Inspection on 07/02/05 for Sloe Hill Residential Care Home Limited

Care Home For Older PeopleSloe Hill Residential Care Home LimitedMill Lane St Ippollitts Nr Hitchin Hertfordshire SG4 7NNAnnounced Inspection7th February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Sloe Hill Residential Care Home Limited Address Mill Lane, St Ippollitts, Nr Hitchin, Hertfordshire, SG4 7NN Email address Name of registered provider(s)/company (if applicable) Lazyday Investments Limited Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 28 Tel No: 01462 459978 Fax No: 01462 437497Category(ies) of registration, with (number of places) Old age, not falling within any other category (28), Physical disability over 65 years of age (28) Registration number I020000323 Date first registered Date of latest registration certificate 29th August 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 2nd September 2002 YES YES 22/04/04 If Yes refer to Part CSloe Hill Residential Care Home LimitedPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 37th February 2005 10:00 am Pat HouseID CodeName of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone present Ms Violet Endersby, Manager.Sloe Hill Residential Care Home LimitedPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementSloe Hill Residential Care Home LimitedPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Sloe Hill Residential Care Home Limited. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Sloe Hill Residential Care Home LimitedPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Sloe Hill is an independently run home owned by Lazydays Investments Ltd. 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. The ground floor comprises an entrance lobby, lounge, lounge/diner, conservatory, dining room, main kitchen, kitchenette, laundry, 19 bedrooms, 1 assisted bathroom and 4 WCs. The first floor comprises of 6 bedrooms, 1 non-assisted bathroom and a WC. 14 bedrooms are en-suite with a toilet and a hand-wash basin. There is parking around the front of the home. The home transferred ownership to the current proprietors in 2002.Sloe Hill Residential Care Home LimitedPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Sloe Hill Residential Care Home LimitedPage 6 The manager and staff at the home have clearly worked very hard and have implemented almost all of the required actions listed in the last report. All the policies and procedures are now in place, and care plans have been updated and are working documents. Service users were very happy with the running of the home and felt there were much improved levels of activities provided now. Comment cards received by the CSCI from service users and families were all positive. Visitors and a district nurse spoken to during the inspection praised the care provided. Choice of Home: Standards 1 ­ 6 5 of these 6 standards were met. One standard does not apply to this home. The Manager and staff have updated all the service users records and plans, and the Statement of Purpose and Service Users Guide now meet the requirements of the standard and are now offered in large print or on audio tape if necessary. Staff demonstrated they were fully aware of and able to meet the needs of the current service users and handled the necessary move of a service user with dementia in a sympathetic way during the inspection. Health & Personal Care: Standards 7 ­ 11 3 of these 5 standards were met. One standard was fully assessed and met at the last inspection and was not checked on this occasion. Care plans had been thoroughly updated and contained relevant information and risk assessments. Service users confirmed that their health needs were being met and praised the care staff for their encouragement. There were no service users with pressure sores at the time of the inspection and a visiting district nurse praised the care given by care staff in the home. Generally the system for administrating medication was sound, but two small errors were found. The homes policy needs some amendments to ensure all areas are covered. Daily Life and Social Activities: Standards 12 ­ 15 3 of these 4 standards were met. One standard was fully assessed and met at the last inspection and was not checked on this occasion. Service users told the inspectors that activities had really increased since the last inspection and they were very happy with the events. The food was also praised by all those spoken to. The Manager has introduced Age Concern to the home and information about advocacy services is being explained to service users and their families. Complaints and Protection: Standards 16 ­ 18 All of these 3 standards were met. The Manager has now amended the homes complaints policy as required at the last inspection and has produced a policy on service users finances. All service users have now been offered lockable space in their bedrooms. Environment: Standards 19-26 2 of these 8 standards were met. 4 were fully assessed and met at the previous inspection and were not assessed on this occasion. A maintenance programme of redecoration has already started at the home and this will be on-going. The requirement that another assisted bathroom be provided is still outstanding, but plans are now with the Local Authority. A requirement has been made that all radiators and exposed pipe work in the home are risk assessed to ensure service user safety.Staffing: Standards 27 ­ 30 3 of these 4 standards were met. One Standard was fully assessed and met at the last Sloe Hill Residential Care Home Limited Page 7 inspection and was not checked on this occasion. The Manager has clearly worked very hard and staff have received all appropriate training, with more booked for the coming year. Six care staff are doing NVQ training at present and recruitment procedures now meet the requirements of this standard. Management & Administration: standards 31 ­ 38 6 of these 8 standards were met. One standard was fully assessed and met at the last inspection and was not checked on this occasion. Staff confirmed their confidence in the Manager and were aware of the amount of work the Manager has undertaken to produce and update all the required policies. A Quality Assurance system has now been set up and all other procedures were in order. A requirement is on ­going that a certificate must be produced to confirm that electrical work has been completed at the home.Sloe Hill Residential Care Home LimitedPage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action N/A Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard N/ASloe Hill Residential Care Home LimitedPage 9 CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Bedroom 11 which measures less than 9.3 square metres must not be used to accommodate any resident after the date of registration. Bedroom 10 on the ground floor measures less than 9.3 square metres. When the service user accommodated at the date of registration vacates this bedroom it must not be reoccupied. The maximum number of service users to be accommodated in the home will then be reduced from 28 to 27. The Hertfordshire Area Office must be notified when this room becomes vacant. All bedrooms will be occupied by one person apart from bedrooms 2 (23.9 sq metres), 4 (19.3 sq metres) and 6 (18.8 sq metres), which may be shared by a maximum of 2 persons. These bedrooms may only be shared by service user who have made a positive choice and mutual agreement to do so. This must be recorded. Bedrooms 6 and 7 on the first floor, which are only accessible via some steps, may only be used to accommodate ambulant residents. Nonambulant residents must not be accommodated in these bedrooms unless ramps have been fitted to make them accessible to non-ambulant residents. One additional assisted bathroom must be installed by 1st June 2003Met (Yes / No) YESYESYESYESNOSloe Hill Residential Care Home LimitedPage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Registered Provider must ensure that an additional assisted bathroom is installed at the home (this was a condition of registration) THIS REQUIREMENT HAS BEEN CARRIED FORWARD FROM PREVIOUS INSPECTION REPORTS The Registered Provider must provide the CSCI with a copy of the certificate confirming that electrical repair work has been completed. The Registered Provider must ensure a safe and accurate system for administering medication is maintained and must amend the medication policy to include nonprescribed and covert medication administration. The Registered Provider must complete risk assessments for all uncovered radiators and pipes in the home, to ensure service user safety The Registered Provider must ensure that copies of reports from the monthly unannounced visits to the home from the proprietors are sent to the CSCI 1st September 2005.123(2)(j)OP21213(4)(a)OP381st April 2005313(2)OP97th February and henceforth413(4)(a)OP251st April 2005526 (5)OP381st April 2005Sloe Hill Residential Care Home LimitedPage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * There were none. * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Sloe Hill Residential Care Home LimitedPage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NO YES YES YES NO YES YES YES YES YES YES NO YES 8 2 0 YES YES YES NO 18 0 7/02/05 10.00 6.30Sloe Hill Residential Care Home LimitedPage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Sloe Hill Residential Care Home LimitedPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 385 To (£) 550Any charges for extras If yes, please state what the extras are:YESHAIRDRESSING; CHIROPODY; NEWSPAPERS 3 Key findings/Evidence Standard met? Since the last inspection, the Manager has updated the Statement of Purpose, and Service Users Guide and these now give thorough and detailed summaries of the homes ethos and facilities. Details of actual room sizes are being inserted at the back of the Statement and information as to where the last CSCI inspection report can be seen are being added to the Guide. With these additions, all the elements required by this standard are met. The home also has these documents available in large print and on audio tape. Copies of these documents are available in the entrance hall and the Manager said they are also placed in the bedrooms of all new service users.Sloe Hill Residential Care Home LimitedPage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? All service users receive written contracts and signed copies are kept on file. The contracts include details of the actual room the service user will occupy.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? Service user records checked during the inspection, contained appropriate pre-admission assessments, individual care plans and risk assessments. The manager said that all staff have been involved in updating these records and the care plans contained all the elements required by this standard. Funeral wishes were in place on most records. Care plans and reviews were signed by service users or families. Inventories of possessions were seen, but staff were advised to have these signed by service users or families when completed. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Extensive staff training has been provided since the last inspection and there is a dedicated training room on site. Staff have received dementia training, although the home does not have registration to meet the needs of those with this diagnosis. On the day of the inspection one service user moved to another home which had dementia registration. Currently there are no service users in the home with special cultural needs. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The home does not have a written policy on admissions, but staff confirmed that all prospective service users are invited to visit Sloe Hill prior to admission. The Manager said there was a four week trial period for all new service users and that unplanned admissions were avoided. The Manager also said that prospective service users would be visited in their own homes if this was practical. Emergency admissions are not accepted at the home and this is made clear in the Statement of Purpose.Sloe Hill Residential Care Home LimitedPage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This service is not offered at the home.Sloe Hill Residential Care Home LimitedPage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Care plans were tracked during the inspection and contained all the required information to meet this standard and reflected the current situation of the service users. The plans and monthly reviews were signed by service users or relatives where appropriate and risk assessments were in place. One or two files did not contain a service users photograph, but staff said there were plans to take these photographs.Sloe Hill Residential Care Home LimitedPage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 10 03 Key findings/Evidence Standard met? During the day the inspector spoke to a district nurse who visits the home regularly. The nurse was complimentary about the care provided in the home and said staff always involved the health services at appropriate times. Service users confirmed they had seen the optician, the dentist and the chiropodist during the year,and that staff encouraged them to do as much personal care for themselves as they could, (but always assisted when required). Staff recently had training from the continence advisor and said they work closely with the district nurses. District nurses complete records for service users with pressure sores, but staff are aware of equipment necessary for skin care promotion and consult with the nurses to order this equipment. One service user had recently been referred for assessment from health professionals and was moving to other residential accommodation as a result. Service users are weighed monthly and records were seen during the inspection. Service users are able to register with any G.P. they choose. Staff said they encourage appropriate exercise and there are weekly movement to music activities in the home. One service user said she regularly walks around the outside of the home, using her zimmer and said that staff encouragement had enabled her to walk again after being quite immobile. There are a selection of leaflets in the reception area about benefits and NHS services, for the information of service users and families. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? A new written policy on the administration of medication was implemented in January. Only named senior staff, who have received training, administer medication in the home. Training for all staff has been planned. A pharmacist provides audits at the home every three months. Although no non-prescribed medication is currently administered, the homes written policy needs to clarify procedures for homely medication and also needs a statement covering the covert administration of medication. Staff said that service users sometimes kept and applied their own prescribed creams and that these were always kept in locked drawers in service users bedrooms. In such cases, service users sign the medication sheets and have risk assessments completed to ensure the procedure is safe. Generally the systems for administration were sound, but two errors were found when spot checks were made and tablets counted during the inspection.Sloe Hill Residential Care Home LimitedPage 19 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Staff said there had been three deaths in the home and one in hospital in the past year. Staff felt that service users and their families would always be given all possible care and comfort at such times and that all stated wishes would be followed. Staff said they were aware of the homes policies on death and dying.Sloe Hill Residential Care Home LimitedPage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service users who spoke to the inspector, all praised the improved levels of activities now offered in the home. Staff are all involved in providing activities, but there is one senior carer who co-ordinates the events. A new shop has been set up and small items can be purchased each week. Service users said they enjoyed film afternoons, flower arranging, talks, entertainment and outings. Newspapers are delivered each day and there are posters and notices around the home advertising the events. The home has a cat which service users enjoy seeing and one lady has a bird feeder hung outside her bedroom window which she maintains. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? None of the staff in the home are appointees for service users and most service users have families who handle their financial affairs. Service users confirmed they could bring some of their own furniture into the home and inventories of items were seen on files. None of the service users have advocates at present, but Age Concern are holding meetings about this service in the home. There are leaflets with information in the entrance hall.Sloe Hill Residential Care Home LimitedPage 21 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users spoken to all praised the food served in the home, said they had a choice of meals and made their choices each morning with staff. The mid-day meal was observed, was beautifully presented and was hot and nutritious. Service users said they could have drinks or snacks when they wanted and that there were always jugs of drinks in their rooms. The cook said there were no special cultural diets needed at present, but that she prepared low sugar meals for diabetics. The cook also said she had a generous budget allowed for food purchase and used only fresh vegetables and produce. There is a four-weekly menu cycle in operation and menus were provided for the inspector. All staff who prepare food have had up to date training in food hygiene. The Manager is currently planning the best way to display the daily menu for service users.Sloe Hill Residential Care Home LimitedPage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? The homes complaints policy and information in the Statement of Purpose have been amended. These meet the requirements of this standard and include time scales for responses as well as details of the CSCI. The home has a complaints book, but there have been no complaints received since the last inspection. Service users told the inspector that they had been told they must tell staff if they were concerned about anything. Those spoken to said they would feel comfortable making a complaint if that situation ever arose.Sloe Hill Residential Care Home LimitedPage 23 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Service users who had been resident in the home for some time, said they had been registered for a postal vote in elections. Advocacy services are being introduced in the home, as already described.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The home has policies in place to deal with Adult Protection and staff were aware of these and the Whistle Blowing policy. There is a new policy in place regarding service users money and procedures meet the requirements of this standard. The Manager said that service users had been asked if they wanted lockable space in their rooms and some had requested this while some did not want it. Lockable space has been provided where requested and where there was self-medication. Several of the service users spoken to confirmed they had been asked, but said they had refused the offer of lockable space. The Manager said that when a room became vacant, lockable space would be installed prior to a new service user entering the home.Sloe Hill Residential Care Home LimitedPage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? On the day of the inspection, the home was clean, bright and odour-free. Service users told the inspector that the home was always kept very clean. Two bedrooms had been decorated since the last inspection and two had new carpets. A toilet had been redecorated and tiled, and flooring had been replaced in one en-suite. The entrance, hallway and corridors had also been decorated. All windows now have restrictors fitted. The CSCI has been given the maintenance/redecoration plan for 2005. This includes timescales for work to be done and covers the fitting of locks to drawers for service users who want this, as already discussed in this report. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Sloe Hill Residential Care Home LimitedPage 25 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? The proprietor of the home told the inspector that the plans to install an additional assisted bathroom at the home are now with the planning authority. The work to install this room will commence as soon as the plans are agreed. The requirement for this addition is on-going and has been made a condition of the homes registration. The Manager must inform the CSCI as soon as the plans are agreed with an update of the situation. The upstairs bathroom now has a window restrictor fitted, as previously required. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Sloe Hill Residential Care Home LimitedPage 26 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not assessed on this occasion. YES NO NO 21 14 3 0 Standard met? 0 21 00 0 3 0Sloe Hill Residential Care Home LimitedPage 27 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Service users said they were very happy with the furniture and fittings in their bedrooms and many have brought their own furniture to the home. However, the Manager said that where appropriate seating for two, and a small table will be installed in bedrooms (as listed in this standard as a requirement). Care plans now have details of service users being offered keys to their doors and of their refusal to have locks fitted. One service user asked for a chain for the outside of her door and this has been fitted. Lockable space inside bedrooms has been supplied where agreed with service users as already noted in this report. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? Service users said they were happy with the heating and lighting in the home. However, as noted at the last inspection, some pipes and the radiators do not have low temperature surfaces, and are not covered. Although radiators can be individually controlled, risk assessments should be produced for all areas to ensure service user safety. Generally the hot water was being delivered at safe temperatures, but in one bathroom it was measured at 49°, which is too hot. The thermostat was adjusted immediately and the temperature was reduced. The Manager is advised to record the temperatures at regular daily intervals to ensure safe delivery of hot water. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Sloe Hill Residential Care Home LimitedPage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX 18 X Standard met? 0Key findings/Evidence This standard was not assessed on this occasion.Sloe Hill Residential Care Home LimitedPage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 33 3 Key findings/Evidence Standard met? Currently three care workers are studying for level 2 NVQ, and three for level 3. There are no care workers under 18 in the home.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home has a recruitment policy which meets the requirements of this standard. Staff files were checked and were in order. A new staff hand book has been issued to staff, which contains details of staff terms and conditions. CRB clearances are in place, including one for the regular hairdresser. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The manager has worked hard to ensure that staff training has taken place since the last inspection. Sloe Hill has a dedicated training room, which enables courses to be provided in the home.The Manager said that all staff will now receive more than three paid training days each year. All new staff have completed a Topps accredited induction and foundation training course. Staff spoken to confirmed that they have all now completed the required mandatory training and in addition have been on courses covering Dementia and Fire Training. The continence adviser has provided training for all staff, and medication administration training has been booked. Refresher courses for mandatory training are also being planned for this year.Sloe Hill Residential Care Home LimitedPage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The Manager of the home has over four years experience in managing care and has started training for the Registered Managers Award. Staff confirmed there are clear lines of accountability in the home and felt confident in the Managers ability to run the home successfully and support staff. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Sloe Hill Residential Care Home LimitedPage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? There is a Quality Assurance policy in place and the CSCI has received a copy of the homes Quality Assurance Manual which has been recently completed. The Manager said that service user meetings and questionnaires will be assessed and feed into planning and it is intended to publish the results of surveys. Similarly, family and friends have been sent questionnaires, along with other stakeholders. The Manager said the outcomes of monitoring the results will feed into the next annual development plan for the home. The previous annual development plan has been submitted to the CSCI. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? A financial spreadsheet was available for inspection, and this and other financial budgeting is the responsibility of the proprietors. Appropriate insurance cover is in place for the home and certificates were on display in the entrance hall.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? Service users finances are managed by families, but some personal allowances are kept in the safe. Financial records are kept of all proceedings. Two signatures are in place for all transactions. Only the Manager and Deputy can access the safe and none of the staff act as an agent or appointee for any service user.Sloe Hill Residential Care Home LimitedPage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? The Manager has now completed all the required policies and procedures for the home. Copies are kept on files in the office and in the home. Staff said they were aware of these new policies and knew where to find them. Appropriate employment procedures are now in operation and staff confirmed that they now have regular, formal supervision.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records are kept in locked areas of the home and office and those checked were well maintained and up to date. Policies and procedures have been thoroughly reviewed and the manager said service users could have access to their own records whenever they wished, subject to the Data Protection Act.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? First aid training is now completed for all staff and staff have had recent training in COSHH assessments. Risk assessments are in place for all substances used. Senior staff confirmed they are now responsible for fire alarm testing and service users confirmed these tests take place weekly. Regular fire drills take place and are recorded and again, service users said they are involved in evacuating the home during drills. Water temperature checks are recorded and records of equipment checks were in place. PAT tests were recorded in September and the five year electrical test was done. The work has been partly completed. The Manager must submit a copy of the certificate for completion of this work to the CSCI as soon as possible. No doors were seen wedged open during the inspection and some door guards have been installed on fire doors. The Manager said that an assessment was completed and the doors with the highest priority had door guards installed first. Other doors will be fitted in turn. Generic risk assessments for the home have been amended and increased.Sloe Hill Residential Care Home LimitedPage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Bedroom 11 which measures less than 9.3 square metres must not be used to accommodate any resident after the date of registration. CommentsYESYES Condition Compliance Bedroom 10 on the ground floor measures less than 9.3 square metres. When the service user accommodated at the date of registration vacates this bedroom it must not be reoccupied. The maximum number of service users to be accommodated in the home will then be reduced from 28 to 27. The Hertfordshire Area Office must be notified when this room becomes vacant. CommentsYES Condition Compliance All bedrooms will be occupied by one person apart from bedrooms 2 (23.9 sq metres), 4 (19.3 sq metres) and 6 (18.8 sq metres), which may be shared by a maximum of 2 persons. These bedrooms may only be shared by service user who have made a positive choice and mutual agreement to do so. This must be recorded. Bedrooms 6 and 7 on the first floor, which are only accessible via some steps, may only be used to accommodate ambulant residents. Non-ambulant residents must not be accommodated in these bedrooms unless ramps have been fitted to make them accessible to non-ambulant residents. CommentsSloe Hill Residential Care Home LimitedPage 34 Condition Compliance One additional assisted bathroom must be installed by 1st June 2003 CommentsNOLead Inspector Second InspectorPat HouseSignature Signature SignatureRegulation Manager Robert Kittle Draft Date Final Report Date 2nd March 2005 8th April 2005Public reports It should be noted that all CSCI inspection reports are public documents.Sloe Hill Residential Care Home LimitedPage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 07.02.05 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request from the Hertfordshire Area Office.Sloe Hill Residential Care Home LimitedPage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 30th March 2005 which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOSloe Hill Residential Care Home LimitedPage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I V Endersby of Sloe Hill confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Violet Endersby Violet Endersby Home Manager 08 03 05Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Sloe Hill Residential Care Home LimitedPage 38 Sloe Hill Residential Care Home Limited / 7th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000037036.V198937.R01© This report may only be used in its entirety. 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