Inspection on 03/12/07 for House On The Hill

This inspection was carried out on 3rd December 2007.

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 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

House On The Hill 23/06/08

House On The Hill 12/12/06

House On The Hill 02/05/06

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 Mandy Brassington Key Unannounced Inspection 3rd December 2007 10:15 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.V343915.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. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 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 F/P 0121 353 0464 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 Mrs Gerlinde Taylor 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.V343915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: House on the Hill is a residential home that provides a service for up to 13 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 people who use the service. 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 Service user Guide includes a contract with details of the fees charged. The manager confirmed to us on 3 December 2007 that the fee level for House on the Hill is between £465 and £493.50 per week. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 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 the core standards. The inspection took place over 7.5 hours by one inspector who used the National Minimum Standards for Older people as the basis for the inspection. Prior to the inspection the manager had completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. Two completed questionnaires was returned from relatives. A tour of the home was undertaken and a meal was eaten with people who use the service. On the day of the inspection, the home was accommodating eight people. The inspection included an examination of records, indirect observation, discussion and observation of people who use the service, and staff on duty. Four Plans of care were examined along with four staff records. Observation of daily events took place. Inspection of the storage system and medication procedures were inspected. Twelve requirements and two recommendations were made as a result of this visit including five immediate requirements. What the service does well: The home provides a good standard of accommodation. One lounge and the main dining area have recently been redecorated and refurbished to a good standard providing pleasant communal areas. The home is small in size and people living in the home reported that that they like the size of the home, and are able to develop close relationships with other people resident. The food is presented to people individually on a tray, and a good quality dinner service and crockery is used. People stated they enjoy drinking from cups and saucers. The main meal consists of three courses and a choice of House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 6 food was available. Meal times are a relaxed event with discreet support provided by staff, where necessary. There was a relaxed atmosphere between individuals and staff. People who use the service and their relatives spoke well of the staff team. Comments included, ‘carers here are very good’, ‘you couldn’t get better staff, and they’re very friendly’, ‘the staff are always there if you want them.’ Individuals are able to maintain contact with family and friends and able to receive visitors in private. Friends and family may join in activities and events organised for individuals and attend residents meetings. What has improved since the last inspection? What they could do better: The medication systems need to be developed to ensure that all medicines received into the home, are in accordance with the presriber’s instructions, and recorded correctly by two persons to ensure accuracy. Details of all precriber’s instructions including the dosage, time, route and name of the drug are to be recorded on the medicine and the Medication Administration Record. This will ensure people receive the right medicine, at the correct time, in an appropriate way. Where medicines need to be stored at a low temperature, the facilities must be checked daily, and kept within the required limits to ensure all medicines are safe to use. People who administer their medication need to have been suitable assessed to ensure they are safe, and understand how and when to have the medicines. Secure storage facilities need to be provided in the room. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 7 The registered person has employed two people to work in the home and live within a private residence, with access through the home, without any preemployment checks. This could place people who use the service at risk, as the people have not been assessed as being appropriate to have access to, or work with people in the home. An immediate requirement notice was issued in relation to this, and to ensure that alternative arrangements are made to ensure people are not placed at risk. Due to the poor outcomes for individuals in relation to health and personal care and staffing, the home will be subject to a Management review by the Commission for Social Care Inspection. A management review is a key part of the enforcement process whereby the Commission sets out what we will do to get the care provider to improve their service. The action the Commission will take will depend upon what effect this is having on the people using the service and how the care service provider responds. 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. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 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.V343915.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective individuals are given the opportunity to spend time in the home with family members and given information relating to the service. Admissions are not made until a needs assessment has been undertaken and new residents are provided with a Statement of Terms and Condition, and a Contract. EVIDENCE: The home has a Statement of Purpose available for all people in the home. As part of the visit a review of the Registration of the home was conducted. Discussion with the manager confirmed that the Statement of Purpose needs House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 10 to be reviewed, to reflect the service provided to people who use the service in line with the review. Each person has a Service User Guide that sets out the objectives and philosophy of the home, and includes a contract with details of the fees payable. There had been one new referral to the home since the last inspection and inspection of records revealed that a full needs assessment was completed by senior staff in the home, along with a Care Management Assessment. The initial assessment included confirmation of the information received by a representative of the person. People living in the home confirmed that they or family members were able to visit prior to deciding to move in. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service are aware that they have a care plan about the support they require and are encouraged to be involved in its review or development. The medication procedures are not robust where any changes are made and medication is not always labelled correctly from the pharmacy. This could place people at risk. EVIDENCE: Three plans of care were inspected, and the plans included personal details of the individual, including a brief description in case of an emergency admission to hospital. The plans have a residential care plan, which covers aspects of daily care and support, including mobility, vision, hearing, sleeping House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 12 arrangements, likes and dislikes, hobbies and interests, religion and a persons wishes in the event of death. The plans progress to record ‘Care delivery needs’. This plan focuses on the specific areas of support required, and includes information relating to support with bathing and frequency, and how to support a person to transfer or move. There is a risk assessment for Moving and handling. The plans have been reviewed monthly and where possible people who use the service evidence their involvement with the review and the support they continue to need. Within the Annual Quality Assurance Audit (AQAA) the manager reported that senior staff audit the plans, and any omissions are highlighted with the Key Worker; staff receive guidance to complete the plans to a good standard. Health care needs are recorded and whether a person wishes other people, including family members to be aware of any appointments and outcomes. A record of appointments and contact with Health care professionals including chiropodist, optician, continence advisor and dentist was recorded. All people are registered with a local General Practitioner. One person requires their blood pressure monitoring on the advice of the GP. A friend brings in personal equipment and takes the blood pressure, which is recorded. This practice was discussed with the manager as the equipment used must be suitable, and people using the equipment must be assessed as having the necessary skills. Where a medical practitioner has advised monitoring, the registered person needs to ensure trained staff with suitable equipment complete this. One person administered their medication. The plan of care included a checklist for taking medication, including whether there was a secure place to store the medication. The checklist recorded this facility was not available. The list did not include an assessment of risk to ensure the person could safely administer medication. The Medication Administration Record did not record how many tablets were given to the person, in order that an audit could be maintained to ensure the tablets were taken. A month’s supply was given to the person. Where people wish to continue to administer their medication, suitable storage procedures must be provided. An assessment of risk is to be conducted to ensure the person’s safety and suitable procedures for recording medicines, and agreed monitoring systems to ensure medicines continue to be taken. The Monitored Dosage system (MDS) is used and medication is administered from Blister packs. Medication was stored securely in a medicines trolley. Examination of Medication Administration Records (MAR) identified that where there had been a change in medication during the month, the MAR sheets were House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 13 completed by staff. All entries on a MAR sheet must be recorded by two people and signed to evidence this to ensure accuracy. Where changes have been authorised by a general practitioner, this needs to be evidenced and two people involved to ensure accuracy. A number of medicines and MAR Sheets were recorded ‘As directed’. All medicines and MAR sheets are to record the name of the person, the name of the drug, the strength of the drug, times of administration and route, to ensure medication is administered in line with the Prescriber’s instructions. The home has a separate medication fridge in a locked room. A small amount of medication was stored. The medication recorded that it was to be stored between 2 and 8 degrees. The staff recorded a daily minimum and maximum temperature, the average recording were between –1 degree and 1 degree. Medicines must be stored in line with manufacturers instructions. Suitable checks need to be made to ensure the integrity of the medicines currently stored. Where the integrity has been compromised, medicines are to be disposed of and new medicines obtained. An Immediate requirement notice was issued in relation to the current Medication practices. The home must review the current systems and practices to ensure the health and welfare of people who use the service. The manager reported within the AQAA that anew Policy and procedure for all aspects of medication had been produced; it is recommended that this be reviewed to demonstrate safe practices. Discussion with people who used the service confirmed that staff address personal needs sensitively and ensure people’s dignity. From observation, staff were relaxed and approached people calmly, talking at a pace to suit the individual and providing discreet support where required. All people were well presented and dressed in a style of their choosing. From observation, it was evident, that staff have ensured that individuals are able to receive support to address personal care issues and personal hygiene. One person commented, ‘the staff always make sure you look your best, they can’t do enough for you.’ House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 14 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, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. Individuals are involved in some daytime activities of their own choice, according to their interests and capability. EVIDENCE: The home has an Activity Plan, which is displayed in the Hallway. On the day of the inspection Board games were planned. People who used the service knew the planned activity for the day, stating usually a large snakes and ladders and Ludo Board was used. During the week of the inspection, other planned activities included knitting, manicures, keep Fit and a Christmas Pantomime in the home, to which friends and family had also been invited. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 15 Discussion with people who used the service revealed that activities were generally well attended. One person commented, ‘I like to play Bingo, we play for prizes. We often talk about old times, they’ve got a box with old things in, and we’ve got our photos.’ People who use the service reported a representative a local Methodist Church visits the home monthly to conduct a service and individuals are able to receive Holy Communion. Staff stated this service reflects the religious observance of people in the home. Discussion with people who use the service confirmed there were no restrictions on visiting from family and friends, individuals are also able to stay away from the home with family members. During the inspection, family and friends were observed coming to the home to visit. The design of the home provides seating within the communal areas of the home where individuals can entertain their visitors, in addition to the privacy of their own room. At lunchtime, people who use the service were able to choose to eat in the main dining area or in their room. The main meal is served at lunchtime, and on the day of the inspection, the meal prepared was tomato soup to start, a choice of paella or chicken in a white wine sauce with potatoes and vegetables, and orange sponge and custard for dessert. Discussion with staff revealed that the home is able to cater for individual’s cultural needs and personal preferences. Meals are served individually to people and pattern tableware and glasses are used. People are given a choice of hot or cold drinks, and a choice of cup and saucer. One person stated, ‘there’s nothing like having a cup of tea after a meal in a nice cup and saucer’. People are encouraged to take responsibility for their own financial affairs and to keep and use their money as they wish. The manager confirmed that the bedrooms do not have a lockable facility for people to keep personal items and money secure. It is recommended that this be available for people to ensure their property is secure. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 16 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, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a suitable complaints procedure and an open culture that allows residents to express their views, and concerns. Recording of complaints means that information has not been stored confidentially. Staff are aware of the procedures for Safeguarding Adults and how to respond to an alert. EVIDENCE: The home has an open culture in relation to receiving complaints, and discussion with people who use the service stated they would feel confident raising a concern. Inspection of the complaints book demonstrated that family members regularly record any concern or complaint, and from survey information, people felt confident that it would be addressed. The complaints book was discussed with the manager, as each entry had a written response from the manager. Information included in the response related to action taken against staff, and some concerns and responses referred to personal information about people who used the service. The manager stated that the current complaints book would be reviewed to ensure House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 17 that personal information and outcomes of complaints would be treated confidentially. The manager has produced an accessible Complaints Procedure, which is clearly displayed in the hallway. Staff reported that individuals are able to use an advocacy service. Records demonstrate that some of the staff have received training in Safeguarding Adults. From discussion with staff individuals were clear on how to recognise signs of abuse and would report any suspicion. Staff confirmed a copy of the Safeguarding Procedure was available in the home. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 18 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, 20, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable clean and warm, and has different communal areas for individuals to choose from. People are able to personalise their rooms according to their interests. Suitable laundry facilities are not in place, which has resulted in poor infection control standards. EVIDENCE: 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 people who use the service. Since House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 19 the last inspection the dining room has been redecorated and new furniture provided to create a pleasant room with many period features in place. The former green lounge has been redecorated and new furniture purchased, and renamed the Gold Lounge. People who use the service commented that the home’s appearance has improved and the lounge is now a pleasant place to be. 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. Located off the dining room is a well-appointed 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 laundry facilities were not working and an external service was completing the laundering of clothes and linen. The laundry was collected after three bags were full. The laundry room contained three black bags of dirty laundry that was not fully sealed, along with an open laundry basket of dirty linen. A face cloth, which staff reported was stained by faeces, was in soak in a bowl. Staff confirmed that people are incontinent in the home, and this linen would be sent to the external service; this was being hand sluiced prior to being sent for laundering. The supply of linen and towels was very low and face cloths being used were towels that had been torn to use during this period. It is required that suitable laundry facilities are provided at the home to ensure individual’s clothes and linen are washed to a good standard. Where individuals are incontinent sluicing facilities are to be provided to ensure suitable arrangements are in place for maintaining satisfactory standards of hygiene in the care home. Sufficient linen and towels are to be provided to ensure that there is adequate equipment available for people and that hygiene standards are maintained. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 20 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, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use service have confidence in the staff that care for them, and there are sufficient numbers of staff available to work in the home. The home has not carried out suitable pre-employment checks for all staff working in the home, which could place people at risk. EVIDENCE: On the day of inspection, there were eight people receiving a service in the home. Inspection of the staff rosters and discussion with the manager revealed the home has three shifts over a twenty four hour period, and on the day of the inspection there was: The manger who was supernumerary and working 8.00am – 4.00pm 1 senior care worker on duty from 7.30am – 2.00pm 1 care assistant on duty from 7.30am – 2.00pm 1 domestic staff working 8.15am - 12.15pm 1 cook working 7.30 am – 2.30pm House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 21 In the afternoon there was: 1 senior care worker from 2.00pm – 9.30pm 1 care assistant from 2.00pm – 9.30pm During the night there was one waking night staff working 9.30pm - 7.30am. The private first floor apartment has access gained from inside the home. There is currently a family residing in the private residence. One person is providing a sleep in cover during the night, and one person is working in the home providing domestic cover. Discussion with the manager confirmed that no pre-employment information in relation to the people was obtained prior to moving into the home and starting employment. The manager confirmed that a check for the Protection of Vulnerable Adults (PoVA first) had not been completed, along with a Criminal Bureau Records check, there were no references, proof of identity, an application had not been completed and there had been no induction into the home. An immediate requirement notice was issued to address this as the registered person must have robust recruitment procedures, to ensure that all persons working with, or who have access to people who use the service, have completed all pre-employment checks to ensure the safety and welfare of people living in the home. This is a serious concern to the Commission as this has been discussed with the registered person in relation to the previous occupants of the flat. This information will be considered as part of a management review conducted by the home. A management review is a key part of the enforcement process whereby the Commission sets out what we will do to get the care provider to improve their service. Inspection of three additional staff files revealed that documentation in relation to recruitment was available including references, proof of identity and a Criminal Records Bureau Check. Discussion with the manager and staff, and records demonstrated that people have attended training for infection control, Mental Capacity Act, Emergency Life Support, Fire Safety, medication, moving and handling, and Food Hygiene. It was identified that the two night staff have not completed training for moving and handling. This is required. There was a relaxed atmosphere between individuals and staff. Staff were observed providing sensitive care and using appropriate communication. Discussion with staff and comments received from people who use the service and relatives clearly revealed that staff are committed to providing a good House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 22 service and staff had developed good relationships individuals. Comments received included, ‘carers here are very good’, ‘you couldn’t get better staff, and they’re very friendly’, ‘the staff are always there if you want them.’ Comments from survey information, discussion with relatives on the day of the inspection and from telephone conversations prior to the inspection confirmed they were satisfied with the care provided by the staff, and reported, ‘Staff always advise me of anything important,’ I can always approach the staff and the manager.’ House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 23 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, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the Home and is aware of the work required to meet the National Minimum Standards. EVIDENCE: House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 24 From observation and discussion with the manager, revealed she is committed to developing the home and providing a good service. The manager is open and transparent in all areas of managing the home, and notifications of incidents in the home relating to people who use the service, and staff are sent promptly to the Commission. Prior to the Inspection the Registered manager completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. The AQAA was completed to a good standard and related to the National Minimum Standards for each outcome area. Evidence within the AQAA was sampled and found to be accurate. The registered manager recorded that all maintenance work, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. The manager reported that the home is developing partnership with families of people who use the service and relatives are invited to meetings in the home; a copy of the last meeting was available in the reception area. An annual quality review is conducted on an annual basis and the outcome of the previous report was sent to us. The manager reported she is currently preparing to implement the next review. Comments are sought from people who use the service, family, friends and professionals. House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 25 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4 (1)(2) Requirement To review the Statement of Purpose to reflect the registration review to ensure the guide reflects the service provided including who the home is able to accommodate Where a person is identified as requiring monitoring of blood pressure, this needs to be carried out using suitable equipment by a competent trained person and recorded to ensure accuracy Timescale for action 03/02/08 2 OP8 12 (1)(a) 17/12/07 3 OP9 13 (2) Where a person is responsible 04/12/07 for self-medication a risk assessment is to be completed to ensure the person’s safety. Where a person is responsible for their medication, suitable secure facilities need to be available to ensure the medication is kept safely All entries on a Medication Administration Record (MAR) Sheet must be entered by two DS0000005119.V343915.R01.S.doc 4 OP9 13 (2) 06/12/07 5 OP9 13 (2) 04/12/07 House On The Hill Version 5.2 Page 27 members of staff, and signed to ensure accuracy. 6 OP9 13 (2) A record of the maximum and 04/12/07 minimum temperature of the medication fridge is to be recorded daily and changes made to ensure medicines are stored at the correct temperature. Suitable checks must be carried out to ensure the integrity of the medicines stored has not been compromised. All medicines must be labelled with the person’s name, name of drug, dosage, route and time to ensure medicines are administered in line with the prescriber’s instructions. To review recording of complaints and outcomes to ensure all information is kept securely and confidentially Suitable laundry facilities are to be provided to ensure people’s clothes and linen are washed to a good standard and meet Infection Control Standards. 04/12/07 7 OP9 13 (2) 8 OP16 22 03/01/08 9 OP26 16 (2)(e) 10/12/07 10 OP26 23 (2)(k) Where it is identified as required, 10/12/07 suitable sluicing facilities are to be provided in the home. All people working in the home, or having access to the home must have suitable preemployment checks carried out to ensure the safety of people using the service. Where people have been identified as receiving support with moving suitable training is to be provided to ensure the DS0000005119.V343915.R01.S.doc 11 OP29 19 (1)(2)(3 (4) 04/12/07 12 OP30 13 (5) 03/02/08 House On The Hill Version 5.2 Page 28 health and welfare of people and staff. 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 2 Refer to Standard OP9 OP24 Good Practice Recommendations To review the medication Policy and procedure to reflect reviewed practice To provide lockable facilities for people to store valuables House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 House On The Hill DS0000005119.V343915.R01.S.doc Version 5.2 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!