Care Home: Hillgrove

What the care home does well People who are thinking of moving in are given information about the home and their needs are properly assessed so that they can be sure that it is the right home for them. Available at the home was a care plan for each resident, which clearly set out how staff need to meet the persons health, personal, and social care needs. Care plans were signed by residents and/or their representatives to show their involvement in the planning of their care. There was also evidence to show that care plans are being regularly reviewed and updated when a persons needs have changed. Staff showed a good understanding of care plans and how they use them to care and support the residents. The following comments made by staff supported this: "Care plans are a way of monitoring the persons care needs". "They help us understand what care a person needs and about the things they like and dislike". "They provide us with all the information we need to know about a resident". During the inspection visit staff were observed talking to residents in a polite manner and treating them with respect and they made the following comments, which supported their understanding of care values such as privacy, dignity and respect: "I always close doors when helping residents with personal care" "Knock on doors before entering a room which, is or could be occupied" "Treat and talk to people with dignity, politely and do not shout" "Allow people quiet time alone and when providing personal care make sure rooms are warm, doors and windows are shut and always knock on doors before entering a room" Residents spoken with said that staff are always polite and treat them well they made the following comments to support this: "The staff always treat me well" "I am well cared for" "Everybody is very kind and polite" "Staff knock on my bedroom door before entering" The home had in place appropriate procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. Everybody spoken with during the inspection said that they had been given information about how to make a complaint if they needed to. People were confident that their complaints would be listened to and dealt with in the correct way. The home was comfortable, well maintained and free from hazards making it a pleasant and safe place for people to live in. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 or above and they have all completed or are planning to complete training linked to the aims and objectives of the home and the needs of the residents. The home is managed and owned by a person who is patient, caring and considerate towards the needs of the residents. Residents and staff were complimentary about the owner and manager and the way the home is run, they made the following comments: "The manager and owner are supportive, caring, they look after the residents well". Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 7"The manager and owner are very good and will listen if you have a problem". "You can talk to them". "They are kind to the residents, hard working and put the residents first" "The manager is confident, approachable and always available". "The owner visits the home regularly and always talks to residents and staff and she always asks if we need anything". What has improved since the last inspection? Pre-admission assessments have been improved, they included more detailed information about the needs of the residents so that people have all the information they need to decide if the home is the right place for them and on which to base a care plan. The homes Statement of Purpose and Service User Guide have been reviewed and updated. They included all the information that is required so that people know about the services and facilities available at the home. Residents care plans have been developed and now include all the information as to how their health and social care needs are to be met. Care plans are now reviewed and updated each month as required and were possible with the involvement of the resident and/or their family/representative. Medications awaiting disposal are now stored securely in the home ensuring e peoples health and safety Many parts of the home have been improved enhancing the comfort, safety and dignity of the residents. Residents are given a better choice of meals and are offered alternatives to what is on the main menu. CARE HOMES FOR OLDER PEOPLE Hillgrove 79 Eleanor Road Bidston Wirral CH43 7QW Lead Inspector Julie King Key Unannounced Inspection 09:30 28th March 2008 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillgrove Address 79 Eleanor Road Bidston Wirral CH43 7QW 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) 0151 652 1708 Mayflower Care Homes Ltd Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 Brief Description of the Service: Hillgrove is a large detached property adapted for use as a care home, situated in a quiet residential area of Bidston, Wirral. The home is registered with the Commission for Social Care Inspection for the personal care and support of twenty-three older people who suffer from dementia and other organic psychoses. Accommodation is provided in both single and double rooms on three floors. Access to the upper floors is via a passenger lift. The home is equipped with appropriate aids such as grab rails, ramp, assisted bathrooms and a call alarm system. There is a car park at the front of the home and garden at the rear. Hillgrove DS0000040990.V344396.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 2 star. This means the people who use this service experience good outcomes. This was a key inspection. The Commission considers 22 standards for Care Homes for Older People as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection which took place in June 2006 and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a self-assessment and dataset, has replaced the preinspection questionnaire. The document, which was sent out to the service was completed by the owner/manager, Mrs Eleanor Charsley and returned to the commission before the site visit took place. A number of surveys were given out to people as part of the inspection. Responses and comments from those returned to us have been used to help support the judgements, which have been made in the relevant sections of this report. The inspection also involved an unannounced visit to the home (site visit). This was carried out with the owner/manager, who was on duty at the time of the visit. Records that were examined, comments made by residents and staff and observations made during the visit have also been used as evidence for the report. A number of residents were case tracked. This process involved talking to residents and staff, looking at the environment and a selection of residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and have been agreed by themselves and/or their representatives. What the service does well: People who are thinking of moving in are given information about the home and their needs are properly assessed so that they can be sure that it is the right home for them. Available at the home was a care plan for each resident, which clearly set out how staff need to meet the persons health, personal, and social care needs. Care plans were signed by residents and/or their representatives to show their involvement in the planning of their care. There was also evidence to show Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 6 that care plans are being regularly reviewed and updated when a persons needs have changed. Staff showed a good understanding of care plans and how they use them to care and support the residents. The following comments made by staff supported this: “Care plans are a way of monitoring the persons care needs”. “They help us understand what care a person needs and about the things they like and dislike”. “They provide us with all the information we need to know about a resident”. During the inspection visit staff were observed talking to residents in a polite manner and treating them with respect and they made the following comments, which supported their understanding of care values such as privacy, dignity and respect: “I always close doors when helping residents with personal care” “Knock on doors before entering a room which, is or could be occupied” “Treat and talk to people with dignity, politely and do not shout” “Allow people quiet time alone and when providing personal care make sure rooms are warm, doors and windows are shut and always knock on doors before entering a room” Residents spoken with said that staff are always polite and treat them well they made the following comments to support this: “The staff always treat me well” “I am well cared for” “Everybody is very kind and polite” “Staff knock on my bedroom door before entering” The home had in place appropriate procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. Everybody spoken with during the inspection said that they had been given information about how to make a complaint if they needed to. People were confident that their complaints would be listened to and dealt with in the correct way. The home was comfortable, well maintained and free from hazards making it a pleasant and safe place for people to live in. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 or above and they have all completed or are planning to complete training linked to the aims and objectives of the home and the needs of the residents. The home is managed and owned by a person who is patient, caring and considerate towards the needs of the residents. Residents and staff were complimentary about the owner and manager and the way the home is run, they made the following comments: “The manager and owner are supportive, caring, they look after the residents well”. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 7 “The manager and owner are very good and will listen if you have a problem”. “You can talk to them”. “They are kind to the residents, hard working and put the residents first” “The manager is confident, approachable and always available”. “The owner visits the home regularly and always talks to residents and staff and she always asks if we need anything”. What has improved since the last inspection? What they could do better: Meals for residents, which are mashed up or liquidised, should be better, presented to ensure they are more appetising. The menu, which is displayed in the dining room, should be provided in a more accessible format so that residents have the information they need and can understand. Please contact the provider for advice of actions taken in response to this Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 9 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 Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home so that they can be sure it is the right place for them to live. EVIDENCE: The manager said that the homes Statement of purpose and Service User Guide have been reviewed and updated since the last inspection. Both documents were looked at, the manager pointed out the changes, which have been made to them. Both the homes Statement of Purpose and Service User Guide included all the information, which is required by regulation for example, details of the manager and staff and the services and facilities, which are available at the home. All surveys completed by residents showed: That the people were asked if they wanted to move to this home and people did receive enough information about the home before they moved in. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 11 As part of the last inspection report a requirement was given because preadmission assessments seen lacked the information required to put together an initial care plan. The manager confirmed that she has put a lot of work in to developing the homes pre-admission assessment. Pre – admission assessments for three residents who have recently been admitted to the home were looked at during this inspection visit. Assessments carried out by the manager of the home and other professionals such as health and social care workers were in place. The assessments were detailed and covered all aspects of the person’s social, emotional and physical care need requirements such as, sight, hearing, communication, health and personal care, daily living skills, medication, mobility and finances. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs were clearly set out in an individual plan of care ensuring that they are understood and met. EVIDENCE: A requirement was given as part of the last inspection report to ensure that all residents have an agreed care plan in place that identifies all their health, care and support needs. The manager said that that care plans have been improved since the last inspection. Staff spoken with showed a good understanding of care plans and how they use them to ensure that resident’s needs are identified and met. Staff said care plans are important because: “They are a way of monitoring the persons care and support needs”. “They helps us understand what care a person needs and about the things they like and dislike”. “They provide us with all the information we need to know about a resident”. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 13 Care plans for 4 residents were looked at in detail as part of the case tracking process. All the care plans looked at were complete and reflected the care need requirements, which were detailed in the person’s pre-admission assessments. Contained within each persons care files were review records, the records showed that each section of the persons care plan has been reviewed and updated each month up to date. All surveys completed by residents indicated that they always receive the medical support that they need. Records of medical appointments were kept in good detail and showed that residents have regular access to specialist medical, nursing, dental, chiropody and GP services. Residents spoken with confirmed that they could see their doctor when they choose. The manager confirmed the arrangements that are in place at the home to enable residents to access other specialist services such as speech therapists and dieticians. The AQAA provided details of a number of policies and procedures, which relate to the health care of residents. They include control, administration, recording, safe keeping, handling and disposal of medication. Medication was stored safely at the home and records, which were looked at, were well maintained. A requirement was given as part of the last inspection report to ensure that all unwanted medication is disposed of in the correct way. This inspection visit evidenced that this is now done. There was also evidence to show that controlled drugs are being stored and recorded in the correct way. Staff were seen, knocking on doors before entering rooms, assisting residents with personal care in private, talking to them in a polite manner and treating them with respect. Residents spoken with said that staff always treat them well and respect their privacy and dignity. They made the following comments to support this: “The staff always treat me well” “I am well cared for” “Everybody is very kind and polite” “Staff knock on my bedroom door before entering” Comments made by staff, which supported their understanding of, care values such as privacy, dignity and respect included: “I always close doors when helping residents with personal care” “I knock on doors before entering a room which is, or could be occupied” “I treat and talk to people with dignity, politely and do not shout” “I think it is important to allow people quiet time alone and when providing personal care. I make sure the room is warm, doors and windows are shut and I always knock on doors before entering a room” Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 14 Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a wide range of daily and social activities, which match resident’s preferences, interests and needs. EVIDENCE: An activities co-ordinator is employed at the home and was on duty at the time of the inspection. Discussion took place with the activities co-ordinator who confirmed that she works 20hrs per week usually between the hours of 10am and 2pm 5 days a week although she did confirm that she is flexible towards the social needs of the residents. Activities facilitated by the activity co-ordinator include a library table, board games, painting, woodwork, and softball games such as tennis, golf and netball. Art and craftwork are also part of the resident’s activities. Work completed by residents is sold in a craft fair, which is held at the home, and the money raised is used to purchase art and craft materials, games and to fund trips out. Gardening is also enjoyed by some residents, there were potted plants displayed around the garden, which were made by residents. The activities co-ordinator said that all residents are given the opportunity to take part in the activities, which are on offer. She said that she maintains Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 16 detailed records of resident’s involvement in activities as well as a record of their progress and achievements. An activity programme was on display in the hallway, which displayed details of planned activities for the forthcoming week it also included details of the time, and date the activity is taking place. Activities for the week included, library table, music, games, and gentle exercise. Also displayed in the hallway were photographs of residents taking part in activities at the home as well as photographs of a group of residents enjoying a trip out to Ness Gardens in October 2007. One resident said, “I absolutely love the activities, I wouldn’t miss out on them”. Staff said, “There is a good level of activities the activity co-ordinator us is excellent, she encourages all the residents to join in activities. “The residents do some amazing things with her, she encourages movement and exercise”. “The activities have improved the resident’s lives”. The lunchtime meal was observed. Tables were attractively laid with tablecloths, mats, napkins and cutlery of a good standard. Each table had a water jug and drinking glasses. The atmosphere was pleasant, there was music playing in the background, residents said they liked listening to music at meal times. Staff transported food to the dining room using a trolley and served residents individually. A gravy jug was put on each of the tables and residents helped themselves. Staff were observed talking to residents and offering encouragement and assistance were necessary. There were a number of residents who were offered alternatives because they chose not to eat the lunch of the day. They were offered a variety of sandwiches and soup. Residents appeared to be satisfied with the options they were given. Residents were offered hot and cold drinks during and after their meal. Rice pudding, jelly and moose where offered for dessert. The quality, quantity and presentation of the meals served in the dining room looked well. A member Staff was observed assisting a resident to eat in the sitting room, which is next to the dining room. The member of staff sat close to the resident and assisted her in a gentle and unrushed way, she explained to the resident what she was doing and described the food she was about to eat. The resident required her food to be mashed. The meal of meat, vegetables, potatoes and gravy was mashed up all together. This method of presenting food was discussed with the member of staff and later with the manager. They were advised that it is not appropriate to serve food this way as it looses its taste and looks unattractive. They were advised to ensure that each food item be separately liquidised and served as you would with food which is not liquidised. They agreed to do this. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 17 The homes menu was displayed on a board in the dining room it was only available in small typed print and difficult for most people to see. The manager was advised of this. She said she would look at other ways of displaying the menu so that people can clearly see and understand it. The use of large print and colourful pictures of meals was discussed as an option. Residents and staff spoken with spoken with all said that the quality, quantity and choice of food is very good. Comments made by residents and staff included: “The food is good.” “There is always a good choice of food”. “Residents are always given a choice of food”. “There is always enough food and a good variety”. The food stores were looked at. There was plenty of tinned, dried, fresh and frozen foods. The manager said that food is bought and delivered from the local supermarket, a local farm, and a local butcher. Freezers were well stocked with such things as meat, bread and fish. The kitchen was well equipped and there were a variety of pots and pans. There was plenty of crockery for resident’s use, which was matching, and of good quality. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes procedures for responding to Concerns and complaints and for ensuring that they are safe from Abuse, harm or neglect. EVIDENCE: There was a complaints procedure on display at the home. It is also available in the homes Statement of Purpose and Service User Guide. Residents and staff spoken with during the inspection all said that have the information that they need to make a complaint if they wish to and they would feel confident about making a complaint. The following results of surveys and comments made by residents and staff supported this: People know who to speak to if are not happy People do know how to make a complaint Carers always act on what people say “If I had a problem I would ask to speak to some one”. “I would write a note if I had a complaint”. “Go to office or staff to complain”. “I would speak to a member of this wonderful staff”. “I would definitely would complain if needed to”. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 19 The manager confirmed that all staff are provided with a copy of the homes policies regarding complaints, whistle blowing procedure and Protection of Vulnerable Adults and that they are provided with training in recognising the signs of potential abuse and how to report them appropriately. This was also confirmed during discussion with staff and from details provided in the AQAA which told us staff have been given the above policies and have received protection of vulnerable adults training. Staff spoken with were confident about complaining if they needed to, they made the following comments which supported this: “Yes I do know what to do if saw or thought a resident was being abused”. “I feel confident about what to do”. “I Know about the homes complaints procedure and would complain if I needed to”. Examination of records and discussion with people showed that staff have completed protection of vulnerable adults (POVA) training. One member of staff said, “yes, I have completed POVA training and I enjoyed it very much, it raised my awareness about the protection of people and made clear what I should to do if I saw or thought somebody was being abused”. Another member of staff also confirmed that they have completed POVA training and correctly explained the procedures they would follow in the event of an allegation or suspicion of abuse. A copy of the Local Authority Protection of Vulnerable Adults policy was available in the office for people to refer to. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Extensive improvements made to the environment have enhanced the dignity, comfort and safety of the residents. EVIDENCE: The home is located in a popular residential area of Bidston, Wirral, Merseyside, close to public transport links. Community facilities including churches, shops, cafes and community health centres are within close distance of the home. Parking is available at the front of the building and on the road outside the home. There are gardens to the front and back of the house, which were planted out with various plants, shrubs and trees. There is a patio area at the back of the house which has been re flagged new garden furniture has also been purchased including benches, tables and chairs, bird tables and decorative wall trellis. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 21 Staff said the gardens are used regularly by residents during the warmer weather. Residents have shared use of a large lounge, a dining room a sitting room and a quiet area near to the hallway. Since the last inspection improvements have been made to all shared rooms including new furniture, carpets, wooden flooring and redecoration. There are a number of toilets and bathrooms located around the home, which are easily accessible to residents. Some of them have been redecorated and the manager confirmed that there are plans to redecorate others including the one, which had tiles missing from the wall. The first floor bathroom, which has been refurbished to a high standard has also had a ‘Parker’ bath installed. The hairdressing room has recently been refurbished; it was decorated to a high standard and equipped with a salon style sink and professional hairdressing equipment. A selection of resident’s bedrooms was looked at during the visit. A number of them have been refurbished since the last inspection. They have undergone redecoration and been provided with new furniture such as wardrobes, chest of drawers, and easy chairs. Bedrooms have also been fitted with matching curtains bedding and headboards, professionally made to a very high standard. Bedroom carpets have also been replaced. Minor repairs are required to items of furniture in some resident’s bedrooms; the owner/manager said that she would arrange for the repairs to take place. Residents have been encouraged to personalise their rooms with items such as pictures photographs, ornaments and plants, which made them, look homely and comfortable. Manager confirmed that there is a handy man, a joiner and a plumber who all visit the home to carry out work that needs doing. There were records of monthly checks on the environment which included details of any action required, the person responsible and confirmation of when the work was completed. The owner/manager said that she carries out monthly checks of the environment following which she produces a report, which includes details of any work/improvements, which need to be carried out. These records were viewed. A number of domestic staff are employed at the home. Residents spoken with said that their rooms and other parts of the home are always kept clean and tidy. They made the following comments: “My room is always kept clean and tidy” “The home is always clean” “Yes, my room is always kept clean and so is the rest of the home” All the people who completed surveys commented that the home is always fresh and clean. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 22 Most parts of the home viewed were clean, peasant and hygienic, however there was a strong smell of urine in one residents bedroom and paper on the ceiling was peeling in parts. This was pointed out and discussed with the owner/manager who confirmed that the room was soon to be refurbished along with a number of others, which have not yet been done. Since the last inspection a professional company has carried out a deep clean of the kitchen. The manager produced a certificate to evidence this. The certificate listed the parts of the kitchen and equipment, which were cleaned. The laundry, which is located in the basement, was equipped with sufficient washing and drying machines and ironing facilities. The laundry was clean and well organised. Detailed in the AQAA and available at the home were a number of policies and procedures, which aim to ensure a clean and safe environment, they include infection control and disposal of soiled waste. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a competent and qualified staff team. EVIDENCE: There were 3 care staff, the owner/manager, a cook and a domestic staff member on duty at the time of the inspection. Four members of staff were interviewed on a one to one basis as part of this inspection. General discussion also took place with other staff at intervals throughout the visit. The staffing rota for a period of four weeks was examined as part of the inspection and showed a minimum of three care staff and a manager on duty during the day and two waking care staff during the night. Staff spoken with agreed that there are always sufficient staff on duty to meet the needs of the residents they said the following: “The staffing levels are good, there is always enough on duty”. “There are always enough staff on duty to care for the residents. Sickness and holidays are always covered”. Staff spoken with showed a good understanding of their roles and responsibilities and were very knowledgeable about the needs of the residents. Each member of staff spoken with said they enjoyed their job and agreed that the staff team all work well together. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 24 Residents spoken with during the inspection visit were all complimentary about the staff group and were confident that they are able to do their jobs well, this was supported by the following comments made by residents during the visit: “Can’t find fault, the staff are always here to help you”. “All the staff are very good”. “The staff are always available”. “I find them very helpful”. Surveys completed by residents showed the care staff always treat people well and they have the right skills and experience to look after the residents properly. Several staff have started work at the home since the last inspection. Personal files for the most recently recruited staff were looked at during the inspection visit. Each of the files were well presented and organised and contained all the documents which are required by law to show that they are the right people for the job, for example, completed application forms, police checks and references. The manager confirmed that all new staff receive induction training. Induction training records were looked at for those staff that have recently started work at the home. These showed that they all received comprehensive induction training covering topics on the principles of care, safe working practices, the organisation, the workers role and the needs of the residents. Records which were looked at showed that the manager carries out regular audits with regard to staff training needs and produces a training and development plan for each of them to ensure they are trained to meet the needs of the residents. Discussion with staff and copies of certificates which were looked at showed that since the last inspection staff have completed training to update their knowledge and skills and that the training is linked to the aims and objectives of the home and the needs of the residents. Staff spoken with said that they have completed a lot of training and gave the following examples, health and safety, dementia care, first aid and lifting and handling. A training programme, which was viewed, showed that staff are receiving a good level of training. The AQQA and staff training records held at the home evidenced that at least half of the staff team have achieved or are currently undertaking a National Vocational Qualification in care level 2 or above. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of the residents. EVIDENCE: Eleanor Charsley the owner/manager of the home was on duty at the time of the inspection. The registration certificate, which was on display showed the registered manager as Kathleen Parker. Mrs Charsley explained that the registered manager had left and that she was going to put forward an application to become the registered manager of the home. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 26 Information detailed in the AQAA and examination of a selection of records during the inspection showed that the records required by regulation are available, up to date and accurate. Residents and staff spoken with during the inspection were complimentary of the owner/manager and the way she runs the home, the following comments made during the inspection supported this: “The manager/owner is very good, and will listen if you have a problem”. “You can talk to her”. “She is Kind to residents, a hard worker and always puts the residents first”. “She is confident, approachable and always available”. “The owner visits the home regularly and always talks to residents and staff. She always asks if we need anything”. “We are well supported”. “I get on well with the manager”. “The manager is supportive and caring, she looks after the residents well. Discussion with the manager and records, which were examined, showed that the home has in place a number of quality monitoring systems, which aim to ensure that the home is run in the best interests of the residents. Satisfaction questionnaires are given out to residents and their representatives as a way of seeking people’s views about the home and the results of them are used to plan for the future. The health safety and welfare of residents are well protected this was supported by a set of policies and procedures, which were detailed in the AQAA and available at the home. Information provided in the AQAA and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. Staff and residents spoken with confirmed that they hear the fire alarm system regularly being tested. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP15 Good Practice Recommendations Meals for residents, which are mashed up or liquidised, should be better, presented to ensure they are more appetising. The menu, which is displayed in the dining room, should be provided in a more accessible format so that residents have the information they need and can understand. Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillgrove DS0000040990.V344396.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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