Care Home: Hilcote Hall

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What the care home does well We found that Hilcote Hall offers an improving commitment to care with a relaxed, open and friendly atmosphere between carers and those people using the service. Comments received from surveys and talking with people during the inspection include: "I took the opportunity to look around and found it was a good place with good people". "We have found that staff have been very helpful to us and have made a positive difference to mum`s outlook on life. She appears to have much more confidence than she had whilst living on her own". "It has very good medical care, if mom required a doctor they are always very proactive. Mom`s room is always clean and tidy, Mom is kept clean". We established that there are good pre admission assessments, care planning of individual needs, and meaningful reviews, monitored in formulating a satisfactory standard of personal care. People using the service that we talked to, told us that they are happy at the Home, and are cared for appropriately, with their health care needs met. Comments we received from relatives during the inspection include: "Last week we visited early and mum was still in bed, staff had let her sleep in but checked her ever so often to see if she was awake, that`s what I call normal life, and I like it, and she enjoys it". "I feel that when it comes to the needs of our mom, the care staff are always on form to the best they can be. There is always a pleasant atmosphere, but need more staff at mealtimes and the evening". We recognise that the housekeeping, catering and support services have all contributed significantly to the team approach in supporting the caring process. We also accept a much improved relationship with community medical and nursing services. We acknowledge the arrangements made to appoint the appropriate calibre of staff through a sound recruitment and induction programme, and the willingness on the part of the Providers in their support and direction given, demonstrating their commitment to securing an improving standard of service and care at Hilcote Hall. What has improved since the last inspection? Our inspection has identified a more positive `person centred` approach to care, especially for people with dementia. A less institutionalised process was seen to prevail, although tasks remain the major objective in certain situations. The majority of the recommendations of the previous report have been met. The arrangements for activities and socialisation have shown some improvement, although much still needs to be accomplished to offer people an inclusive quality of life, and a sound foundation to provide a good standard of care. Various comments we received through surveying from people in the home: "It provides a friendly family atmosphere for everyone". "They could have better occupational health facilities, especially for disabled patients". From the Expert by experience: `Members of the care staff were seen to treat residents with consideration and patience and to interact well with residents whilst carrying out their tasks. They appeared friendly and attentive to the needs of residents and during the lunch period offered assistance and advice in an appropriate and timely manner`.. We have acknowledged that there have been improvements in the furnishings and decor throughout the Home, presenting a comfortable, safe environment, and to assist people, especially those with a higher dependency of care or dementia needs, although there remains much to achieve. Our discussions with staff confirmed an improvement in the standards of staff morale, motivation and training, through effective management. Information gathered from the AQAA, and discussed during our inspection found this to be true. What the care home could do better: We found an overall satisfactory quality of care and service that was not always evidenced through consistent record keeping. We advised that all records generated through the assessment process, care planning and review process are to be signed and dated by the assessor, to ensure accountability and audit of care. We felt that this approach should be applied in the recording of staff appointments and maintenance of staff records, to ensure a consistent and thorough approach to effective employment procedures. We were concerned that our recommendation to secure the Carers station on the first floor had not been addressed, and now require that the Care Manager address the confidentiality issue as a matter of some importance. Consideration should be given for the Statement of Purpose and Service User Guide to be reorganise and updated to reflect changes that have occurred recently; and that an audio and pictorial version would help people to make an informed choice. That people with more complex needs require a more detailed assessment to facilitate their needs are fully met, especially for those with impaired vision and hearing. We recommend that the `Homely remedy` procedure requires a re-assessment to ensure that General Practitioners clearly recognise certain staff to administer certain medicines, through dated and signed declaration; and that all medicines are kept secure to ensure the safety of people living in the Home. We considered that more variety in indoor activities would be beneficial, especially for people with dementia and other cognitive impairments. To consider the environmental arrangements for people with dementia, including provision of easy recognition, dignified identification of bedrooms and facilities, to enhance their well being. We found a menu was available but the print was too small and it was not in a very conspicuous place. Laminated menus with photographs of the meals available would add visual interest, and provide a topic of conversation. We would recommend that the Provider reviews the staffing provisions throughout the shift structure to accommodate the increased demands for meeting dementia care needs, and to be aware of potential increased occupation of beds available. We would expect that the Registered Manager addresses inconsistencies in providing training opportunities and management, including dementia awareness. We also note that formal staff supervision and staff meetings should be implemented to ensure that all staff receive appropriate support, guidance and communication, enhanced to benefit people living in the Home. Key inspection report Care homes for older people Name: Address: Hilcote Hall Stone Road Eccleshall Stafford Staffordshire ST21 6JX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Keith Jones     Date: 0 6 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Hilcote Hall Stone Road Eccleshall Stafford Staffordshire ST21 6JX 01785851296 01785851853 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Select Health Care (2006) Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 44 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be registered is 44 The registered person may provide the followng category of service only: Care Home Only (Code PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Older People (OP) 44 Dementia (DE) 18 Physical Disabiltiy (PD) 2 Date of last inspection Brief description of the care home Hilcote Hall is a care home registered to provide residential care for 44 older people; there were 37 people in residence on the day of inspection. The needs of the people who may wish to live at Hilcote Hall range from old age to dementia or a physical Care Homes for Older People Page 4 of 37 0 2 0 7 2 0 0 9 18 0 2 Over 65 0 44 0 Brief description of the care home disability. The registered Provider is Select Healthcare Ltd. who has overall responsibility for the home; the registered manager position is presently vacant, a new appointee will commence during May 2010. The Home provides accommodation on three floors in a mixture of single and shared rooms. Communal areas are sited on the ground floor; there is one dining room and a number of lounge areas. Suitable facilities are available for people who use the service to sit outside and enjoy the surrounding countryside. The Home lies just over a mile from the local shops and services of the town of Eccleshall. A reduced bus service passes the home, and the nearest railway station is Norton Bridge, about one and a half miles away. Those who wish to confirm up to date information about the fees for this service will need to enquire directly to the Homes Care Manager to obtain this information. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection for this service took place on 1st July 2009, and the Home was given a quality rating of one stars (adequate). This Key Inspection was conducted against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The objective of the inspection is to evaluate whether people who use the service, and their family carers experience services of good quality that offer, and promote independence. We conducted this unannounced inspection with the Area Manager Select Healthcare, the acting Care Manager, and an Expert by experience, whose input contributed to this report. An Expert by experience is a person who, because of their shared experience of using services and ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in, or use the service. Information for the report was gathered from a number of sources: a questionnaire, Care Homes for Older People Page 6 of 37 that is the Annual Quality Assurance Assessment (AQAA), which was completed before the inspection by the former Care Manager and the Area Manager, and one survey form, that we sent out some weeks before the inspection to people who use the service, which was returned to us in good time; six staff returns were also received. There were 33 people in residence on the day of our inspection. We looked at the environment, including looking at the communal areas and a sample of the peoples bedrooms, there was discussions with the managers, care staff, people who live at the Home and visitors to the home. We looked at how the service has responded to any concerns, and how the service was protecting people from abuse, including how the service recruited and trained staff. We also looked at the number of staff available to care for people at the Home. Four people who live in the home were case tracked, this involves establishing peoples experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of the care that they receive. Tracking peoples care helps us to understand the experience of people who use the service, how they spend their time and whether the service was promotes peoples privacy and dignity. We looked also looked at the arrangements for storing and administering medication. There followed an inspection report feedback, involving the Area Manager, acting Care Manager and the administrator of the Home, in which we offered an evaluation of the inspection, indicating those requirements and recommendations resulting from the inspection. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? Our inspection has identified a more positive person centred approach to care, especially for people with dementia. A less institutionalised process was seen to prevail, although tasks remain the major objective in certain situations. The majority of the recommendations of the previous report have been met. The arrangements for activities and socialisation have shown some improvement, although much still needs to be accomplished to offer people an inclusive quality of life, and a sound foundation to provide a good standard of care. Various comments we received through surveying from people in the home: It provides a friendly family Care Homes for Older People Page 8 of 37 atmosphere for everyone. They could have better occupational health facilities, especially for disabled patients. From the Expert by experience: Members of the care staff were seen to treat residents with consideration and patience and to interact well with residents whilst carrying out their tasks. They appeared friendly and attentive to the needs of residents and during the lunch period offered assistance and advice in an appropriate and timely manner.. We have acknowledged that there have been improvements in the furnishings and decor throughout the Home, presenting a comfortable, safe environment, and to assist people, especially those with a higher dependency of care or dementia needs, although there remains much to achieve. Our discussions with staff confirmed an improvement in the standards of staff morale, motivation and training, through effective management. Information gathered from the AQAA, and discussed during our inspection found this to be true. What they could do better: We found an overall satisfactory quality of care and service that was not always evidenced through consistent record keeping. We advised that all records generated through the assessment process, care planning and review process are to be signed and dated by the assessor, to ensure accountability and audit of care. We felt that this approach should be applied in the recording of staff appointments and maintenance of staff records, to ensure a consistent and thorough approach to effective employment procedures. We were concerned that our recommendation to secure the Carers station on the first floor had not been addressed, and now require that the Care Manager address the confidentiality issue as a matter of some importance. Consideration should be given for the Statement of Purpose and Service User Guide to be reorganise and updated to reflect changes that have occurred recently; and that an audio and pictorial version would help people to make an informed choice. That people with more complex needs require a more detailed assessment to facilitate their needs are fully met, especially for those with impaired vision and hearing. We recommend that the Homely remedy procedure requires a re-assessment to ensure that General Practitioners clearly recognise certain staff to administer certain medicines, through dated and signed declaration; and that all medicines are kept secure to ensure the safety of people living in the Home. We considered that more variety in indoor activities would be beneficial, especially for people with dementia and other cognitive impairments. To consider the environmental arrangements for people with dementia, including provision of easy recognition, dignified identification of bedrooms and facilities, to enhance their well being. We found a menu was available but the print was too small and it was not in a very conspicuous place. Laminated menus with photographs of the meals available would add visual interest, and provide a topic of conversation. We would recommend that the Provider reviews the staffing provisions throughout the shift structure to accommodate the increased demands for meeting dementia care needs, and to be aware of potential increased occupation of beds available. We would Care Homes for Older People Page 9 of 37 expect that the Registered Manager addresses inconsistencies in providing training opportunities and management, including dementia awareness. We also note that formal staff supervision and staff meetings should be implemented to ensure that all staff receive appropriate support, guidance and communication, enhanced to benefit people living in the Home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering using the service have an assessment of their needs to assist the service to decide if they can provide them with the support they need. People with more complex needs require closer assessment to ensure that their needs are fully met. Evidence: We examined the services recently revised Statement of Purpose and Service User Guide and found that they provided an informative description of Hilcote Halls aims, objectives, and the way it operated, although the presentation needs review and updating to meet contact and service changes. We advised that the Statement of Purpose represent the full and comprehensive detail, and be readily available for general distribution. We consider the Service User Guide to be used widely and presented to all enquirers, be produced in large print as and when necessary, and that an audio and pictorial version would help people to make an informed choice. Information concerning fees payable were included in the Statement of Purpose. Care Homes for Older People Page 12 of 37 Evidence: Peoples care records seen showed us that people wishing to live at the home have their needs assessed. We found that the pre-admission assessment contained good information about peoples needs and gave staff instructions on how their needs can be met, offering those people who may use the service, and their relatives, the opportunity to make an informed choice about where to live. One person made the following comment: I lived somewhere else before, but Im much happier living here. Our examination of four peoples care records and plans, indicated that each person had an individualised pre-admission assessment, the amount of information recorded was adequate in forming an appraisal of that persons needs and capabilities, assessing the social background, and were consistent with dating and ownership of the assessor. We identified that the Acting Care Manager or her deputy, at the point of referral, conducts the pre-admission assessment. We found through our discussions with relatives and people using the service, that their involvement was taken into account, and that they felt included. We advised that each record showed the attention to details of individuality to allow the formulation of a care support plan, based on assessed, individual needs. A relative we talked to informed us: I took the opportunity to look around and found it was a good place with good people. From our examination of care files we found that the assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the person and any special needs. We are aware that people are informed of those facilities, but have recognised several people with severe sensory difficulties whose care process would be greatly enhanced with a more detailed personal and social assessment report. a member of care staff commented: Management has a commitment to improve the continuity of admission and discharge processes so that no one gets missed. A plan of care based on personal needs and daily living processes is then produced from the assessment information obtained. From our discussions it was evident that people are able to visit and assess the quality, facilities and suitability of the Home at any reasonable time, to meet with staff and management. Care Homes for Older People Page 13 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health care needs are generally met but there would be even greater confidence of this with improved assessment, and record keeping. Medication practices are generally satisfactory, although require review to protect the well being of the people living at the home. Evidence: The AQAA tells us that each person has a care plan and that the person or their family is involved in its development. An examination of documents confirms that everyone has an individual plan with four individuals care files examined in detail, each demonstrated essential information on the individual, brief life style and needs, events and contacts, procedures and actions monitored on a daily basis and reviewed. There were adequate risk assessments completed in areas such as manual handling, falls, nutrition, personal hygiene, and continence. At our last inspection we saw progress had been made in developing person centred plans and on this occasion we saw that the management is continuing to try to Care Homes for Older People Page 14 of 37 Evidence: develop these plans. In some files there is little information about peoples social care needs, also where people have communication needs, plans should contain detailed information to enable staff to understand how a person communicates. We have previously reported that we saw people with challenging hearing and sight who felt excluded from daily events through a less thorough assessment of need as expected. Risk assessments were carried out on an individual basis, and now reviewed on a regular basis. Included in the care records were applications of established monitoring systems, following a process of recognition and evaluation. Our observations showed that generally people using the service appeared to be content, comfortable and happy with their lifestyle, complimentary regarding the quality of their lives and the care they were receiving at Hilcote Hall. People that use the service do have access to health care services and they are supported by visits to the home by health care professionals. The General Practitioner (GP) of choice service is supportive; through which arrangements are made to provide professional support. There is evidence to show that the service is meetings peoples personal care needs. People appeared to be suitably dressed and well groomed. People that answered our surveys tell us that they always or usually receive the care they need, and comments we received from people using the service and visitors included: We have found that staff have been very helpful to us and have made a positive difference to mums outlook on life. She appears to have much more confidence than she had whilst living on her own. Works well with all health care professionals to provide the best level of care possible. It has very good medical care, if mom required a doctor they are always very proactive. Moms room is always clean and tidy, Mom is kept clean. They care for residents, keep the home clean, washing and laundry up to date. There was a clear appreciation of the openness and opportunity to contribute. Staff were seen to interact well with people who were seen to be supervised in the lounge areas. In the progress of meeting people who use the service it was acknowledged that their general appearance indicated that their health and personal care was attentive and effective. Care Homes for Older People Page 15 of 37 Evidence: Medication practices are generally safe and protect the people living there, although some improvements are needed. There are appropriate systems in place to order repeat prescriptions, although this requires staff to leave the building to collect supplies. We found the receipt of drugs and accountability required review to comply with, and demonstrate, a suitable audit trail that is accurate and appropriate. We noted a used, prescribed cream left in a bathroom, which should be safely stored at all times. The disposal of unused medicines was seen to be effectively controlled. The acting care manager is required to upgrade all documents and records accordingly, with the provision of dates and signatures of staff involved. We advised that when bottles or tubes of medicines were used, that a when opened date be written on the container, to ensure usage within prescribed time scales. The medicines fridge was secured and used appropriately. Controlled drug arrangements were satisfactory, although closure of prescriptions need to be clear and unambiguous. Self-medication and risk assessment policies were seen to be satisfactory, with no one in at the time who wished to participate in the scheme. The Homely remedy procedure requires a re-assessment to ensure that General Practitioners clearly recognise certain staff to administer certain medicines, through dated and signed declaration. We confirmed that only suitably qualified staff administer medication, all have received updated training in the Safe Handling of Medications. It is stated in the services Statement of Purpose and the AQAA, that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of people. This was confirmed in our discussions with people who use the service. visitors and staff, and that relatives have freedom of visiting, which emphasised the importance of maintaining social contact. We looked at bedrooms presented to facilitate privacy for the individual, which included medical examinations and personal care procedures being performed in private. In our discussions with people who use the service and staff it was recognised that diverse needs were accommodated within the planning of care, with dietary, religious and personal matters identified, along with the diverse physical needs. Generally the arrangements for care planning are satisfactory with fair assessment, wide based risk analysis and care plans regularly reviewed, and adequate daily reports. We saw that people were treated respectfully and were spoken to politely. Some staff initiated conversation and involved people in decision making. Cross referencing accidents and events with care plans showed a connection of appraisal, and regeneration of plans or risks assessments were noted. Care Homes for Older People Page 16 of 37 Evidence: The Expert by experience stated: Members of the care staff were seen to treat residents with consideration and patience and to interact well with residents whilst carrying out their tasks. They appeared friendly and attentive to the needs of residents and during the lunch period offered assistance and advice in an appropriate and timely manner. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples rights to live a meaningful life are central to the homes aims and objectives, and are offered opportunities to exercise choice and control over their lives. Some activities are available but more could be provided including for those people with dementia and mental health needs. People are offered a healthy, well balanced diet. Evidence: Throughout the period of inspection we found the daily routine to be flexible, offering choices and diversity for personal and social activities, religious needs and meals. Our discussions with people who use the service, and staff, clearly identified a relaxed and informal atmosphere in which the peoples needs were respected, with the security that there are familiar events to the day they could relate to. People also exercise choice in the time they get up and go to bed. One daughter expressed her initial surprise and delight at this: Last week we visited early and mum was still in bed, staff had let her sleep in but Care Homes for Older People Page 18 of 37 Evidence: checked her ever so often to see if she was awake, thats what I call normal life, and I like it, and she enjoys it. We reinforced the principle that activities are a key element in the socialisation and motivational approach to care, and involvement. The home has an enthusiastic, part time activity coordinator, working with a limited budget, in an unstructured format, which showed deficiencies in the programme of events and commitment. During the course of the inspection we saw staff interact with people in a positive and polite manner, although we observed there were instances of lower levels of contact with people with dementia. We continue to consider that there is insufficient attention drawn to offer a therapeutic service for people with dementia, and for people who have greater dependency needs. It remains our recommendation that creative ways of providing activities such as adapted equipment for those with disabilities; life story work and seeking individual interests would enhance life for people living in Hilcote Hall. This would be consistent with a Person Centred Care approach as stated in the Statement of Purpose. We also recognised that people would like the opportunity to enjoy outside activities in a potentially very attractive garden and patio area, well suited for the task. Comments we received from surveys issued to people who use the service before the inspection: It provides a friendly family atmosphere for everyone. They could have better occupational health facilities, especially for disabled patients. They could do more activities and spend time with us. The report from the Expert by experience indicated: I spoke with the activities coordinator, who works 21 hours over three days. She informed me that she tries to get the residents involved in activities like snakes and ladders, throwing ring games, skittles, quizzes, bingo etc, and plays music, etc. and that there is no regular time slot for these, which are done on an ad hoc basis. She admitted that only a few residents participate in these organised activities, although it was evident that she and other care staff had taken pains to get to know individual residents and their preferences, though I did not witness any individuals actually engaged in any form of occupational therapy or activity during my visit, and I was not sure when and how they were able to pursue any kind of individual interest. Around once a month someone comes in to sing or play music to the residents. Most residents were just sitting in their chairs doing nothing. I learned that the allocated budget for Care Homes for Older People Page 19 of 37 Evidence: resource materials for activities is very limited and any new items have to be paid for through fund raising. Given that the emotional well being of residents is as important as their physical well being, currently there appears little or no specialised provision for residents suffering from dementia or activities appropriate to their needs. I learned that the activity coordinator had received no specialist training in dementia, and she only works for 21 over three days, this means that for four days a week there is no activity provision at all. It is stated in the Statement of Purpose that personal choice and relative self determination are respected in policy and action. Throughout the inspection we found this to be true. Those individuals rooms inspected showed an influence of personalisation in the inclusion of belongings, some furniture and general decor, although attention was drawn to addressing the personal needs of people with dementia, in the furnishing of bedrooms. Our inspection of the Home demonstrated a degree of expressed individuality in most of the bedrooms inspected. Relatives and friends are encouraged to maintain social links as part of the planning of care. A Roman Catholic priest attends on request, and a Church of England communion is given once a month. No other religious or spiritual needs were presented at this time. We found that the standards of catering continue to offer a satisfactory service, to which those people we spoke with were complimentary. A menu, on a four weekly cycle offered a varied and suitable choice. We observed a pleasant lunch served during inspection, a choice of two main meals, and desserts. The quality and quantity of the food offered on the day was observed to be of a good standard, confirmed by those people we talked with, served in a comfortable and clean dining room. Most people were able to eat independently, but where assistance was needed it was offered in a polite and respectful manner, and at a level appropriate to individual need to encourage independence and maintain dignity. The choice of dining room, lounge or bedroom was at the discretion of people living in the home. People interviewed confirmed that that the quantity and quality food provided was good: The food here is always good and tasty, always hot, and the staff are very helpful. Very good standard of cooking and choice available. Its always set out so nice. The Expert by experience reported: I observed the lunch time session and sampled one of the meal (faggots, potatoes and green beans; chicken casserole was also available), which was quite tasty, hot and well seasoned. Dessert was apple pie (home made with ice cream) or cheese and Care Homes for Older People Page 20 of 37 Evidence: biscuits. Yoghurt was also available. The dining room for the majority of residents was pleasantly furnished although there were no menus on the tables. There was a choice of three squashes served as usual in plastic beakers. The adjoining smaller dining area for higher dependency residents, was less pleasant and the tables lacked a cloth or any embellishment. Lunch here was quite task orientated, although there appeared to be sufficient care staff to cope with the assistance needed by all the residents to eat their meals. Assistance was being given here in an appropriate and considerate manner. In the main room there was little interaction between residents, but staff were on hand to offer advice or help with queries when needed. A weekly schedule of menu was available outside on the notice board but the print was too small and it was not in a very conspicuous place. Laminated menus with photographs of the meals available would add visual interest and provide a topic of conversation. We confirmed that the cook knew each person using the service, and some of the relatives. We discussed diversity with the cook, who indicated an awareness in meeting individual needs; there were no special (cultural) needs at the time. Individual preferences were recorded in assessment and conveyed to the catering staff, who met with, and discussed with them their requirements. Care Homes for Older People Page 21 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given opportunities to freely express any concerns, and these are quickly responded to. People are protected from abuse, and their human rights are promoted. Evidence: We found that the Home does have a complaints procedure, and the acting Care Manager told us that she has an open door policy which means that people pop in and discuss any concerns that they have. She feels that any concerns can be easily addressed before they become a major problem, which is crucial given the needs and dependency of people living at the home. We identified that there had been three complaints received by the Registered Provider, both seen to have been dealt with in a responsible manner. We have been aware of one safeguarding issue raised concerning people who are living in the home, with a satisfactory outcome from the action taken. Information on Advocacy services was not seen during this inspection. The Manager did say that advocacy services are contacted when people have no one to assist them to make decisions. The Home has appropriate adult protection policies and procedures, and our discussion with the acting Care Manager confirmed that there is satisfactory evidence Care Homes for Older People Page 22 of 37 Evidence: of a protocol and response, to anyone reporting any form of abuse, to ensure effective handling of such an incident. Comments we received from people on the day of inspection: I dont know who to speak to if Im not happy, but the carer listens, and the matron deals with it, I dont have to worry about anything. Im happy in that there is usually some one to speak to. We examined three staff records to confirm that staff were suitably checked through Criminal Records Bureau (CRB), and Protection of Vulnerable Adult (POVA) disclosure. We found staff received training on abuse at induction, this includes the right to whistle blowing, consistent with the Public Disclosure Act, 1998. It is positive that staff have had training to highlight their awareness and responsibilities under the Mental Capacity Act. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home provides a safe, satisfactorily maintained, clean and comfortable environment for the people who live there. Evidence: Hilcote Hall is a large Georgian House overlooking picturesque Staffordshire countryside, approximately half a mile from Eccleshall market town. The Home is registered to provide residential care for 44 older people; the needs of the people who may wish to live at Hilcote Hall range from old age to dementia or a physical disability. Hilcote Hall is situated in its own, extensive grounds, with accommodation provided on three levels, which are accessed, by stairs or a passenger lift. We found the grounds spacious, and there are pleasant country views all round, although with a good car park. The attractive garden and patio areas are well maintained and secure, and we were informed, increasingly used during the summer months. There was level access into the building, which was suitable for people who use wheelchairs, or have mobility problems. We were informed that the front entrance is to be repositioned to the side of the building, to minimise disruption to the lounge areas adjacent to the front entrance. We found that there is a some deterioration of window frames and general paintwork, including the frontage of the Home. We found that internal access was facilitated with suitable fittings of hand and grab Care Homes for Older People Page 24 of 37 Evidence: rails, in adequate, well lit and airy corridors. We have acknowledge some progress, but reinforced the continuing need to develop the decor of corridors and living areas, to reflect assistance to people with dementia in pathway location signs, including corridors with themes and easily recognisable colour coordination, linked in with familiar and individulised bedroom doors. Wheelchair access was generally satisfactory throughout all areas of the home, although constrained by an elaborate internal locked door system, and a poorly performing lift, however we confirmed that on admission the acting Care Manager or her deputy assesses each individual persons needs for equipment and necessary adaptations. We continue to find the siting of the carers station on the first floor, does not allow for confidential discussion, and that the care files were unsecured, openly available in an unmanned area. The acting Care Manager responded immediately to address this issue. We recognise the efforts made to provide a comfortable and homely atmosphere, and the decor in most areas of home was found to be of an adequate standard. The Home provides four lounge areas that were pleasantly decorated, providing essential furnishings and items to provide comfortable areas where people were able to interact, or to entertain their guests. A compact, homely dining area was clean and conducive to enjoy a good meal. The Expert by experience reported: There were a number of lounge areas and one dining area (split into two sections) all on the grounds floor. The communal areas were clean and pleasant, with no detectable odours. The two bedrooms I saw were clean and well furnished with plenty of personal items, lending a homely feel. Bedrooms were generally well maintained to meet peoples personal preferences. On inspection, most bedrooms were personalised, with some displaying personal furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. We noted that curtain tracks have been fitted to facilitate privacy in double bedrooms, although the wheeled curtains remain. It was accepted that they continue to present an unacceptable risk to accidental injury to staff, and people living in the home, and were removed. Some of the original furniture is in continuing need of renewal. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration, as confirmed during the Inspection. We have considered that there is a need to enhance personal space for people with dementia, in identifying bedroom doors, fitting items of Care Homes for Older People Page 25 of 37 Evidence: easy recognition and usage, and installing a personal ownership to their rooms. An effective call system was tested, and a locked facility and lockable bedroom doors are available on request. Those people we spoke with expressed a sense of belonging and satisfaction in the quality and presentation of their living areas with no one expressing any dissatisfaction. Toilets were located on both floors and were in close proximity to bedrooms and communal areas. We found the heating and ventilation to be satisfactory, and lighting was domestic in style. Fire equipment was inspected, and seen to be serviced and up to date. The kitchen was inspected, and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. The kitchen was clean and records confirmed a diligent address to hygiene. Access to the kitchen should be for catering staff only, with suitable over clothing for visitors. We recognise the structural improvements made with the preparation room annex, near to completion. We spoke with the cook who confirmed to us that he actively engages with people who use the service to determine their needs and little ways. He was aware of the issues of culture, ethnicity and age diversity, having had experience in dealing with a diverse population, and presented a four weekly menu and display the days meals for peoples information, although not presented clearly. We support the idea that a pictorial menu for display would help people. The laundry remains in a poor position, but was equipped to a satisfactory standard, that red alginate laundry bags were available for handling soiled linen, and that there were appropriate notices regarding chemical handling openly displayed. Peoples belongings were seen to be handled piecemeal, in an organised process, with no evidence of communal usage. Disposable gloves and aprons were seen in use, and liquid soap and paper towels were evident throughout. The home presented a clean and pleasant, mainly odour-free atmosphere, much to the credit of staff. We recognised the advanced plans to resite the laundry to more practical accommodation. Personal Appliance Testing (PAT) was noted as being done on an annual cycle, and on an as and when basis when new equipment is brought in. Fire equipment was inspected and seen to be serviced and up to date. Care Homes for Older People Page 26 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the Home require consistent training in mandatory and relevant subjects to maintain a skilled presence, and in sufficient numbers to fulfill the aims of the service to meet the changing needs of people using the service. Evidence: We confirmed that there were 33 people using the service on the day of inspection, of which 16 people were receiving care for dementia. We examined three weeks of duty rotas, and on the day of inspection the staffing levels were seen by us to be: Morning shift: 1 Senior Carer and 4 carers (Plus acting care manager). Afternoon shift: 1 Senior Carer and 3 carers Night duty: 1 Senior Carer and 2 carer. We recognised that the acting Care Manager is supernumerary to the staffing roster. Flexible rostering with agreed overtime are used to accommodate shortfall due to sickness and absence, and that Agency staff are deployed, having worked 13 shifts in the past three months. It was evident throughout the inspection that the demands placed on Hilcote Hall Care Homes for Older People Page 27 of 37 Evidence: through increased dependency, and a higher number of people with dementia care needs, that overall staffing levels have not been adapted to cope with the demands. We have considered that each shift coverage requires review to meet those needs, although recognising that there is a present low occupancy of beds. The acting Care Manager and Area Manager was advised to ensure adequate provisions of staffing be in place to meet the expected increase in occupancy. Interviews with relatives, people who use the service and staff raised concerns regarding the current staffing levels provided within the Home. There is a growing recognition that the arrangements for activities are inadequate, with people getting inconsistent supervision in communal places, and motivation to socialise and engage, especially in addressing dementia care needs. The catering, maintenance and domestic hours were determined and found to be appropriate for the size of the home and the needs of people. Comments we received from people and staff we surveyed some weeks before the inspection: I feel that when it comes to the needs of our mom, the care staff are always on form to the best they can be. There is always a pleasant atmosphere, but need more staff at mealtimes and the evening. There are many times when there isnt enough staff at night time to answer peoples bells and calls. The staff look after the service users very well, keeping the home running smooth, making sure residents families and friends are happy with the service we provide. Could do with more staff. Sometimes short staffed, we cannot fulfill everything we need to. The Provider has established, and continue to pursue satisfactory procedures for interview, selection and appointment of staff. We examined three staff records, including the last person employed by the home, and those records told us that staff have received appropriate pre-employment checks prior to commencing work at the Home, including Criminal Records Bureau (CRB), and Protection of Vulnerable Adult (POVA) disclosure. We advised that Proof of Disclosure with Number and date be kept on file to comply with Data Protection requirements. We found staff received training on abuse at induction, this includes the right to Whistle blowing, consistent with the Public Disclosure Act, 1998. We consider that the process would be enhanced with interview notes, and a letter of appointment. An up to date photograph is recommended for inclusion in all staff files. Our discussions with the Acting Care Manager confirmed that more than 80 per cent of Care Homes for Older People Page 28 of 37 Evidence: care staff had receipt of the National Vocational Qualification (NVQ) at level II or III, with three new staff members currently undertaking the training. There was evidence that a training schedule has been established, and that training is undertaken, although records showed that mandatory subjects have not been addressed to ensure that all staff have up to date portfolios of achievement, to ensure a level of qualification is offered to maintain quality of standards. We recognized the arrangements and plans made for training are beginning to take effect, but an over reliance on electronic learning on the computer has diluted the impact of direct tuition. The computer facility is situated in the managers office which will seek to deter staff from access. A staff member stated: Management commitment to live training instead of computer based training using the one and only unreliable laptop available to staff, and to allow staff to train during working hours, not to assume they will do it in their own time at home. The thoroughness of staff selection has a significant effect upon the provision of care to ensure protection of people. Three staff were interviewed and confirmed our observations. All new staff goes through a satisfactory induction process, that will ensure that they are going to be the right person for the home. All staff have the General Social Care Council code of conduct. We advised that the staff record be reviewed in the way information is organised and presented. Discussion with staff demonstrated an inconsistent process of supervised practice, failing to meet the required six sessions a year. Staff meetings are organised on a six month basis and require a more frequent address and consistency. Care Homes for Older People Page 29 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care team promote the health, safety and welfare of people using the service, and working practices are safe. The ethos of the service is based on openness and respect. The care team, through good working practices, promote the health, safety and welfare of people who use this service. Evidence: The previous Registered Manager had recently moved on to work nearer to her home, and an Acting Care Manager has been standing in for the week before the inspection. She is presently a nursing home manager for the elderly, and is supported closely by Sue Jones, the Area Manager of Select Health Care, who was present throughout the inspection. We also met with the Companys Estates Director to discuss issues raised from our inspection We have identified in this report our concerns over a number of issues to which the Area and acting Care Managers have acknowledged and demonstrated a positive Care Homes for Older People Page 30 of 37 Evidence: response and reinforced their commitment in promoting best practice to improve the service delivery. We also discussed the management and direction issues with the Area Manager, representing the Registered Provider, and established the foundation of those concerns, linked to the need to evaluate a resource plan to meet our requirements and recommendations. An examination of administrative, monitoring, planning and care records showed to us a need to streamline effective record keeping, to ensure that the peoples rights and best interests are safeguarded. We expressed concern over the security of confidential records, and that a convention of consistently signing and dating records be observed. We were satisfied that care records are well maintained and that staff records are secure. We examined servicing records included recent fire prevention, hoists and water inspections, each were found to be up to date. The Manager offered evidence of procedures and safe working practices including: Movement and handling, Medication and Confidentiality. The policy and procedure manual has recently been generally reviewed, and would be of greater help to staff to be consistently reviewed to meet new situations, especially in light of changes in Mental Capacity, Deprivation of Liberties and Safeguarding regulations. We found that formal staff supervision had been held on an infrequent basis, were had not been kept up to date. It was agreed that a cascaded staff supervision programme would be reviewed to continue to meet a two monthly target. The accident book was seen and found to be in order, with a regular analysis of trends and frequency. Our examination of those records showed an effective follow through of action taken, including a review of care plans if necessary. Accidents occurring to those people we case tracked were seen to be cross checked with care plans, and logged into day report. We would advise that the accident log, following analysis be placed in the persons care file. Care plans were seen to have accommodated increased risk and alternative action. We were informed through the AQAA, and by the manager that financial arrangements are supervised and administered by the Home administrator and Care Manager in respect of pocket money, comfort fund and petty cash management. We advised that two signatures be on the transaction and dated, and that the Provider does an annual audit of accounts. General comments received: Care Homes for Older People Page 31 of 37 Evidence: For the past 18 months the managerial set up has improved greatly, with the current manager being supportive of patients, staff and relatives. It provides a friendly family atmosphere for everyone. They could do more activities and spend time with us. The managers could reduce emphasis on cost cutting and increase on quality of service, and employee recognition. Staff training and employment of genuine caring professionals who provide a good quality of care to service users Could arrange more activities and outings. Through the inspection process we found appropriate risk assessments in place for people using the service, through care planning, review and monitoring, and of the general environment, these are to be reviewed to encompass peoples security and safety, including a full unit inventory of risk. Health and safety notices can be seen throughout the Home, although Chemicals safety notices should be prominent in appropriate areas of use and storage. Care Homes for Older People Page 32 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 33 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 17 That the Care Manager ensures that the carers station be secured. To ensure that care files are kept safe, and to maintain a good standard of confidentiality. 31/05/2010 2 27 18 We have considered that each shift coverage requires review to meet increasing demands and needs, although recognising that there is a present low occupancy of beds. The acting Care Manager and Area Manager was advised to ensure adequate provisions of staffing be in place to meet the expected increase in occupancy. 31/05/2010 3 37 17 That the Registered Provider 31/05/2010 addresses our concern over the security of confidential records, and that a convention of consistently Page 34 of 37 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action signing and dating records be observed. To ensure that peoples care will be administered in an appropriate fashion at all times. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 That the Statement of Purpose and Service User Guide be reorganise and updated to reflect changes that have occurred recently; and that an audio and pictorial version would help people to make an informed choice. That people with more complex needs require a more detailed assessment to facilitate their needs are fully met. That an assessment on admission reflects a comprehensive appraisal of life style and special needs, to ensure an effective provision of care are met. That the Care Manager review the receipt, administration and disposal of medicines on the MAR charts to facilitate a full audit accountability of all medicines. That all documents and records are duly signed and dated. That all medicines are kept secure to ensure the safety of people living in the Home. The Homely remedy procedure requires a re-assessment to ensure that General Practioners clearly recognise certain staff to administer certain medicines, through dated and signed declaration. We found a menu was available but the print was too small and it was not in a very conspicuous place. Laminated menus with photographs of the meals available would add visual interest and provide a topic of conversation. We continue to consider that there is insufficient attention 2 3 4 7 4 9 5 6 9 9 7 15 8 15 Care Homes for Older People Page 35 of 37 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations drawn to offer a therapeutic service for people with dementia, and for people who have greater dependency needs. It remains our recommendation that creative ways of providing activities such as adapted equipment for those with disabilities 9 19 We found that there is a some deterioration of window frames and general paintwork, including the frontage of the Home, which requires redress. That portable bedroom curtains be removed, to ensure the health and safety of people living in the home, and staff working in those bedrooms. To consider the environmental arrangements for people with dementia, including provision of easy recognition, dignified identification of bedrooms and facilities to enhance their well being. We advised that regarding Criminal Records Bureau (CRB), and Protection of Vulnerable Adult (POVA), that the proof of Disclosure, only the number and date be kept on file, to comply with Data Protection requirements. We consider that the process of appointing staff would be enhanced with interview notes, and a letter of appointment. An up to date photograph is recommended for inclusion in all staff files. Discussion with staff demonstrated an inconsistent process of supervised practice, failing to meet the required six sessions a year. Staff meetings do not have an organised structure. That mandatory subjects have not been addressed to ensure that all staff have up to date portfolios of achievement, to ensure a level of qualification is offered to maintain quality of standards. We recommend that the Care Manager establish formal staff supervision to be held on a two monthly basis, recorded and kept up to date. We would advise that the accident log, following analysis be placed in the persons care file. 10 24 11 24 12 29 13 29 14 30 15 30 16 36 17 38 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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