CARE HOMES FOR OLDER PEOPLE
Sloe Hill Residential Care Home Limited Mill Lane St Ippollitts Nr Hitchin Hertfordshire SG4 7NN Lead Inspector
Mrs Sheila Knopp Unannounced Inspection 26th October 2005 14:30 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 Sloe Hill Residential Care Home Limited DS0000037036.V260996.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. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sloe Hill Residential Care Home Limited Address Mill Lane St Ippollitts Nr Hitchin Hertfordshire SG4 7NN 01462 459978 01462 437497 sloehill@hotmail.com www.sloehill@hotmail.com Lazyday Investments Limited 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) Violet Jane Endersby Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability over 65 years of age of places (28) Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Bedroom 10 on the ground floor measures less than 9.3 square metres. When the resident accommodated at the date of registration vacates this bedroom it must not be subsequently re-occupied. The maximum number of residents to be accommodated in the home will then reduce from 28 to 27. The NCSC Hertfordshire Area Office must be notified when this bedroom becomes vacant. Bedroom 11, which measures less than 9.3 square metres, must not be used to accommodate any resident after the date of registration. All bedrooms will be occupied by one person apart from bedrooms 2 (23.9 square metres), 4 (19.3 square metres) and 6 (18.8 square metres), which may be shared by a maximum of two persons. These bedrooms may only be shared by residents who have made a positive choice and mutual agreement to do so and this must be recorded. Bedrooms 6 and 7 on the first floor, which are accessible via some steps, may only be used to accommodate ambulant residents. Non-ambulant residents must not be accommodated in these rooms unless ramps have been provided to make them accessible to nonambulant residents. The home must have three assisted bathrooms. To achieve this, one of the two existing bathrooms must be upgrated and one additional assisted bathroom installed by 1st June 2003. 5 July 2005 & follow up visit 19 July 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service:
Sloe Hill is an independently run home owned by Lazydays Investments Ltd. The home transferred ownership to the current proprietors in 2002. It is situated down a narrow lane about mile from Hitchin town centre. It is a large attractive Edwardian house set in two acres of grounds overlooking a rural setting of villages, farms and fields. The home has been extensively converted and an annexe has been added. The annexe blends in with the existing premises. The home is registered to provide personal care to 28 elderly persons. It has a total of 25 bedrooms, 3 of which may be shared by 2 people. Accommodation is on 2 floors served by a passenger lift. There is no level access from the lift to two rooms on the first floor. The ground floor comprises an entrance lobby, lounge, lounge/diner, conservatory, dining room, main kitchen, kitchenette, laundry, 19 bedrooms, 1 assisted bathroom and 4 WC’s. The first floor comprises of 6 bedrooms, 1 non-assisted bathroom and a WC. 14 bedrooms are ensuite with a toilet and a wash-hand basin. There is parking around the front of the home. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second of two planned inspections for the year April 2005 – March 2006. An additional visit was carried out on 19 July 2005 to confirm that the hot water temperatures had been reduced to safe levels. This report needs to be read in conjunction with the report dated 5 July 2005 as the majority of standards were assessed on that occasion. The focus of this inspection was to follow up requirements made as a result of the previous inspection and to look at staff training, quality assurance and health and safety standards. This report reflects what was seen on the day of inspection. The inspector spoke with 13 relatives individually and as part of groups, 1 visitor and 3 staff. Risk assessments fire safety records, servicing records and training records were checked. A total of 5 hours 25 minutes has been allocated to this inspection. What the service does well:
Residents describe Sloe Hill as their home and there is a very real sense that their day to day experiences confirm that their decision to move in was a positive one. One person said ‘I couldn’t have chosen better’. Another person said ‘it’s like home’. A resident said their ‘visitors feel free to come and go and treat it like home’. Sloe Hill has a quiet country feel with beautiful gardens which are enjoyed by the residents. There is a lively good humoured atmosphere with residents interacting well with each other and continuing to follow interest and hobbies. The residents expressed a high level of satisfaction with the support and care provided by staff. A resident said ‘the girls (staff) are very good I couldn’t choose between them’. Another person described the staff as being ‘very friendly’. The staff spend time talking with the residents and have a good understanding of their needs. The residents felt that the programme of social activities offered a good balance and did not want to make any changes. They appreciate being able to buy things off the well stocked trolley shop and enjoy the choice of meals served. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sloe Hill Residential Care Home Limited DS0000037036.V260996.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 Sloe Hill Residential Care Home Limited DS0000037036.V260996.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): Not inspected. Refer to inspection report dated 5 July 2005. EVIDENCE: The conditions of registration were reviewed and a further update on the progress to provide an additional bathroom has been requested. Sloe Hill Residential Care Home Limited DS0000037036.V260996.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): Not inspected. Refer to inspection report dated 5 July 2005. EVIDENCE: Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 10 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): Not inspected. Refer to inspection report dated 5 July 2005. EVIDENCE: Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 11 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): Not inspected. Refer to inspection report dated 5 July 2005. EVIDENCE: Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 12 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): Not inspected. Refer to inspection report dated 5 July 2005. EVIDENCE: With reference to requirements made following the last inspection thermostatic valves have been fitted to the hot water bath taps to reduce the risk of accidental scalding. These were found to be in working order on the day of inspection. A carpet in an identified room has been replaced. Doors which are required to be locked to prevent accidents to residents were locked on this occasion. Hand towel dispensers have been provided in the required areas to reduce the risk of cross infection. Risk assessments have been carried out in relation to ensuring residents are not placed at risk where radiators are not covered or do not have thermostatic controls. It has previously been recommended that a programme to provide low surface temperature radiators / radiator covers and thermostatic valves where these are needed is put in place. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 13 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): 30 Residents are supported by well trained staff who receive regular updating to enable them to carry out their jobs safely and effectively. EVIDENCE: The manager has an annual training programme in place and a system for checking staff have received the required statutory training. There is an induction programme in place for new staff. The staff interviews and records confirmed that staff had received regular updates in their statutory training. Staff are involved in National Vocational training (NVQ) at level 2 & 3. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 14 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): 33 & 38 The manager has introduced a quality assurance system which monitors standards in the home and seeks the views of residents, relatives and other health & social care professionals. This now needs to be developed to produce an annual report and feedback to those involved with the home including the Commission. There are a number of outstanding health & safety checks that need to be addressed to ensure that the premises are maintained in line with the relevant legislation. The manager has confirmed she has completed the Registered Managers Award. EVIDENCE: Details of the quality assurance monitoring being carried out were reviewed by the inspector.
Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 15 The system in use enables the manager to seek the views of residents, relatives and health & social care professionals involved with the home. This system is in its first year and the manager intends to involve staff more widely in assessing standards through out the home and produce a report and feedback to residents, relatives and stakeholders on completion of the assessment cycle in line with Regulation 24(2). Following checks on service and maintenance records it was identified that an annual gas safety certificate and legionella test certificate are required. The issue of a 5 yearly electrical safety certificate remains outstanding from the last inspection and work required to sand the bottom of automatic fire doors to enable them to shut effectively remains outstanding from a visit by the contractors. The manager reported quotes had been obtained in October 2004 but the work had not been carried out. A recent fire safety service (22.10.05) identified an additional alarm sounder was required in one area. Weekly fire alarm checks are recorded by staff. Following a review of the risk assessments it was recommended that: 1. The risk assessment required under The Fire precautions (Workplace) regulations 1997 (as amended) is reviewed as it did not detail all the required areas. The manager was advised that the Hertfordshire Fire Safety service web site contains the required information. 2. The risk assessment for checking the safety of the hoists also included details of checks on the hoist slings. 3. The risk assessment to prevent accidental falls from windows was updated to include regular checks that the window restrictors remained in place and were in working order. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 1 Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? 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 OP25 Regulation 13(4)(a) (c) Requirement Confirm action and timescales to provide low surface temperature radiator covers and thermostatic valves where these are not currently provided. Update CSCI on progress to achieve local authority building control approval to provide an additional bathroom and anticipated timescales for completion. *(a)&(c) Provide a copy of the annual gas safety check. *(a)&(c) Provide a copy of the Legionella test certificate *(a)&(c) Provide a copy of the electrical safety test certificate. Outstanding requirement brought forward from 7.2.05 Confirm work to ensure automatic doors close efficiently and an additional sounder has been provided as detailed in the contractors service report has been completed. Provide copy of updated risk
DS0000037036.V260996.R01.S.doc Timescale for action 31/12/05 2 OP1 17(4)(c) 23(2)(j) 31/12/05 3 4 5 OP38 OP38 OP38 13(4)* 23(2)(c) 13(4)* 23(2)(c) 13(4)* 23(2)(c) 31/12/05 31/12/05 31/12/05 6 OP38 23(4)(c) (iv)(v) 31/12/05 7 OP38 23(4)(c) 31/12/05
Page 18 Sloe Hill Residential Care Home Limited Version 5.0 (iv)(v) assessment required under The Fire Precautions (Workplace) regulations 1997 (as amended). 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 3 4 Refer to Standard OP33 OP38 OP38 OP31 Good Practice Recommendations Aim to provide residents stakeholders and CSCI with a report on the outcome of the quality reviews and surveys carried out by 30.4.06 Update hoist risk assessment to include checks on the hoist slings. Update falls from window risk assessment to include regular checks that window restrictors are in place and working. The manager should provide a copy of the completed RMA certificate. Sloe Hill Residential Care Home Limited DS0000037036.V260996.R01.S.doc Version 5.0 Page 19 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
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