Care Home: Hillside

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What the care home does well Residents were supported to make decisions about their lifestyles and individual`s independence was promoted. Each person living in the care home had a comprehensive care plan. A key worker system was in place which residents were proud of and the support they received from their individual keyworker. Staff training, supervision and support has equipped the team with a good skill mix and competence to support both the residents and one another. The AQAA received from the home states that the home does well in individual support plans and risk assessments, residents attending external clubs, their involvement in advocacy group and attending involvement groups. What has improved since the last inspection? A new kitchen has been fitted and stated in the AQAA that the home has introduced accessible complaints and compliments procedure. It has also introduced quality assurance reviews involving residents. A new shower tray has been fitted and broken tiles in the shower room have been replaced. Hand paper towels and liquid soap is now being provided in communal bathrooms. Staff now receives an annual appraisal. The temperature of the fridge and freezers is being checked and records kept. What the care home could do better: The broken medicine cupboard must be repaired or replaced so that medicines are stored securely. Dampness in the kitchen and the ceiling of the upstairs bathroom in House No: 4 must be rectified. The fire door in the laundry room must not be wedged open and advice from the Community Fire Safety Officer must be sought for appropriate door holding mechanism to be fitted. A copy of each medicine prescription (FP10) should be kept for auditing. Some furniture in the sitting rooms were worn, torn and badly stained. These should be replaced. A plan maintenance and renewal programme should be devised with reasonable timescales. Fire drills should be carried out on a regular basis and records of all who participated should be kept. The followings have been deduced from the AQAA and the management of the home has identified below what they would do in the next 12 months to improve the quality of service delivery: - Develop support plans so that these are more person centred. - Introduce an accessible licence agreement. - Introduce needs assessment forms for individuals. - Improve policies and procedures on resident finances. - Produce more user friendly accesible information. - Decorate ground floor and first floor kitchens. - Replace existing kitchen flooring on the first floor. - Decorate first floor bathroom. - Decorate both bathroom and shower room at no 4. - Replace existing settee on the ground floor. - Decorate bedroom 1 at no 4. CARE HOME ADULTS 18-65 Hillside 82 Pinner Road Oxhey Hertfordshire WD19 4EH Lead Inspector Bijayraj Ramkhelawon Unannounced Inspection 15th November 2007 10:00 Hillside DS0000019428.V356408.R01.S.doc Version 5.2 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 Hillside DS0000019428.V356408.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 Adults 18-65. 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. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Address 82 Pinner Road Oxhey Hertfordshire WD19 4EH 01923 245 466 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) Watford and District Mencap Mrs Amanda Richards Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (1) of places Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home is registered for 11 people with learning disability - 8 in Pinner Road and 3 in 4 Hillside. This variation applies to a named service user. One of the bedrooms does not meet the required standard and should not be used once vacant. Date of last inspection 21st February 2007 Brief Description of the Service: 82 Pinner Road This is a detached building providing personal care and accommodation for eight people who have a learning disability. Three of the service users live a more independent life in a self-contained flat that is situated on the first floor of the building. All other service users have single occupancy bedrooms in a purpose-built extension on the ground floor. The property has a small frontage with steps leading to the front door. At the rear of the property, the garden is mainly laid to patio. 4 Hillside Crescent This is a smaller mid-terrace property accommodating three service users who also live more independently. The property is in close proximity to 82 Hillside Road and has a small rear garden. Both properties are managed and staffed by one staff team and is known collectively as Hillside. The home was first registered with Hertfordshire County Council in 1993. It is located close to Watford Town Centre that offers numerous amenities including Watford Town football stadium, theatres, a multi-screen cinema and a large undercover shopping mall. The ‘Statement of Purpose’, ‘Service User’s Guide’ and the ‘Complaints procedure’ are available for current and prospective service users. Current fees charged are £463.50 per week. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 15th November 2007 and took one day. The inspector looked at care plans pertaining to the care and welfare of the people living in the care home and other records. A tour of the buildings was carried out and the inspector spoke residents and the staff on duty. A completed Annual Quality Assurance Assessment (AQAA) was received from the care home and information from this document is reflected in this report. Policies and procedures, a sample of people’s care plans, staff files and other documents were examined. General observation including interaction between staff and people living at the care home, the management and administration of medicines, adherence to health and safety regulations, fire safety and other linked legislation were also carried out. What the service does well: What has improved since the last inspection? A new kitchen has been fitted and stated in the AQAA that the home has introduced accessible complaints and compliments procedure. It has also introduced quality assurance reviews involving residents. A new shower tray has been fitted and broken tiles in the shower room have been replaced. Hand paper towels and liquid soap is now being provided in communal bathrooms. Staff now receives an annual appraisal. The temperature of the fridge and freezers is being checked and records kept. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this 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. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information was available to current and prospective residents. Each person had an assessment of his or her needs carried out and a key worker system help and support individuals about life in the home. EVIDENCE: The home has a procedure where prospective residents visit the home and ‘test drive’ before any decisions for placement are made. Individual’s needs were assessed and whole life reviews were held annually. The current ‘Service User Guide’ and ‘Statement of Purpose’ were being reviewed to include pictures and symbols so that it would be easy for the residents to read and understand. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are fully involved with care planning reviews and they are supported to make their own decisions. Residents participate in all aspect of their life in the home and are supported to develop their daily living skills. Confidentiality is guarded and individual records are securely stored. EVIDENCE: Care plans examined contained a full and comprehensive assessment of service users personal needs, goals and aspirations and these were reviewed on a regular basis. These care plan provided evidence of how residents were being supported so that their identified needs were being met. Risk assessments were carried out to support individuals to live a fulfilling and meaningful lifestyle within a risk management framework. People living in the Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 10 care home were observed taking part in domestic activities as part of their individual’s responsibilities to help with house chores. Good interaction between residents and staff were observed and the atmosphere was relaxed and friendly. People living in the home said that they were happy with the service provision and appreciated the support they received from staff including their key workers. Information about individuals was securely stored in the main office. Data protection policies and procedures were in place and staff were provided with training on how to maintain confidentiality. Each resident has a yearly whole life review. Comprehensive, regularly reviewed care plans were in place and in a format appreciated by residents, it is easily evidenced on reading through these that they are live documents and that individual’s assessed needs were being met. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service promotes personal development and has a strong commitment to enabling residents to develop their skills, including social, emotional, communication and independent living skills. Personal, family and other relationships are supported. Rights and responsibilities of individuals were recognised and respected. The menu is varied with a number of choices including a healthy option. EVIDENCE: Care plans and individual’s progress records showed that people were provided with a wide variety of activities both at home and in the local community as well as further a field including short break and holidays. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 12 Individuals were supported to exercise their rights and be respectful of others; the “my time” sessions provided an excellent tool for supporting the ongoing development. People living in the care home are able to choose from a varied and healthy menu. The dining area of the home was comfortable and reasonably spacious. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support was provided in accordance with the individuals’ needs and preference. People are supported to retain and administer their own medication wherever possible; policies, procedures and protocols were in place. However, minor shortfalls in the management of medicines were identified and these must be addressed so that residents are not put at risk. EVIDENCE: People living in the care home said that they were supported to be as independent as possible and to have control over their own lives. Interaction between staff and residents was seen to be warm and appropriate. Individuals said that staff respected their privacy and dignity and that they were able to see other professionals, friends and relatives in private. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 14 Care plans were detailed and comprehensive. These showed how identified needs were being met. ‘My Health’ folders, were extensive profiles of individuals health status and needs which formed part of the care plan. These were reviewed on a regular basis. One resident self medicates and another receives some assistance from staff. The administration of medicines was kept in good order. However, one of the medicine cupboards was broken and some medicines were still being stored due to lack of space. The manager said that a new cupboard has been ordered. It was also noted that a copy of each medicine prescription (FP10) was not being kept at present. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do feel that their views are listened to and acted on and they are protected from all forms of abuse, neglect and self-harm. Training in safeguarding adults are provided to care staff. EVIDENCE: Residents said that their views were listened to and acted on. They were actively encouraged to air their views during the one to one “My Time” sessions with their individual key workers. There had been no complaints received since the last inspection. Staff training in abuse awareness, policies and procedures and health and safety protocols were all in place to provide safeguards. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The individual style of each of the bedrooms helps to promote resident’s independence and good communal facilities help to meet their needs. However, the general décor, furnishing, floorings and repair works in some areas must be carried out so as to maintain a clean and homely environment. EVIDENCE: Residents’ bedrooms were personalised with individual’s belongings. Staff encouraged people to bring and/or choose their own furniture and can decorate and personalise their rooms, subject to fire and safety regulations. Internal works have been carried out and damp proofing course applied. Small amount of Asbestos were found under the stairs and this area has been made secure and safe. A new kitchen was fitted recently and the manager said that this area would be redecorated within the next three months. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 17 However, it was noted (4 Hillside Crescent) that the flooring in the lounge and one of the residents’ bedroom were badly worn and stained. The bedroom and bathroom doors were squeaking very noisily. Dampness in the kitchen and the ceiling of the upstairs bathroom was not rectified. The hand washbasin tap in one of the resident’s bedroom in the main house has been out of order for over two months. The settees in the main lounge and upstairs flat were badly stained, torn and very dusty. A plan maintenance and renewal programme has not been devised. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The skills and experience of staff were varied. There was an enthusiastic, dedicated and caring staff team. Appropriate training for care staff is provided and there is a robust recruitment procedure in place. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. Staff files examined had all the relevant documents required by this Standard. Staff spoken to confirmed that they received appropriate training and regular formal supervision. Staff were provided with relevant training and the ‘Mental Capacity Act’ training was planned for November 2007. At present there were eight care staff employed of whom 2 have completed the NVQ Level 2, 1 has attained Level 3 and a further 2 have completed the NVQ Level 4. 1 member of care staff has completed the LDAF. Staff spoken to said that the management team was supportive and approachable and that they have been given a copy of the General Social Care Council Code of Conduct. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home that has a good ethos and leadership; the registered manager’s approach is good. Residents have a strong sense of ownership and know that their views underpin the reviews and developments of the home. However, fire safety regulations must be adhered to so that people living in the care home and staff are not put at risk. EVIDENCE: Staff confirmed that the registered manager operated an open door policy to staff, residents and to their representatives. Good professional interaction between staff and residents was observed. Staff confirmed that they had undertaken all the mandatory training. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 20 All statutory records were available for inspection and maintained in accordance with legislation. Staff spoken to were aware that residents can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of service users. However, it was noted that the laundry door was wedged open and that fire drills were not carried out on a regular basis and previous fire drill undertaken did not indicate the names of those who participated and the duration of these exercises. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents. A valid insurance certificate (expires on 29/11/07) was displayed in the office and this offered cover of no less than £5 million. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard YA20 YA24 Regulation 13 (2) 23 (2) (b) Timescale for action Broken medicines cupboard must 31/01/08 be repaired or replaced so that medicines are stored securely. Dampness in the kitchen and the 29/02/08 ceiling of the upstairs bathroom in House No: 4 must be rectified. (This requirement is outstanding from the last inspection of 4th August 2006). The fire door in the laundry room 31/01/08 must not be wedged open and advice of the Community Fire Safety Officer must be sought for appropriate door holding mechanism to be fitted. Requirement 3. YA42 23 (4) (c) (i) 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. Refer to Standard YA20 Good Practice Recommendations A copy of each medicine prescription (FP10) should be kept for auditing. Some furniture in the sitting rooms were worn, torn and DS0000019428.V356408.R01.S.doc Version 5.2 Page 23 Hillside 2. 3. 4. YA24 YA24 YA42 badly stained. These should be replaced. A plan maintenance and renewal programme should be devised with reasonable timescales. Fire drills should be carried out on a regular basis and records of all who participated should be kept. Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Hillside DS0000019428.V356408.R01.S.doc Version 5.2 Page 25 - 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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