Care Home: Hillersdon Court

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What the care home does well The home ensures that pre admission assessments are carried out on all new and potential residents, with only those whose needs can be met, being admitted to the home. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Residents expressed a good level of satisfaction with the care provided and with the staff working in the home. There is a stable and committed team working in the home. The registered manager and staff have good working relationships with health care professionals who visit the residents in the home. Meals provided in the home are varied, nutritious and appealing and the manager promotes a relaxed and friendly atmosphere in the home for residents, staff and visitors. What has improved since the last inspection? Although the key inspection completed in June 2007 was on the whole mainly positive it did identify a number of areas that needed improvement particularly around medicine handling the environment, quality monitoring staff recruitment and training. Two random inspections completed in 2007 identified further additional requirements in relation to the plans of care, individual risk assessment, the homes management, fire safety, medicine handling, staffing arrangements and activities in the home. Following these inspections a new manager was appointed in October 2007 and she has gone a long way to respond positively to the requirements made. Improvements have been made to the care documentation including further use of risk assessments to inform the care provided. Further attention however needs to be given to recording resident choices, preferences and ensuring all documentation is dated and signed and the necessary photographs are retained in the home. All matters relating to medicines have been addressed with the advice and support of a new supplying pharmacist. Although some quality monitoring systems have been established these need to be built on. The manager confirmed that recruitment practice in the future will be robust and it was noted that all the required CRB and Pova checks are in place. Staff training has improved with all staff providing care having attained a National Vocational Qualification in care level 2 or above. The manager confirmed that staff training was being established to ensure all resident’s needs are met, and that all fire safety matters had been addressed. What the care home could do better: Whilst it is acknowledged that the new manager has gone a long way inHillersdon CourtDS0000021137.V375469.R01.S.doc Version 5.2 addressing the shortfalls identified in previous inspections. The report has reflected that there are some ongoing issues that the manager has confirmed that she will address. Clearly in order to do this she needs the support and the necessary resources from the registered provider. Who have been written to separately on this matter. It has however been necessary to make some further requirements in this report. The manager needs to ensure that all care plans are reviewed on a monthly basis and more often if necessary. In addition these care plans need to be composed and reviewed in consultation with either the resident or an allocated representative, unless this offer is declined. This will ensure the care provided is appropriate and those residents and/or their representatives are in agreement with the care provided. During the inspection visit a number of areas and furniture in the home were identified as needing repair and or replacement. The registered person must ensure that the premises and furniture within are kept in a good state of repair. To ensure the safety of the staff and residents, to ensure infection control measures are in place, and to provide an attractive environment for residents to live in. The staffing arrangements did not allow for any activity of social care and did not take into account the extra time needed when looking after residents with a dementia type illness. The registered person must ensure that there are suitable staffing arrangements to meet the health and welfare needs of all residents in the home. This will ensure the safety and well being of residents and should also take into account the provision of social care and activity in the home. Although some resident/representative questionnaires had been used to gain some views these had not been audited. The registered person must develop a full quality assurance system for the home, ensuring that stakeholders views are sought and taken into account, that regular recorded monitoring of systems used in the home are carried out, and that a report is generated. Key inspection report CARE HOMES FOR OLDER PEOPLE Hillersdon Court 18 College Road Seaford East Sussex BN25 1JD Lead Inspector Melanie Freeman Key Unannounced Inspection 26th May 2009 09:10 DS0000021137.V375469.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillersdon Court Address 18 College Road Seaford East Sussex BN25 1JD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01323 897706 01323 898689 bevhillersdon@aol.com Mr James Lord Mrs Sylvia Lord Mrs Beverley Newton Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 20. Date of last inspection 5th October 2007 Brief Description of the Service: Hillersdon Court is registered to provide residential care and support for up to twenty older people. The premises comprise of a large detached house, which has been extended over the years. The home is situated close to the shops and railway station in Seaford town centre and within walking distance of the seafront. Service user accommodation comprises of seventeen single rooms and one double room, eleven of which have en suite facilities. All rooms are fitted with a call bell system. The proprietors of Hillersdon Court Mr and Mrs Lord, also own Bybuckle Court, another care home for older people situated in the Seaford area and are registered as individuals. Weekly fees range from the funding supplied from the placing 450 pounds a week. The fees do not include hairdressing, chiropody, newspapers and any personal toiletries. Some specific outings are included in the fees. Information about the service is available from Mrs Newton, the homes registered manager. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 uses the term service user to describe those living in care home settings. For the purpose of this report, those living at Hillersdon Court will be referred to as residents. This was a key inspection that included an unannounced visit to the home on Tuesday 26 May 2009, and follow up contact with a visiting health and social care professionals. The allocated inspector spent approximately six hours in the home and was able to discuss matters with the manager who received the inspection feedback at the conclusion of the visit. A tour of the premises was undertaken and a range of documentation was reviewed including the homes service users guide, pre admission assessment procedures, the systems in place for handling complaints and protecting resident’s from harm, staff recruitment files, staff training records, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth and the inspector ate a midday meal with a group of residents in the dining room. Comments shared by residents and their representatives during the inspection process included ‘It’s pretty good here, food is good if you do not like anything they give you something else. ‘They do your washing well and all the staff are good’ ‘We are looked after very well and I am able to keep active with odd jobs around the place. I can also go out for walks’. The required Annual Quality Assurance Assessment (AQAA) was completed by the manager and returned when requested and was used to inform this inspection report. What the service does well: The home ensures that pre admission assessments are carried out on all new and potential residents, with only those whose needs can be met, being admitted to the home. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 6 Residents expressed a good level of satisfaction with the care provided and with the staff working in the home. There is a stable and committed team working in the home. The registered manager and staff have good working relationships with health care professionals who visit the residents in the home. Meals provided in the home are varied, nutritious and appealing and the manager promotes a relaxed and friendly atmosphere in the home for residents, staff and visitors. What has improved since the last inspection? What they could do better: Whilst it is acknowledged that the new manager has gone a long way in Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 7 addressing the shortfalls identified in previous inspections. The report has reflected that there are some ongoing issues that the manager has confirmed that she will address. Clearly in order to do this she needs the support and the necessary resources from the registered provider. Who have been written to separately on this matter. It has however been necessary to make some further requirements in this report. The manager needs to ensure that all care plans are reviewed on a monthly basis and more often if necessary. In addition these care plans need to be composed and reviewed in consultation with either the resident or an allocated representative, unless this offer is declined. This will ensure the care provided is appropriate and those residents and/or their representatives are in agreement with the care provided. During the inspection visit a number of areas and furniture in the home were identified as needing repair and or replacement. The registered person must ensure that the premises and furniture within are kept in a good state of repair. To ensure the safety of the staff and residents, to ensure infection control measures are in place, and to provide an attractive environment for residents to live in. The staffing arrangements did not allow for any activity of social care and did not take into account the extra time needed when looking after residents with a dementia type illness. The registered person must ensure that there are suitable staffing arrangements to meet the health and welfare needs of all residents in the home. This will ensure the safety and well being of residents and should also take into account the provision of social care and activity in the home. Although some resident/representative questionnaires had been used to gain some views these had not been audited. The registered person must develop a full quality assurance system for the home, ensuring that stakeholders views are sought and taken into account, that regular recorded monitoring of systems used in the home are carried out, and that a report is generated. 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. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents receive sufficient information on the home to enable them to make an informed decision over whether the home is the right place for them. The admission procedure allows for the needs of prospective residents to be assessed by the manager before admission. EVIDENCE: The manager confirmed that the home has a statement of purpose and service users guide and that these are usually displayed in the front entrance area. On request the service user’s guide was provided although the statement of purpose was not found. The service user’s guide was a useful document although this needs to be updated to reflect fully, and accurately the required information. For example it Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 10 did not record resident’s views on the service or include reference to the last key inspection or where it could be accessed, it also referred to the Commission completing two inspections a year, which is not the case. The manager said that she was looking to update both these documents and would review and updated accordingly, taking into account the standards and the associated regulations. She said that she would ensure that both documents are readily available to residents and other interested parties, and that all residents are given a copy of the service user’s guide when they are admitted to the home. An assessment of the admission process included a review of the documentation used in respect of the last two admissions to the home. This demonstrated that all prospective residents are assessed prior to admission by the registered manager. It was however not possible to confirm when this was completed or where, as the assessment documents were not dated or signed and did not record where the assessment was completed. Although prospective residents and their representatives are told verbally if the home is able to meet their needs following their assessment, this is not currently confirmed in writing. This was discussed with the manager who was made aware that this is required, whenever possible and she agreed to compile a suitable letter for use in the future. Intermediate or rehabilitative care is not provided at Hillersdon Court. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using the 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 was found to be meeting residents health and general needs with assessed additional community support when needed, although the regular reviews and resident’s consultation needs to be clearly recorded. On the whole the homes practice ensures residents medicines are administered safely. Care is delivered in such a way that promotes and protects the residents privacy, dignity and individuality. EVIDENCE: The care documentation pertaining to two residents were reviewed in depth as part of the inspection process and each of these residents was met with during the inspection visit to the home. These confirmed that the care needs of each resident are fully assessed and the needs identified are reflected in plans of care. On the whole the care documentation was informative and included Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 12 relevant risk assessments that were responded to, that included an in depth nutritional screening, and a moving and handling assessment. Risks associated with skin damage and continence however needs to be established. Although the plans of care were person centred they need to record more clearly people’s individual choices and preferences. The system for recording and reviewing the care plans and the resident’s involvement in the planning of care are not implemented. Therefore there was no evidence to confirm that the plans of care are reviewed regularly or that they take into account resident’s views. This was discussed with the manager who was able to recognise this shortfall. The care documentation looked at did not include photographs of residents as required, and it was also noted that some documentation at all levels was not dated or signed. Again the manager said that these matters would be addressed. Peoples preferred term of address was recorded within the care documentation and during the inspection visit residents were addressed by their preferred names. All feedback about the care provided was positive and comments received included we are looked after very well and I am able to keep active with odd jobs around the place’ ‘I am well looked after here’. A visiting health care professional also expressed praise for the home on how they looked after a dying resident. Medicines are supplied in a Monitored Dosage System, and each floor has a drugs trolley to store, and administer from. There is also a small room that is used to store some stock and ‘as required’ medicines, along with the care plans. This area does not have any natural ventilation and needs to have its temperature monitored to ensure that it is suitable for medicine storage. The manager agreed to do this. The manager was aware that legislation around the storage of Controlled Drugs has changed and was consulting with her supplying pharmacist with regard to improving these facilities. Further information on this matter is available on the CQC Internet within the guidance document The safe management of controlled drugs in care homes. Records seen were found to be accurate and clear. Some medicines are prescribed on an as required basis and discussion took place with the manager around providing written individual guidelines to ensure staff administers these in a consistent way. She agreed to progress this matter. It was clear from direct observation that residents are treated in a respectful manner with their views and choices being taken into account at all times. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 13 Staff knew all the residents well and addressed them by their preferred name. Resident’s rooms are seen as their own personal accommodation and those viewed were attractive and personalised. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a relaxed atmosphere where some activity is supplied and residents are supported in maintaining relationships with their families and friends. The meals in the home are good offering both choice and variety and catering for special diets. EVIDENCE: During the inspection visit it was noted that the interaction between staff and residents was very important to residents, who clearly enjoyed the time spent with staff. The time available for this was obviously restricted, and there was no time or person specifically allocated with the role to promote resident’s social activity. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 15 The manager confirmed there are some activity arranged by staff along with a visiting entertainer who visits 6 weekly, and that a recent trip out had to be cancelled due to the taxi bus breaking down. During the visit most residents were seen to be watching the television in the lounge. Further emphasis needs to be placed on entertainment and activity in the home, to give residents a fuller life, and this was raised with the manager during the visit. This should be progressed by staff that are appropriately trained to promote this important area. One resident was pleased that she was able to do some ‘small jobs around the home that kept her busy’ along with her knitting and reading. The atmosphere of the home was relaxed and the AQAA confirmed that routines in the home are flexible. Residents were seen to move around the home as they wished and visitors were free to come and go as they wanted to. The food provision in the home looked appetising and reflected the preferences of residents and their dietary needs. The meal eaten with residents was good, and residents were asked if they wanted any more, and if they enjoyed the meal by the staff and cook. Residents spoken to said that the meals on the whole were good with one resident saying ‘food is good if you do not like anything they give you something else’. The dining room provided enough space for all residents to eat a meal communally if this was their preference. Records need to be maintained in respect of what each resident has eaten and in what quantity. The manager said that this would be done. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People using the 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 confident that any complaint made would be listened to and responded to appropriately. The managers overview of the home would ensure that any safeguarding issue raised would be responded to quickly and appropriately, although supporting procedures need to be available. EVIDENCE: The home has a complaints procedure that is displayed in the front entrance along with complaint forms, to be used to record any concern. The service users guide also contains a complaints procedure and this was found to be different from the one displayed. This was raised with the manager who agreed to consolidate the procedure and ensure the appropriate procedure is available to people. The AQAA and the manager confirmed that there had been any complaints since her appointment as manager made 18 months ago. Residents spoken to said that if they needed to make a complaint they would speak to the manager who they believed would deal with it. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 17 Although the manager said that staff had received recent training from an outside training consortium, on POVA and the Mental Capacity Act, the home did not have the most recent local policies and procedures on Safeguarding Vulnerable Adults. When this was raised with the manager she advised that these would be sourced as a priority. The only adult protection procedure in the home available to the inspector was out of date, and did not record that Social Services was the lead authority, and that any allegation or suspicion of abuse needs to be reported to them before an investigation is completed by the home. The manager advised that a more up to date procedure had been written but was unable to provide this to the Commission. She was able to demonstrate a good understanding of safeguarding issues within the inspection visit and confirmed that she would always be contacted if a concern was raised in the home and would ensure suitable procedures are available in the home for future reference. Staff recruitment files confirmed that staff have a Protection of Vulnerable Adults (POVA) check completed along with a Criminal Records Bureau check (CRB). Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the physical environment is suitable to meet the needs of the residents, parts of the home are in need of general maintenance, redecoration and furniture replacement. Further attention needs to be given to maintaining infection control measures. EVIDENCE: The home is a converted premises located in a residential area in central Seaford. The home was found to be clean with many of the resident’s rooms being personalised, often with the input from relatives and residents. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 19 Residents rooms are viewed as there own space and reflect the interests of the person occupying the room. One resident was able to have her own dog in her room. A tour of the home identified that the home was in need of general maintenance, and upgrading. The home does not have a maintenance person and there was no written programme for maintenance, renewal and improvement to the environment, that would ensure that the home was safe and well maintained, providing a suitable environment for residents and staff to work in. A number of areas were noted that needed urgent attention and an example of these included a broken handle in a bedroom that left a sharp edge, broken tiles in communal toilet areas and rusty commodes that could not be cleaned appropriately. All areas identified were raised with the manager at the time of the visit for her to address. The manager advised that one of the bathrooms is to be upgraded and she is having quotes to progress this. The home does not currently have a showering facility and the home needs to be mindful of how it can respond to each resident’s preferences in respect of their personal hygiene needs. During the tour it was noted that not all communal hand washing areas had suitable hand washing facilities that included liquid soap and paper towels. In addition unlabeled creams were found in some rooms. The risks associated with cross infection were discussed with the manager. Who later provided liquid soap dispensers for each communal hand washing area and confirmed that all pots of cream would be suitably labeled. The laundry room is located on the ground floor and the AQAA confirmed that the washing machine has a sluice cycle to deal with any soiled linen. At the time of the visit the laundry room had a flooded floor due to recent heavy rain. This needs to be addressed to ensure high infection control practice in the laundry at all times. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the staffing arrangements allow for the health care need of resident to be met it does not ensure that the social and welfare needs of residents are fully addressed. Staff training needs to be fully established to ensure all staff have the necessary skills to meet the needs of residents. EVIDENCE: At the time of this assessment visit 16 residents were living at Hillersdon Court and three care staff were working in the morning supported by a cleaner, cook and the manager. The manager usually works the weekdays but has been working additional shifts to cover shortfalls including catering and care hours. Staff spoken to confirmed that the morning shifts are very busy depending on the varying needs of the residents and the nights have also been very busy. Staff spoken to have chosen not to work nights because it was so busy and Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 21 choices had to be made about who to respond to first at night, as there was times when a number of residents wanted assistance at the same time. Observation during the inspection visit confirmed that staff were busy during the morning and this was compounded by two residents who were needing close supervision and monitoring due to their level of cognition. It was also noted that care staff complete other duties in addition to caring within the home, which included ironing, laundry and catering duties, and that some shifts did not have the full complement of staff throughout. The staffing levels need to be reviewed in conjunction with the dependency levels of the residents, taking into account times of high activity and allowing the promotion of all resident’s choices and preferences. An example of this is the bathing provision that reflects a weekly bath rather than responding to individual choice and promoting a good level of interaction between resident and staff on a social level that is so important to residents. It was however identified through contact with visiting health professionals that extra staff are provided when residents are in need of end of life care. The manager confirmed that all staff now working in the home as cares have a National Vocational Qualification in care at level 2 or above. She however acknowledged that over the last year the staff training was not well organised and she has been concentrating on ensuring staff have attended the necessary mandatory training. Some further work is needed but there was evidence that staff training was now being organised and the manager said that she was committed to ensuring this matter. The staff team is stable and provides a stability to the residents enabling them to know everyone working in the home. Records seen confirmed this stability with the manager confirming that she had not recruited any staff since her appointment as manager. Recruitment files examined evidenced that the necessary CRB and POVA checks had been completed, and that proof of identity was retained within the home. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an experienced manager who ensures a clear ethos and leadership for the home. Quality assurance processes need to be further developed to ensure that the home is well run and in the best interests of residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted although staff training and a regular maintenance programme, with regular risk assessment needs to be established. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has been in post for approximately 18 months and was previously the registered manager at another home locally, having attained suitable qualifications for her management role. She would normally work office hours Monday to Friday but has been covering illness and annual leave within the catering and caring provision. This impacts on the time available to complete some management roles and needs to be reviewed with the registered provider. An example of this is the lack of appropriate supervision records for all staff. The manager has a good working relationship with local health and social care professionals with comments including ‘ she is on the ball and responsive to resident’s needs’ ‘contact with the home is always positive’ . The staffing team is stable and indicated that they were happy with the management arrangements. It was clear during the inspection visit that the manager was well known to the residents and that there was a close relationship between them. Although questionnaires on the quality of the service have been completed by residents and relatives in February, these have not been reported on and there was no evidence to suggest that the comments within these had been responded to. This was discussed with the manager who was aware that this needed to be addressed. The use of staff questionnaires was also raised as an important resource. Further quality monitoring systems need to be developed and should include regular staff meetings, resident/relative meetings. One resident said there was no opportunity for residents to really say what they thought, and some would not speak out. The required regulation 26 visits were not available in the home although the manager advised that these were completed. The manager confirmed that no monies are held on behalf of residents and they have identified people to deal with their finances. If the home pays for anything this is added to the monthly bill. The manager confirmed that all the necessary safety checks are completed and all the required fire training checks and alterations have been completed to comply with the fire regulations. It was however noted that environmental risk assessments are not recorded and the manager agreed to progress these for all areas of the home in side and out, as a priority. Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be reviewed at least monthly and be composed and reviewed with input from the resident and or their advocate, unless the offer is declined. This will ensure the care provided is appropriate and that residents and/or their representatives are in agreement with the care provided. The registered person must ensure that the premises and furniture within are kept in a good state of repair. To ensure the safety of the staff and residents, to ensure infection control measures are in place, and to provide an attractive environment for residents to live in. The registered person must ensure that there are suitable staffing arrangements to meet the health and welfare needs of all residents in the home. This will ensure the safety and well being of residents and should also take into account the DS0000021137.V375469.R01.S.doc Timescale for action 01/08/09 2 OP19 23 01/08/09 3 OP27 18 01/07/09 Hillersdon Court Version 5.2 Page 26 4. OP33 24 provision of social care and activity in the home. The registered person must develop a full quality assurance system for the home, ensuring that stakeholders views are sought, and taken into account, that regular recorded monitoring of systems used in the home are carried out and that a report is generated. 01/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillersdon Court DS0000021137.V375469.R01.S.doc Version 5.2 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. 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