Care Home: Hillcroft Nursing Home

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What the care home does well There was a range of up to date written information about the home. There were also some alternative formats, such as use of pictures, for people unable to easily understand the written information. The organisation used questionnaires and collated the information to show the homes good points and improve other areas. People living at the home were able to make choices about their daily routines and meals. They told us they liked the food, which looked appealing and smelled appetising. The home had received a Four Star rating and achieved the Silver Award for food safety and healthy eating from Dudley Environmental Services. It was positive that the acting manager had an "open door" policy to encourage relatives and people living at the home to talk to her on an individual basis. There was a warm and friendly rapport between staff and people living at the home. Staff were aware of individual people`s likes and dislikes and generally how to meet their needs. We saw that visitors were warmly welcomed to the home and offered refreshments. A relative told us, "staff are helpful and know about what residents want and information is more available." The bedrooms we looked at were clean, comfortable and contained personal possessions. There was commitment to staff training and development with a ratio of 10 of 13 care staff qualified to the NVQ level 2 or above. All staff were checked to make sure that they are suitable to work with vulnerable people. What has improved since the last inspection? The new acting manager had introduced improvements to all areas of the home in a short period of time. There was improved assessment and management of risks, care planning and care records. These provided better information and clearer guidance so that all staff knew about each person`s needs, preferences and wishes. The records we looked at were better completed and kept up to date, though additional areas for improvement were identified at this visit. Improvements had also been put in place to make the home`s medication system safer. However not all improvements had been put in place at the time of this inspection. A new activities organiser had been recruited, with an enthusiastic approach, providing a wider range of stimulating things for people to do, if they wished. There were improvements to the way concerns, complaints and matters requiring notification to outside agencies were reported and the Local Authority and the CQC had received notifications of any events affecting people living at the home. The acting manager had recruited additional suitable staff and had sourced training so that progress was being made to make sure all staff were up to date with essential training. This meant that staff were generally more knowledgeable and skilled to meet the needs of people living at the home. Maintenance work had been carried out to various parts of the home to improve the safety and cleanliness, making it a better place for people to live. An example was the new carpet in the first floor corridors. The garden areas looked particularly attractive with planters and summer flowers. An efficient new administrator employed and improvements had been made to health and safety systems with records better organised and information readily available. What the care home could do better: There were a number of areas still requiring improvement at this inspection. The registered persons must continue to monitor the way people`s medication is administered and take action to provide additional medication training where needed and continue to assess the competency of staff to make sure issues are recognised and referred to healthcare professionals so that omissions do not pose risks to people`s health and well being. There are also care records, which should be reviewed to avoid unnecessary duplication so that each person`s needs are fully understood met. Full information must be given doctors and other health and social care professionals so that people with complex conditions can be properly monitored. Improvements to provide more individual activities and more opportunities for outings into the community need to be continued and funded appropriately. The registered persons must make progress with a maintenance and refurbishment plan for the tired and generally worn areas with speedier action, to improve the home to make it a pleasant place for people living there. There must also be enough domestic cover for the home, this will help to keep the home clean, fresh and free from unpleasant smells. Staff must have clear instruction about what to do in the event of fire to safeguard all persons at the home from risks of harm. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 1 1 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 36 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS 01384271317 01384271112 christinedalwood@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs. Kailash Jayantilal Patel,Mr. Jayantilal James Bhikhabhai Patel Name of registered manager (if applicable) Mrs Petunia Mthimkulu Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 28 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 10, Old age, not falling within any other category (OP) 28 Date of last inspection 0 4 1 2 2 0 0 8 10 0 Over 65 0 28 Care Homes for Older People Page 4 of 36 Brief description of the care home Hillcroft Nursing Home is situated in a residential area of Wordsley close to a main bus route, shops and other local facilities. The home has been converted from a traditional domestic dwelling and extended for its present purpose a care home providing nursing care to a maximum of 28 residents in the category of old age, many of whom have complex needs and require a high level of care. Ten of these 28 places can be allocated at any one time to older people who have a diagnosis of dementia. Hillcroft is registered to provide nursing care and therefore has a registered nurse on duty at all times. The home is on two floors. There is a lounge, dining area, conservatory, kitchen, laundry rooms, office, a number of bedrooms, toilets and an assisted bathroom on the ground floor. The home has an attractive garden to the rear and car parking space to the side. There are bedrooms, WCs and bathing facilities on first floor. The home has ramped access, a passenger lift, hoisting equipment and other aids and adaptations for safety, accessibility and independence. Care Homes for Older People Page 5 of 36 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 took place on 4 December 2008. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. The inspection took place over two days and the CQC pharmacy inspector visited the home for part of the first day to assess the homes medication systems. We monitored the compliance with all Key National Minimum Standards at these visits. The range of inspection methods we used to gather evidence and make judgements included, discussions with the acting manager, the company representative and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notifications of incidents, accidents and events submittted to the Commission. We looked at number of records and documents during the inspection Care Homes for Older People Page 6 of 36 visits. We looked around the premises, including communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. This service has had a Zero Star, poor, quality rating since 2007, and five inspection visits made in 2008 told us that though there were some improvements people living at the home could not feel assured the service would safely meet their healthcare needs. The process of the inspection was to show where the service was doing well, where improvements were still needed, and to consider the management ability to sustain changes. From all of the information we made a judgment on the outcomes for people using the service for all the different sections as shown in this report and a final quality rating, which will decide what further regulation action we might take. A statement of purpose and service user guide was available. The home had published the weekly range of fees in the service user guide. The weekly fees range from £353 to £540, with additional individual £30 third party top up fees. There are additional charges for hairdressing and private chiropody. People are advised to contact the home for up to date information about the fees charged. What the care home does well: What has improved since the last inspection? The new acting manager had introduced improvements to all areas of the home in a short period of time. There was improved assessment and management of risks, care planning and care records. These provided better information and clearer guidance so that all staff knew about each persons needs, preferences and wishes. The records we looked at were better completed and kept up to date, though additional areas for improvement were identified at this visit. Improvements had also been put in place to make the homes medication system safer. However not all improvements had been put in place at the time of this inspection. A new activities organiser had been recruited, with an enthusiastic approach, providing a wider range of stimulating things for people to do, if they wished. There were improvements to the way concerns, complaints and matters requiring Care Homes for Older People Page 8 of 36 notification to outside agencies were reported and the Local Authority and the CQC had received notifications of any events affecting people living at the home. The acting manager had recruited additional suitable staff and had sourced training so that progress was being made to make sure all staff were up to date with essential training. This meant that staff were generally more knowledgeable and skilled to meet the needs of people living at the home. Maintenance work had been carried out to various parts of the home to improve the safety and cleanliness, making it a better place for people to live. An example was the new carpet in the first floor corridors. The garden areas looked particularly attractive with planters and summer flowers. An efficient new administrator employed and improvements had been made to health and safety systems with records better organised and information readily available. What they could do better: 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 set out 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 9 of 36 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 10 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an up to date statement of purpose and service user guide in an easy to understand format, which means that people have good information to help them make decisions about their choice of home. There are comprehensive assessment tools and people living at the home have been regularly reviewed, which means that all their care needs should be known about and should be met. Evidence: We saw that there were up to date copies of the homes statement of purpose and service user guide available in the reception of the home. We were told that these documents were included in welcome packs, which also included copies of the homes complaints procedure, available in each persons bedroom. It was positive to note that the service user guide was in an easy read format and contained information about the range of fees charged by the home. This meant that people had good information to enable them to make informed decisions about the choice of home. Care Homes for Older People Page 11 of 36 Evidence: We were told that there had been no new admissions to the home since the random inspection on 8 July 2008. The recently appointed acting manager told us that there were 17 people accommodated. We saw evidence from a sample of care records that everyone living at the home had received or been offered ongoing reviews of their care needs and their placement at Hillcroft Nursing Home, the most recent reviews had taken place in May 2009. There was evidence that the acting manager had proactively sought advice and support for someone displaying changes in behaviour, which was positive. We noted that an alternative placement was being sought for someone with behaviours associated with dementia, and as this home has a registration category for 10 places for people with nursing and dementia we had discussions about the homes perceived capabilities to manage people diagnosed with this condition. We were told that the acting manager and staff had undertaken dementia awareness training. The acting manager and registered proprietors representative told us that they wished to retain the homes registration category for the 10 dementia beds but recognised that not having separate facilities could present problems when trying to manage very disruptive behaviours in a shared communal setting for everyone. They suggested they would only wish to offer care for people with mild dementia. We recommended that their admission criteria should be clearly published in the homes statement of purpose and service user guide, so that it would be clear to people and their representatives that they may be moved if the home was unable to meet their needs. We saw that there were updated contract and terms and conditions of residence, which included comprehensive information. At the previous inspection we had discussed concerns about staffing levels and the continuity of care from registered nurses. There had been heavy reliance on the use of agency nurses to provide the necessary cover, who may not have had good in depth knowledge of peoples needs, with extra pressure on the permanent nurses and care staff. At this inspection it was positive to see that the acting manager had taken account of the dependency levels of people living at the home and additional nurses, carers, kitchen staff and people to assist with feeding had been employed. The acting manager had also made sure there was an additional member of staff on duty to someones extra needs. This meant that people were safer and were receiving care and attention in a timely way when they needed it. Care Homes for Older People Page 12 of 36 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. There are care plans and risk assessments, which provide staff with guidance and are generally adequate to meet peoples needs. There are not always assurances that all individual needs will be met for each person. The arrangements for administration of medication do not ensure that every person at the home receives their medicines as prescribed by their doctor, which poses risks of harm to their health and well being. People are generally treated with respect and courtesy, with rights to privacy and dignity maintained. Evidence: We looked at of care records for a sample of people living at the home. The recently appointed acting manager had continued with improvements in the way the information had been used to assess and plan to meet each persons needs. The majority of care plans we saw were more person centred and demonstrated people or their representatives had been involved in developing the plans for their care and Care Homes for Older People Page 13 of 36 Evidence: support. There were generally less variances in how well the healthcare screening tools, risk assessments and care planning were implemented, monitored and maintained. This meant that generally persons living at the home could feel assured that their care needs were known about, understood and would be met. We were concerned that not all the care demonstrated the same positive progress. Notably the care and care records for one person were repetitive and though we eventually found all the information was there, it was difficult to follow and actions had clearly been overlooked, which resulted in some of the persons needs not being met. We looked at the care being provided for a person with diabetes, dementia, renal failure and other complications. Whilst it was positive that a number of risk assessments and care plans were in place, there was insufficient evidence that the nurses had followed up with appropriate actions. In the care plans there were details of daily insulin to be given and blood glucose monitoring, and instructions of action to be taken for readings which were outside of the normal parameters. We saw records of contact with the diabetic service for the previous year and for the weekend prior to this inspect but the acting manager and a nurse acknowledged that there was no evidence to show regular support had been sought in the intervening period for this persons unstable condition. The acting manager also acknowledged there was no evidence that the home had followed up the recommendation issued at the previous inspections, to involve the diabetic specialist nursing team in Dudley, for support and specialist training for nurses and more basic training for care staff. We looked at the homes training matrix with the acting manager, which showed only one day training dates relating to diabetes. We were informed the diabetic training for registered nurses should be four days. We contacted the diabetes nurse specialist who confirmed that the home had sought advice only on a sporadic basis and the specialist service would assume there were no concerns if no contact was made. She also told us there was no information to show that the Registered Nurses or care staff had attended the specialist diabetic training offered and she commented that she had also discussed this training with the home in 2008. The care records did not demonstrate that the full range of diabetic screening for vision, foot and skin care, involving diabetic health screening practitioners was taking place on a regular basis. The person with renal failure had a care plan dated 25/9/08, Management of Renal Failure, which indicated that Blood Pressure was to be monitored, recorded and any fluctuations be reported to the GP. At the inspection in December 2008 we reported that there was no evidence to show that this had been diligently followed up. We discussed this with the acting manager at that time, who acknowledged the omission, Care Homes for Older People Page 14 of 36 Evidence: and wrote to us following the inspection visit to provide assurances that the appropriate monitoring had been put in place. At this inspection visit we noted though the blood pressure readings had been recorded for most months there were some very low readings and for the two months before this inspection the persons mental state had deteriorated and refused was recorded. When we discussed these records with the new acting manager and nurses we were not given any evidence to show that efforts had been made to monitor this persons blood pressure at different times or on different days or that this aspect of the persons care had been discussed with their doctor. There was evidence that the home had struggled to meet this persons needs in relation to her dementia and behaviour, which had resulted in incidents with other people living at the home on at least two occasions. These incidents had been referred to Dudley Directorate of Adult, Community and Housing Services (DACHS) in compliance with safeguarding procedures. There had been involvement of staff from social services and healthcare professionals. However we were concerned to see this person sleeping in the chair in the lounge at 07:30 am. We spoke to the night nurse who told us that this person had been up all night. We noted that this person looked worn out and unkempt wearing the previous days clothes. We were told she frequently refused personal care, meals and medication. We saw that one antipsychotic medicine was being administered covertly, disguised in drinks of tea. From discussions staff seemed only concerned with administering the Promazine covertly and the nurse on duty and the new acting manager acknowledged that they had not specifically sought medical advice about the administration of the other medicines, which were important to manage this persons diabetes, renal failure, pain and anaemia. They acknowledged there were no written care plans or protocols for the covert administration of Promazine. The acting manager told us she felt that there had been reluctance from medical professionals to support the home with this persons care. Additionally there was difficulty in finding another placement because of the presenting problems in managing her needs. We saw notes of a meeting held with the family, which recorded the relatives concern about the persons appearance and care being provided. We looked at the care of another person being nursed in bed. Though there were improved care plans and risk assessments in place, there were still areas which needed further attention. For example the moving and handling risk assessment indicated the person was non-weight bearing, and required the assistance of two carers at all times. It did not mention staff must carry out transfers using slide sheet, which we were told had to be used. Also the monthly evaluations on 25/1/09 made no mention of an accident reported as a Regulation 37 notification to the Commission indicating caught right shin by hoist, causing a skin tear. Similarly the evaluation on Care Homes for Older People Page 15 of 36 Evidence: 21/2/09 did not mention of the incident notified to the Commission indicating bumped on head when moved up the bed. This suggested that evaluations were not carried out diligently and risks to the safety of persons living at the home were not necessarily being controlled or minimised. We saw that this person had lost weight and it was positive there had been liaison with dietician and speech and language therapists. The person could not be weighed and the home was using the Malnutrition Universal Screening Tool (MUST) and measuring the upper arm circumference (MUAC) and this had been recorded by nurse as being between 20cm to 30cm each month. We questioned what this meant and the acting manager spoke to the nurse who acknowledged she did not understand how to use this measurement. We were concerned that nurses were not taking personal or professional responsibilities to update their clinical knowledge and were using assessment tools in a way, which had no meaning in monitoring the persons condition. We noted a large water blister on this persons right arm, approximately 9cm x 9cm, apparently at the site of cellulitis where a prescribed tubigrip bandage had been, removed at the persons request because of pain. We strongly advised that advice from the tissue viability nurse should be sought. We were told on the second day of the inspection a referral had been made. On a positive note we saw generally good evidence overall of referrals to doctors and other healthcare professions, such as speech and language therapists, dieticians, dentists, optician and chiropodists, though as already reported this varied from person to person. We looked at the way people were cared for when they were being nursed in bed and recommended that the pressure setting for pressure relieving mattresses should be recorded and regularly checked to be effective and to be as comfortable as possible. We saw that generally special care records had improved but recommended that food and fluid charts should be accurately collated with daily totals of intake and output with regular monitoring and evaluation. At previous inspections, we discussed the issues of social isolation for people nursed entirely in bed in their rooms. At the random inspection visit in July 2008 there were no socialisation care plans or recorded interaction for the people cared for in bed for lengthy periods. It was positive that there were better records at this visit and one person nursed in bed told us that staff frequently popped in and that they always came promptly when buzzed. The pharmacist inspector visited the home on 9th June 2009 as part of the key Care Homes for Older People Page 16 of 36 Evidence: inspection to check the management and control of medicines within the service. A previous inspection had found that the room where medication was stored was too hot. At this inspection we saw that a new air conditioning unit had been fitted into the room. The temperature of the room was recorded daily between 20 and 22 degrees centigrade, which was within the correct storage temperature for medication. We also saw temperature records for the medication fridge, which was between 3 and 7 degrees centigrade and is within the correct storage temperature. This means that peoples medication was stored correctly within the recommended temperature ranges. We looked at four medication administration records together with each persons care plans. The service had improved their records for the receipt, administration and disposal of medication. For example, we found the medication administration records had been well documented by the nursing staff either with a signature for administration or a code was documented with a reason why medication was not given. This means that the medication records were up to date and clearly documented whether medication had been given to the person or if not a reason was recorded. We saw up to date records for the disposal of medication and current balances of medication were available. This means that medication records were robust and accurate. This improvement was acknowledged and the manager informed. We spoke to the manager and a nurse about medication training for staff. We were informed that two nurses had done training on medication handling in February 2009 and three more nurses will do the training in July 2009. We did not see certificates, however we were shown the names and dates when the training took place. This means that the nurses who administer medication were undertaking training in medication to ensure people receive their medication safely. We found that sometimes there was a lack of clear written instructions linking the medication records with the health care plans to ensure that people received their medication as prescribed. For example, one person was prescribed five medicines, however one of their medicines was being given to them covertly hidden in a drink. The liquid medicine was being given four times a day to help with behaviour control. We were informed by a nurse that it was usually put in a cup of tea. We saw a handwritten note from the doctor, which stated that the medicine could be put in a drink, which demonstrated that the home had involved a healthcare professional and was aware that the medicine was to be hidden in a drink. However, we were concerned because the person was also prescribed four other medicines which were not being given covertly in drinks. We saw that the medication records documented Care Homes for Older People Page 17 of 36 Evidence: that the other four medicines were often refused or not given because the person was sleepy. We asked a nurse what action was being taken to ensure these medicines were administered. We were informed that the Doctor was aware they were being refused but this had not been documented. Therefore, although there was written documentation about ensuring one medicine was to be given hidden in a drink there was no recorded information about administering the other medicines. This means that there is an increased risk to the health and welfare of the person. We found that the times of some prescribed medication had been altered without discussion with the Doctor. For example, one person was prescribed a medicine for behaviour control to be given at night. The medicine can cause drowsiness. We saw that someone had changed the time documented on the medication administration record from 2100 hours to 1800 hours. A sleeping tablet was also prescribed to be given at 2100 hours but the records documented that this was refused because the person was sleepy. We asked a nurse and the manager who had been involved in agreeing this change and if a medication review had been discussed with a Doctor. The manager and a nurse could not say if a doctor had been involved but both said it was changed to stop the person wandering and so that the person was quieter. We saw no record in the care plan of any discussion with a doctor or if the medication had been reviewed. This means that there was an increased risk of harm to the people who live in the service. We were shown documentary evidence on the second day of this inspection visit that the acting manager had sought visits from doctors and the diabetic nurse specialist to review the care and medication for the three people we had raised concerns about. This was positive but we made the management of the home aware it was unacceptable that no action had been taken until prompted by inspectors, and this did not demonstrate a proactive approach to meet the health care needs of people living at the home. We saw that staff treated people living at the home with respect and courtesy, maintaining their privacy and dignity. The majority of people living at the home looked well presented and were appropriately dressed for the time of year. During discussions staff demonstrated a good understanding of how to people wished to have their care provided. Care Homes for Older People Page 18 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at this home have opportunities to take part in activities. People are able to maintain contact with their friends and families who are welcomed. Meals are appetising, and generally people receive a nutritious diet. Evidence: The sample of care records we looked at had been improved to include rising, retiring, bathing or showering preferences and the new activities organiser had started work to make sure activities preferences were recorded in a more meaningful and person centred way. The routines of the home were generally more geared around each persons needs and preferences. From observations and discussions although some routines still appeared to centre around staff availability and how best they feel they could attend to each persons essential needs, the recently appointed acting manager was introducing changes to make sure daily routines were more flexible to accommodate each persons preferences. On arrival at this inspection visit at 07:30 am, we noted that there were eight very dependant people with complex needs already up, some dressed and seated in the Care Homes for Older People Page 19 of 36 Evidence: communal lounge and dining room. We asked the night staff how they had established this was their choice. We were not shown records to demonstrate this was at their choice, though staff told us that they woke early and wanted to get up. We were also told that the three people we saw sleeping in armchairs had refused to go to bed and had been in the chairs all night. These were people with dementia, and the way their care was being managed is reported at the Health and Personal Care section of this report. We discussed our observations with the acting manager, especially as two people looked very tired and unkempt. Staff spoken to told us at times, it was difficult to have sufficient time for each person, particularly in the mornings because of the number of people needing assistance of two staff, as well as trying to support staff in other areas of the home. They acknowledged that there was some improvement at breakfast with the employment of staff to feed people every morning. It was positive that there was now evidence that outstanding recommendations issued at previous inspections, relating to the daily routines, social stimulation, and advocacy had been put in place. We spoke with the recently employed activities organiser, who was very enthusiastic and had lots of imaginative ideas. She had made contact with relatives to involve them in providing information about peoples backgrounds and preferences. She had also contacted a number of organisations such as the Alzheimers Society, Age Concern and other local community groups. The activities organiser had started to put in place an activities programme for planned and spontaneous group and individual activities. There was now better evidence of activities suited to the needs of people with dementia, physical and sensory disabilities. Examples were films from eras people could relate to, taking books, pictorial books as taking points and crafts people could remember, such as podging for one person. There was some evidence of people visiting the home to provide activity sessions such as musical sessions and church services. The majority of materials for activities were acquired as donations and there was no budgetary provision for activities or access to the wider community. We heard lots cheerful banter between staff and some of the people living at the home. We discretely observed meal times during the day. We spoke to staff and examined records and found that generally food and fluid records had improved with better evidence that people received a wholesome, appealing, balanced diet. We were told that the excellent cook had left the homes employ but had recently returned and there were additional catering staff employed. We saw that the basic daily breakfast menu was displayed on the tables but there were still no pictorial menus in evidence, Care Homes for Older People Page 20 of 36 Evidence: which would have helped people with dementia and other sensory impairments make better informed choices. However we saw that people could have cooked options if they wished such as bacon sandwiches or egg on toast and it was positive that we heard staff ask each person what they wanted for lunch and later in the day what choices they wanted at tea time. The meals appeared appetising and the cakes smelled delicious. The home had been inspected by Dudley Environment Health Service and had achieved a Four Star and Sliver Award for food safety and healthy eating. Efforts were made with table settings to make them attractive with tablecloths, all required cutlery and condiments. People told us they liked the food and a visitor told us they thought the meals were very good. Care Homes for Older People Page 21 of 36 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 can have confidence their concerns or complaints will be listened to and investigated and the management practices generally protect people living at the home from risks of harm or abuse. Evidence: We saw that the home had an up to date complaints procedure, which was displayed in the reception area and contained in the service user guide. Information supplied at the inspection showed that the home had received one formal complaint since the last inspection visit in December 2008. The acting manager had also reported the incident to the Local Authority as a safeguarding referral in compliance with multi agency procedures. She had also introduced an informal concerns and complaints record, which was a positive initiative and meant that minor were also issues were looked into and resolved. We saw records to show all complaints and concerns had been investigated within 28 days, with satisfactory resolutions implemented. The responses during the inspection indicated that people were aware of how to raise concerns or use the homes complaints procedure. This demonstrated positive practice and the homes more proactive response to peoples experiences and perceptions of the service. The acting manager had made two recent safeguarding referrals to the Local Authority relating to one persons behaviour, which was posing risks to the safety of other Care Homes for Older People Page 22 of 36 Evidence: people living at the home. As reported at the Choice of Home and Health and Personal Care sections the home were struggling to manage this persons care and behaviour associated with dementia. There was a lack of clarity at the home about this persons mental capacity and we contacted the allocated social worker who told us that the person had been assessed as lacking capacity under the Mental Capacity Act 2005. We emphasised to the acting manager the importance of involving multi agency professionals and as necessary an Independent Mental Capacity Advocate (IMCA) for decisions to be made in the persons best interests. We were given information that the acting manager had recently attended training regarding Mental Capacity Act and Deprivation of Liberty Regulations and she told us about her plans to cascade this training to the staff team, which demonstrated a positive and proactive approach. We looked at a sample of safeguarding training certificates providing documentary evidence of good progress to equip all staff with relevant safeguarding training. We saw from the staff training matrix that the majority of staff had been provided with training, with future training dates planned. This meant that staff had appropriate awareness of safeguarding vulnerable adults and staff we spoke to were aware of what they needed to do should an incident occur. However we recommended that all staff should be given time to read, be aware and understand, the homes and the multi agency procedures for the protection of vulnerable adults. Care Homes for Older People Page 23 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is a safe, homely and comfortable environment for people living there. There are systems in place for maintaining infection control. Evidence: The interior of the home was a generally bright, cheerful and homely. There were attractive, and well maintained garden areas, with garden furniture for people to use in the warm weather. The acting manager told us that there were plans to have planters to grow vegetables as activities and to provide fresh home grown produce for people living at the home. We looked around the premises and identified that improvements were continuing and the acting manager had started to audit and devise a written program of redecoration and refurbishment. A number of recommendations for renovation and redecoration issued at the last inspection were completed. For example new carpet had been provided in the corridors on the first floor. The acting manager had also reorganised some of the communal area to make better use of the space. It looked less cluttered and with net curtains removed between areas, the lounges seemed more spacious and airy. We looked at a sample of bedrooms with peoples permission where possible. Some Care Homes for Older People Page 24 of 36 Evidence: were attractively decorated and personalised according to individual preferences, such as family photographs, ornaments and small items of personal furniture. The acting manager acknowledged that there were still a number of areas, including bedrooms, which needed redecoration. We saw two sets of bedrails, which were fitted, regularly checked and maintained in a safe condition. During the inspection we were told that the home was generally clean, warm, and comfortable. However we saw comments from relatives in peoples reviews with social workers referring to the issue that the home could be cleaner. We were told that the very heavily stained ground floor communal carpet was frequently cleaned but the condition could not be improved. We recommended that this should be replaced if it could not be maintained to an acceptable standard. One persons family had requested a change of bedroom because of the condition of the room. This person had been moved to another bedroom, which was satisfactory. The acting manager took us to a bedroom, which had been completely redecorated and renovated, which would be used to demonstrate the standards the home was aiming for. We saw that all the WCs on the ground floor, which had been recently cleaned, were left with very wet floors. The home had only one domestic assistant in sheltered employment. We recommended that the organisation should provide support for this person with risk assessment and review cleaning arrangements for the home. The small laundry, located on ground floor of the building was well equipped with commercial washers and tumble dryers. The laundry service was generally well organised and the staff demonstrated good standards of infection control. There was a laundry procedure and measures in place for supplies of disposable gloves and aprons to be readily available in the laundry at all times. However there was a large box of tights and socks in the laundry area, not identified in any way as belonging to individual people. We discussed the issues of personal dignity and risks of cross infection from items of clothing, which might be used communally. The member of staff told us they had not considered the issues in relation to these items of clothing. The acting manager arranged the disposal of the contents during the inspection visit. She gave us assurances that this matter would be raised as an issue of concern with the staff to promote better compliance with infection control and to promote improved dignity for people living at the home. She agreed to look for alternative ways to identify clothing with compromising peoples rights to privacy and dignity. The kitchen was maintained in very good order, and it was clean and tidy and well organised. We noted that appropriate food hygiene and safety measures were in place, with well kept Care Homes for Older People Page 25 of 36 Evidence: records, monitored by the registered manager, and Environmental Services. The home had achieved the Dudley MBCs Environmental Health Four Star Food Award for healthy eating and food hygiene. There were some additional areas, which required attention at this inspection, such as: Renovation or replacement of some armchairs and other furniture, which had become very shabby and worn. Consideration of a larger communal TV, the current screen was quite small and difficult for some people to see, especially as it was being used more for old time films and DVDs. Serious consideration of orientation of the environment for people with dementia and / or sensory disabilities. Replacement of very stained beakers for peoples drinks. Bedroom 2, attention to colour coordination and repair or renovation of the chest of drawers. Care Homes for Older People Page 26 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff, generally meet the needs of people living at the home and people at the home receive care more consistently to meet their needs. The homes recruitment procedures provide safeguards to protect people living at the home from risk of harm. Evidence: We saw that there were 17 people accommodated, with a variety of dependency levels and diverse needs. The acting manager told us that she reviewed staffing levels on a regular basis, taking account of the occupancy and dependency levels of the people accommodated, which demonstrated good practice. She had recently increased the care staffing levels when someone was very unwell. Assessment of staffing rotas and information from the records demonstrated that the home was generally maintaining satisfactory staffing levels. There was a qualified nurse on duty on all shifts, with five care staff on the early shift, four on the late shift and two on the night shift. In addition there were catering, laundry and domestic staff. We discussed our concerns about the standard of cleanliness and capability of the only domestic assistant employed with the acting manager, and emphasised that satisfactory levels of infection control and cleanliness must be maintained throughout the home. A number of additional staff had been recruited since the last inspection in December 2008, including the acting manager, two registered nurses, care assistants, catering Care Homes for Older People Page 27 of 36 Evidence: assistants, an activities organiser and a new administration assistant. We noted that the home was much better organised with a calmer atmosphere. We looked at a random sample of staff personnel files, which were generally satisfactory. The organisation demonstrated robust recruitment practices, with well ordered staff files and essential documentation. We noted that the organisation and acting manager demonstrated a good commitment to staff training and development and were generally providing all staff with appropriate training to raise awareness and skills to respond to peoples changing needs. We discussed the need for registered nurses to keep up to date with clinical practices, such as diabetes in the Health and Personal Care Section of this report. We saw evidence that 10 of 13 care staff had achieved an NVQ level 2 or NVQ level 3 care award with new candidates registered for training. The catering staff had been enrolled as candidates to achieve an NVQ in catering, which was very positive. During discussions staff told us they felt supported and could see how much the home had improved over the past year. The comments received from staff included, we look people here well, and we are a good staff team. Care Homes for Older People Page 28 of 36 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. There are more consistent management arrangements in place and generally people who live at the home can feel reassured that their health, well being and safety will be safeguarded. Evidence: Hillcroft Nursing Home had not had a registered manager since July 2008. The home had struggled to demonstrate compliance with Statutory Regulation Notices issued in February 2008. A new acting manager was appointed in January 2009, a Registered General Nurse (RGN) with clinical and management experience in care settings. She had submitted an application to the Care Quality Commission be registered as manager at this home. The formal Fit Person Interview was planned for the week following this key inspection. She demonstrated through the inspection a willingness to co-operate and demonstrated a commitment to her own professional development. It was positive that she had a good awareness of the recently implemented Deprivation of Liberty Safeguarding Regulations and the implications for people living at the home. She planned to cascade the knowledge to all staff at the home. Care Homes for Older People Page 29 of 36 Evidence: During discussions there was evidence of a more open, approachable ethos, which encouraged communication with people living at the home, their relatives and staff. We saw evidence that a nominated person on behalf of the registered proprietor visited the home regularly. We looked at the Regulation 26 Reports held at the home and noted that they were realistic and constructive. We were told that the quality assurance system was based on the National Minimum Standards. The acting manager had introduced useful quality audits for areas such as accidents, skin tears, pressure ulcers and incidents and events affecting people at the home. This meant better outcomes for people receiving the service. There were clearer lines of accountability within the home, and through the management structure. The acting manager told us she had made the decision to undertake an individual supervision session and appraisal with each member of staff to get to know them. She had also introduced a key worker and named nurse system to improve individualised and more person centred care for people living at the home. We saw that staff meetings were also taking place, which improved communication and had benefits for people living at the home. The acting manager and staff team have continued with good efforts to involve people living at the home, their relatives, and representatives in the running of the home. We noted that there had been a meeting with people at the home and their relatives, with minutes available. We recommended that the frequency of meetings should be increased. The homes survey questionnaires were due to be distributed to people at the home, families and stakeholders, in July 2009 and we were told the results would be collated and published. We saw evidence that the results of previous consultations had been acted upon areas where there were concerns, for example the meals were regularly discussed and reviewed. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and well organised. There were some gaps in the mandatory training, however there was evidence that there was a planned programme to make sure all staff would receive mandatory training commensurate with their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training. During the first morning of the inspection visit the fire alarms were activated and the West Midland Fire Service was called in accordance with the homes procedures, which was positive. The incident turned out to be a false alarm. However the written fire procedure in the Care Homes for Older People Page 30 of 36 Evidence: reception area instructed staff to start the evacuation of people living at the home and when we asked what action should be taken there was no clarity about who should be doing what. We discussed with the Fire officer the expectations about the actions the home should take and it was evident the registered persons should seek further advice and revise their fire procedures. There had been 18 recorded accidents involving people living at the home since January 2009. The acting manager had introduced an effective system for auditing, analysing and evaluating accidents, with effective measures implemented. Care Homes for Older People Page 31 of 36 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 32 of 36 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 9 13 The registered persons must 01/08/2009 ensure there are care plans in place for the administration of when and as needed medication and staff act appropriately to monitor and inform the relevant healthcare professionals as needed. This is to safeguard the health and well being of people living at the home. 2 9 13 The registered persons must 01/08/2009 ensure there are agreed risk assessments, protocols and care plans in place for the administration of any medication, which is disguised in food or drinks and that this practice is kept under review with all relevant health and social care professionals. Care Homes for Older People Page 33 of 36 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 This is to safeguard the health and well being of people living at the home. 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 It was recommended that the homes admission criteria should be clear and be published in the statement of purpose and service user guide so that the commissioners of services and people considering living at the home have an accurate understanding about the service the home is able to provide. That the all health care risk assessments and care plans include all of each persons assessed needs, and accurately reflect all changes to health and needs, and be referred for professional advice where necessary. It is recommended that the pressure setting for pressure relieving mattresses should be recorded and regularly checked. It is strongly recommended that advice from Diabetic specialist nursing service be sought for any person with diabetes, living at the home, with records of screening, support and advice offered and that a record be maintained of staff training in relation to diabetes. This is a repeated good practice recommendation, which was not met. It is recommended that food and fluid charts should be accurately collated with daily totals of intake and output with regular monitoring and evaluation. It is strongly recommended that budgetary provision should be made for activities and social stimulation for people living in the home. That behaviour care plans should be diligently completed 2 7 3 8 4 8 5 8 6 12 7 18 Care Homes for Older People Page 34 of 36 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 with fuller and more specific information which can be used to evaluate, understand and improve the management of behaviour triggers for individual people with behaviour that challenges, such as agitation, aggression and wandering. 8 18 It is recommended that all staff should be made aware of the homes safeguarding policies and Dudley MBC multiagency Safeguard and Protect procedures for vulnerable adults, and that that staff signatures should be obtained to demonstrate they have read these documents. The audit of the home should be expanded to include all areas requiring attention such as Renovation or replacement of some armchairs and other furniture, which had become very shabby and worn. Consideration of a larger communal TV, the current screen was quite small and difficult for some people to see, especially as it was being used more for old time films and DVDs. Seriously consideration of orientation of the environment for people with dementia and / or sensory disabilities. Replacement of very stained beakers for peoples drinks. Bedroom 2, repair or renovation of the chest of drawers. 10 21 Consideration should be given to improving the decoration of the WCs shower and bathrooms to promote a more homely feel. It was strongly recommended that there should be support in place for the domestic assistant to ensure safe and satisfactory standards of cleanliness and infection control are maintained at all times. There should be an effective assurance system in place that includes quality checking systems that focuses and measures all outcomes for people living at the home, with remedial actions put in place where needed. The registered persons should review the instructions when fire alarm is activated and ensure that all staff are aware of their responsibilities for people living at the home to assure their health, well being and safety. 9 19 11 27 12 33 13 38 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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