. The staff have not received training to ensure they are competent in moving and handling, health and safety and food hygiene. There is a need to develop an effective quality assurance and quality monitoring system to review the quality of care. In addition, the Provider needs to conduct monthly visits. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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 House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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, 2, 3, 5, 6. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Service users are able to visit the home with family members and have a trial visit before deciding to move to the home. EVIDENCE: The Statement of Purpose and Service User Guide had not been amended and the requirement for including additional information, as included in the National Minimum Standards and Regulations remains outstanding. These documents need to accurately reflect the service provided. Three plans of care were sampled and two did not contain a written contract and statement of terms and conditions. The contract available for inspection contained references to out of date legislation, incorrect information regarding registration of the home and had not been signed by the proprietor. There was no evidence that service users had received a copy of the Statement of Purpose and Service User guide. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 10 There had been one new admission to the home since the last inspection and discussion with the service user revealed family members had visited the home prior to admission and the individual was aware of the terms and conditions of occupancy. A manager within the company had completed an assessment of need. The home does not provide intermediate care. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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, 10. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive support and use appropriate forms of communication. Plans of care do not record how individuals needs are to be met and assessments of risk have not been reviewed. Service users are not involved in devising the plan of care or subsequent reviews. EVIDENCE: Each service user had an individual plan of care; information within the plans was limited relating to individual needs and support required and there was poor evidence of review. All service users spoken with were not aware of their plan of care and had not been included in the review process. Records confirmed there was no evidence of service user participation. The plans did record where health care from health professionals had been sought and details of any monitoring and outcomes of meetings. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 12 Risk assessments had been carried out but did not record the review frequency. Since the initial assessment, many of the plans had not been reviewed. The plans of care and assessment of risk need to be reviewed to ensure individual needs are recorded and to demonstrate how these needs are to be met. The new manager demonstrated a new care planning system that is to be implemented in the home. Daily records were maintained of important events during the shift. These records were kept in a joint folder and filed when complete. Personal information that was relevant to the plans of care were kept with the records; staff confirmed this information was not required on a daily basis and was to support the plans of care. Individual information is to be stored appropriately in line with the Data Protection Act. Observation of staff demonstrated that personal support was delivered in a sensitive manner and appropriate forms of communication were used. It was evident that staff were committed to delivering a good quality service but had not been appropriately supported in the home. Service users spoken to stated that ‘Staff have looked after me well and they’re so kind and thoughtful’, ‘I’m happy to be here’ and ‘It’s like a home away from home’. One comment card from a relative recorded ‘ All the staff are wonderful and work very hard.’ Medication is stored securely in a locked cabinet and in a medication trolley. The MDS System is used and reviewed by the Pharmacy. Controlled medication is stored appropriately and a robust record maintained. Two members of staff were observed safely administering the medication during lunchtime meal. Some staff have received training for safe administration of medication; further training has been planned. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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, 14, 15. The quality in this outcome area is ‘poor’. This judgement has been made using available evidence including a visit to this service. There was no appropriate stimulation within the home or social community activities organised. Service users are reliant on their friends and families to take them out. EVIDENCE: Discussion with staff and service users, information from service users and relatives questionnaires and observation of daily activities revealed that there are very limited activities within the home. Service users stated there have been no activities organised and they are completely reliant on family and friends for community activities and purchasing of personal items. On the day of the inspection, the Activity Board stated Bingo would be played in the afternoon. Staff stated this activity could not take place as there were no prizes and only two staff were on shift, which did not allow for this activity to take place. Two comment cards received from relatives recorded ‘there has not been enough activities’ and ‘there are not many activities’. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 14 Service users stated the home used to provide a ‘therapets’ service, weekly exercises and trips to the theatre; these activities no longer occur. It is required that service users be consulted regarding appropriate activities in the home and the community and implemented. A religious service is conducted each month through a local Methodist church. Staff and service users stated that individual’s spiritual needs were met through the current arrangements. Service users stated they are able to receive visitors throughout the day and receive visitors in private. A record of visitors was maintained. The home has a spacious dining area, where all service users ate lunch. Individuals stated they are able to eat their meal in their room. Breakfast time is flexible to enable individuals to choose the time they want to arise. A menu Board was displayed in the dining room and on the day of the inspection there was a three-course meal served; for starters, it was vegetable soup, the main meal was chicken or lamb cutlets with potatoes and vegetables, and dessert was fruit and ice cream. The meal was relaxed and choices and second helpings were offered, the staff were unobtrusive and served the meal in a professional manner. Service users spoke highly of the meals served though it was reported that condiments were often not provided. The home is to ensure service users have access to condiments that enhance the meals provided. The kitchen was inspected and found to be clean and tidy. The shopping is purchased weekly and was delivered on the day of the inspection; fresh fruit and vegetables were included in the delivery. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 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, 18 The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. The complaints procedure is still to be reviewed to enable service users and their representatives to have a full understanding of the options available to them relating to making a complaint. EVIDENCE: House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 16 The home has a complaints procedure displayed in the front hall, in each bedroom and within the Statement of Purpose. The previous inspection identified that this is to be reviewed to reflect that individuals may contact the Commission (CSCI) to make a complaint; this currently states only if a complaint cannot be resolved successfully or is of a serious nature. A book is available in the front Hall for any compliments and complaints. There had been seven complaints since the last inspection and a response to each issue had been recorded. Two complaints were discussed in depth with the manager; the sink unit in one bedroom and the lack of emergency lights in the lounge. The manager demonstrated the home had investigated many options to resolve this issue relating to the sink unit. The emergency lights had not been dealt with appropriately and an Immediate requirement notice was issued. Family members manage Service users finances. The home has a Safe for storage of valuables and a record is maintained of monies kept on behalf of an individuals. Four individuals had chosen to deposit money within the safe. A sample of two records was inspected and was accurately recorded. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 17 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, 20, 21, 24, 25, 26. The quality in this outcome area is ‘poor’. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and pleasantly decorated communal and private facilities. Environmental risk assessments have identified areas of concern and the risk has not been reduced placing service users at risk within the environment. EVIDENCE: The home is pleasantly decorated and furnished and service users are able to decorate the home with personal belongings. There were a variety of art works displayed that had been painted by one service user. All service users had a large single bedroom; six bedrooms had an en-suite facility. Bedrooms were personalised to reflect the interests and wishes of the individual. Bedroom doors have been fitted with appropriate locks with the exception of one, due to a specialist lock being required, as the door is very ornate; a House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 18 suitable lock is being investigated. Risk assessments are to be carried out concerning whether service users want and are able to have a key to their room. Bathing facilities in the older part of the home did not meet required guidelines and records demonstrated the water temperatures in these areas were too low. It is required that this is regulated to provide water to around 43 degrees. The sinks had been risk assessed and demonstrated there was a high risk and thermostatic valves were to be fitted in January. This work had not been completed. An Immediate requirement notice was issued to fit thermostatic valves to high risk areas within seven days. The laundry area had not been adapted to provide appropriate facilities. The previous inspection identified that the manager was to contact Environmental Health to inspect the premises to ensure it meets Health and Safety Guidelines. This requirement was not addressed. A risk assessment had been completed on the pond and identified there was a high risk to service users and the surrounding fence was unstable. It was recorded that the pond was to be filled in April. This work had not been completed. In March 2005 a risk assessment recorded the wardrobe in Bedroom 12 was to be secured to the wall. This work was outstanding. Environmental risk assessments were not reviewed and appropriate work to reduce the level of risk had not been taken. It is a concern to the Commission that the home does not take appropriate action to safeguard service users welfare. The Commission will monitor this. A fly screen had been fitted to the kitchen as required by Environmental Health. The kitchen window frame was rotten and the woodwork crumbles upon contact in some areas leaving open areas around the glass. The window is to be repaired to a good standard or replaced to ensure the safety of staff and service users and to meet Environmental standards for Food Preparation areas. The home is to ensure the Green house at the rear of the property is fitted with suitable safety glass and a risk assessment is to be completed. There is a large amount of garden rubbish, which has not been cleared away. This is to be removed to ensure the health and welfare of service users. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 19 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): 27, 28, 29, 30 The quality in this outcome area is ‘poor’. This judgement has been made using available evidence including a visit to this service. The staff have not received up to date training required to enable tasks to be carried out competently. The home has not had a stable management team for two years and staff have been unsupported. EVIDENCE: At the time of this inspection, there were two staff on duty and the manager. Inspection of the roster demonstrated that two staff were on duty on each day shift; 7.30 – 2.00 and 2.00 – 9.30. Each shift started ten minutes earlier to carry out a staff hand-over. The cook worked from 7.30 – 2.00 and domestic cover was provided for 5 hours on a Monday and Friday only. Observation and discussion with staff revealed care staff are expected to carry out domestic duties during the day, as domestic hours are only provided on two days; there are only two care staff on duty. The home is required to complete a review of staffing hours provided based upon support needs and lifestyle and demonstrate how individual’s needs are met under the current staffing arrangements. A copy is to be sent to the Commission. During the night one member of staff worked. Above the home is private accommodation. Each night the tenant worked as a sleep in person; the House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 20 access to the flat is in the front hall of the home. The manager reported that in the event of an emergency staff would ring the doorbell to alert the sleep-in person. The previous inspection identified that this system be reviewed as in an emergency it may not be possible for the only member of staff to go to this door; this has not been addressed. It remains a requirement that a more suitable system be provided. Inspection of four staff files revealed evidence that POVA and CRB checks were completed for all staff, there was a photograph, proof of identity and a contract. Only one staff file had two references; two had one reference and one file had no references. Robust recruitment procedures are to be followed to ensure the protection of service users; all staff are to have two suitable references prior to starting work at the home. It was not possible to inspect the Manager’s file, as it was not kept on the premises. It is required that this be available for inspection. The tenants living in the first floor accommodation still require additional documentation in relation to work permits. This information is outstanding from previous reports. The Home Office requires Polish citizens to register with the Accession State Worker Registration Scheme, which needs to record the place of work. This has not been carried out. This documentation is required and the home must ensure appropriate work permits are obtained for staff to work at the home. Discussion with staff and inspection of records revealed some staff have received training for safe administration of medication, Care of the skin and fire training. Staff have not received mandatory training for Health and Safety, Moving and Handling and staff do not have a Basic Food hygiene qualification. In addition, staff confirmed that the induction to the home involved working several shifts in a supernumerary capacity, but no formal induction was carried out, including use of moving and handling equipment within the home. The home is required to ensure that staff receive a comprehensive induction in line with TOPSS foundation training and all staff are to receive the required mandatory training. The manager reported that seven staff have obtained an NVQ II Qualification or above. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 21 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, 33, 35, 36, 38. The quality in this outcome area is ‘poor’. This judgement has been made using available evidence including a visit to this service. The home has been without a stable management team and outstanding areas of concern have not been addressed, and the home has failed to meet the National Minimum standards. Current Fire Safety equipment and means of safe evacuation do not meet required standards and work has not been completed to address the identified risk. EVIDENCE: Since the last inspection in January 2006, another new manager has been appointed. The manager is aware of the need to submit an application to House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 22 begin the Fit person’s process. It is a concern to the Commission that the home has been without a Registered manger for two years. The manager demonstrated an awareness of the need to improve standards and has begun to develop alternative care planning systems and record keeping. The manager was enthusiastic to raise standards, develop the staff team and ensure service users receive a quality service. The home does not have a quality assurance and quality monitoring system. The previous inspection recorded that quality assurance questionnaires had been developed and were to be sent out. This has not been completed and there was no evidence of any quality review. The Proprietors have not completed monthly visits to the home on an unannounced basis. Regulation 26 visits are to be conducted monthly and a copy forwarded to the Commission. The new manager has been in post for three weeks and is aware of the need for formal supervision. The home has had several managers in a short period of time and staff have not been adequately supervised. Formal supervision is to take place bi-monthly and cover all aspects of care, philosophy of care in the home and staff development needs. Service users were encouraged to look after their own financial affairs with the support of their families or representatives. There is a safe where individuals are able to deposit valuables and money. A photocopy of the home’s inspection certificate is still displayed in the front Hall. The Commission is to provide an additional certificate. The home does not have a Fire Risk Assessment. A Fire Assessment checklist was partly completed in July 2004 and has not been reviewed. The home is to carry out a thorough assessment and include the procedures and staffing required for a safe and full evacuation, and is to take into account individual’s needs. This document is to be reviewed at appropriate frequencies to reflect any changes in the home or levels of dependency. Inspection of fire records demonstrated appropriate checks area carried out on the system. There was no emergency lighting in the main lounge area. Following a recent power failure, service users were evacuated from this room, as it was hazardous to remain in the lounge with no lighting. The evacuation was carried out by use of torches. This identified a serious failing in the current fire equipment to ensure the safe evacuation of service users. The risk assessment identified that emergency lighting was to be provided. This work has not been completed. An Immediate requirement notice was issued for the home in consultation with the fire authority, to supply and fit suitable emergency lighting in the main lounge. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 23 The front door is fitted with a Chubb Lock and a key hangs by the door. This form of locking device is not to be used on fire exits. Fire doors are to enable effective evacuation of service users. An immediate Requirement notice was issued stating this practice is to cease. Consultation with the fire officer to provide alternative suitable means is recommended. There are concerns regarding the health and safety of service users and staff due to identified work not being carried out in relation to areas of risk, suitable emergency lighting not fitted, safe evacuation being hindered, and the absence of a comprehensive fire risk assessment. The home is subject to a large number of requirements and additional monitoring visits will be conducted to ensure these requirements are met and the home improves to meet the National Minimum Standards. House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 24 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 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 3 1 X X 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 1 X 1 House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4 (1)(2) 5 (1)(2) Requirement To review the home’s Statement of Purpose and Service User Guide to ensure that the details complied with Schedule 1 and 2 of the Care Homes Regulations. A copy is to be sent to the Commission. THIS REQUIREMENT IS OUTSTANDING FROM REPORTS 01/12/03, 12/09/04, 28/07/05, 17/01/06 All service users are to have a contract, with a statement of terms and conditions The home’s contract is to be reviewed in relation to changes in legislation and changes to the Commission Service users and/or their representative are to be involved with care planning and subsequent reviews and evidence is to be recorded To further develop plans of care to ensure all service users have a detailed plan and to review assessments of risk. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 Individual information relating to DS0000005119.V293059.R01.S.doc Timescale for action 02/07/06 2 3 OP2 OP2 5 (1)(b), 14 (1)(d) 24 (1)(a) 31/05/06 30/06/06 4 OP7 15 (1)(2) 02/06/06 5 OP7 15 (1) 22/06/06 6 OP7 17 (1)(b) 31/05/06 Page 26 House On The Hill Version 5.1 7 OP12 16 (2)(m) 8 OP16 22 (1) 9 OP15 16 (2)(i) 10 11 OP19 OP19 13 (4)(a) 13 (4)(c), 2 (b) 13 (4)(a)(c) 23 (2)(b) 13 (4)(c) 12 13 14 OP19 OP19 OP19 plans of care are to be stored in line with the Data Protection Act To consult with service users regarding choice of activities and provide sufficient staffing to enable community activities to take place. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 To review the complaints procedure to ensure it clearly records individuals have a right to contact the Commission to make any complaint. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 To ensure there are suitable condiments and food to provide a balanced meal in line with service users preferences To secure the wardrobe in Bedroom 12 To carry out the work identified in the risk assessment for the pond to ensure the safety of service users Garden rubbish is to be removed To repair or replace the kitchen window To risk assess the green house and to ensure all glass is toughened or covered with a protective film To fit thermostatic valves to all identified water outlets where a risk has been identified Bath temperatures are to be around 43 degrees To risk assess service users having a key to their room and record the outcome To contact environmental Health to carry out an inspection in the laundry. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 DS0000005119.V293059.R01.S.doc 02/06/06 02/06/06 02/06/06 12/05/06 30/05/06 30/06/06 30/06/06 30/06/06 15 16 17 18 OP21 OP21 OP24 OP26 13 (4) (a)(b)(c) 23 (2)(j) 13 (4)(c) 16 (2)(j) 09/05/06 12/06/06 22/06/06 30/06/06 House On The Hill Version 5.1 Page 27 19 OP27 24 (1)(2) 20 OP27 18 (1), 23 (2)(a) 21 22 OP29 OP29 17 (2) 19 (1)(b)(i) 23 24 25 OP29 OP30 OP30 19 (1)(b)(i) 18 (c)(i) 18 (c)(i) 26 27 OP31 OP33 9 (1)(2) 26 (2)(3)(4) (5) 24 (1)(2)(3) 18 (2) 28 29 OP33 OP36 30 31 OP38 OP38 13 (4)(a)(c) 28(1) To review staffing provided in relation to support needs and lifestyle, a copy of the review is to be sent to the Commission To review the on-call arrangements during the night THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 The manager’s file is to be available for inspection within the home. As Schedule 4 (6) To provide evidence of Night staff having appropriate work permits to work in the home. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 28/07/05, 17/01/06. All staff to have two references, As schedule 2 (3) Staff to receive a comprehensive induction suitable to the home All staff to receive mandatory training in Health and Safety, Moving and Handling, Food Hygiene The manager is to submit an application to begin the Fit Persons Process. Monthly visits are to be conducted by the Proprietor, these are to be unannounced and a copy forwarded to the Commission To develop a quality assurance and quality monitoring system All staff working at the home should receive at least 6 formal supervision sessions per annum. THIS REQUIREMENT IS OUTSTANDING FROM REPORT 06/08/03,17/01/06 To review environmental risk assessment at timely intervals and carry out any identified work The original registration certificate is to be displayed DS0000005119.V293059.R01.S.doc 12/06/06 30/05/06 30/05/06 30/05/06 12/06/06 02/06/06 02/07/06 20/06/06 30/06/06 30/07/06 20/06/06 20/05/06 30/06/06 House On The Hill Version 5.1 Page 28 32 33 34 OP38 OP38 OP38 23 (4)(c)(v) (e) 23 (c)(iii)(v) 23 (c)(iii)(v) within the home. (Regulation: Care Standards Act, Part II, (28)(1)). THIS REQUIREMENT IS OUTSTANDING FROM REPORT 17/01/06 To carry out a comprehensive fire risk assessment Fire doors are to be suitably locked and access not restricted by a locking device In consultation with the fire authority suitable emergency lighting is to be installed in the main lounge. 02/06/06 02/05/06 09/05/06 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 OP33 Good Practice Recommendations Service user meetings to take place bi-monthly and to be recorded House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 29 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 © 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 House On The Hill DS0000005119.V293059.R01.S.doc Version 5.1 Page 30 - 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!