Inspection on 15/10/07 for Hill House

This inspection was carried out on 15th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hill House 26/02/09

Hill House 21/02/08

Hill House 01/05/07

Hill House 05/04/06

Hill House 24/10/05

Hill House 07/04/05

Hill House 22/09/04

Hill House 29/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hill House Elstree Hill South Elstree Hertfordshire WD6 3DE Lead Inspector Julia Bradshaw Unannounced Inspection 15th October 2007 9:00 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 Hill House DS0000019427.V352904.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. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hill House Address Elstree Hill South Elstree Hertfordshire WD6 3DE 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) 0208 236 0036 0208 236 0944 BUPA Care Homes (AKW) Ltd A R (Ben) Domah Care Home 76 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (58), of places Physical disability (19) Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. This home may accommodate 6 older people who require personal care. This home may accommodate 17 people (aged 18-65 years) with physical disability who require personal care. This home may accommodate 53 older people who require general nursing care. The home may admit one named service user who is under the age of 65 years. This condition will cease to be in force when the service user Permanently leaves the home for any reason or reaches the age of 65 years. The number of places for YA with PD will revert to 17 when a named service user either leaves the home permanently or is transferred to the ground floor YPD unit. 1st May 2007 5. Date of last inspection Brief Description of the Service: Hill House is a care home situated in the village of Elstree, which offers nursing and residential care to elderly people and residential care to young adults with physical disabilities. The building is a period building with modern additions. All rooms are in excess of the National Minimum Standards for Older People. In the two areas used for the young adults the rooms also meet National Minimum Standards for Young Adults with additional space now available in the ground floor therapy room and the bedrooms are large enough to count towards the day space standard. All rooms have en-suite facilities and there are a variety of day rooms throughout the building. Hill House is situated in a convenient location for links with motorways and routes to London. There are small shops, a post office and a GP surgery nearby. The home has extensive grounds to the rear and off road car parking facilities to the front of the building. Information regarding the service is available in the Statement of Purpose and the Service User Guide. These and a copy of the last inspection report are freely available on request. The range of fees for Hill House are between £650 and £850. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection for the inspection year 2006/7. The last inspection was carried out over two days on the 13/4/07 and 1/05/07. On this occasion there were two inspectors and also an expert by experience (from Help the Aged) who took part in this inspection specifically to obtain the views of people living at Hill House. For the purposes of this report, the information supplied by the expert by experience will be incorporated into the relevant standards and will be referred to as “the ex by ex”. The ex by ex report states; - The inspector indicated that she would like me to look at the ‘quality of life’ aspects from the residents’ perspective – for example, if people are satisfied with the care that they receive in the home; if they are satisfied with the meals and the quality of support from staff. Hill House is one of several BUPA Nursing Care Homes establishments in Hertfordshire. It is registered to accommodate a maximum of 76 elderly people including 17 young adults with a physical disability who require nursing and social care. At the time of the visit there were 76 service users residing at the home. The inspection was carried out over one full day during which time 25 service users were spoken to. Discussions were held with service users, head of care, the activities/training coordinator, other staff on duty and two visiting relatives of one of the service users. Documentation examined included 7 service users’ care plans, medication records, complaints records and activities records. The manager of the home was on annual leave at the time of this inspection. Requirements were made as a result of this inspection in relation to medication, care plans, environment, the standard of meals provided, personal care, risk assessments, quality assurance and the overall management of the home. The summary by the ex by ex stated, “all the members of staff I spoke with seemed attentive and caring and this was confirmed by all the residents’ comments. The main issue brought to my attention was the mixed views concerning the meals. I would have expected better quality ingredients, served more attractively, so as to make them appear more appetising, especially for those with little appetite.” The ex by ex stated “I would like to extend my thanks to the Head of Care, who was managing the home on the day of the visit, and the staff, for their hospitality and co-operation.” Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 7 The inspector received negative feedback from several service users regarding the standard of meals provided within the home. On further discussions with both service users and the chef on duty it transpired that service users were not receiving nutritional value or adequate quantities of food. Both the inspector and expert by experience joined service users for lunch and were able to observe the standard of lunchtime meal for themselves. The alternative meal that was being offered was either a salad or poached egg and chips. The aforementioned meal was bland, uninteresting and inedible. The chef’s response to one request from a service user for more green vegetable, “ such as broccoli” was “ it is currently too expensive”. There were several areas of service user documentation that were incomplete, including care planning, risk assessments, nighttime recording and pressure sore evaluations. Some individual risk assessments had not been reviewed or updated. There was no risk assessment found for a service user who is at risk of choking. Two items of furniture were seen during the inspection that the inspector had to asked to be removed immediately as they were presenting a health and safety issue. Hoists were seen that were dirty and presented a possible infection control risk. The only bathroom available on the first floor was being used as a storage facility and could not be accessed by service users, if they chose to have a bath. One member of staff spoken to was unaware of the whistle blowing policy, which may leave people at risk. Hand –written instructions were seen on a MAR chart, which is poor practice and against both the providers own company policy and Royal Pharmaceutical society policy and guidelines. 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. Hill House DS0000019427.V352904.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 Hill House DS0000019427.V352904.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 –5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All new service users have their needs fully assessed before entering the home and are able to visit the home before admittance. In this way both the service user and the care staff can be sure that the home can meet these needs. EVIDENCE: The admission notes and the care plan files of the service users examined confirmed that a full assessment was carried out before a prospective service user was admitted into the home. Records of service users examined contained signed copies of the home’s contract and these listed all relevant information, including the room to be occupied. A copy of the home’s Statement of Purpose and Service User’s Guide were displayed in the reception area of the home on the day of the inspection. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 10 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 –11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users health care and dignity is currently being compromised and medication procedures are not being adhered to which may leave residents at risk. EVIDENCE: There were several discrepancies within the seven care plans inspected. These include risk assessments that had not been updated or reviewed. There was no risk assessment in place for a service user who was at risk of choking. There was not a current risk assessment in place for each recliner chair used by service users. Some service users (or their representatives) had not signed their care plans. The inspector found the following issues in relation to service users care plans: -The size and depth of pressure sores was not recorded, photographic evidence was not carried out monthly, turn chart not completed since 25/09/07. Some nighttime records were found to be incomplete. The case tracking of one service user revealed that although the daily record stated that ‘personal care’ had been given, it did not explain what type of care Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 11 this was. A service user stated that they “couldn’t remember when they last had a bath. I love a bath, but never get offered one, only a shower”. This was further evidenced by the staff on duty who stated that they never use the first floor bathroom as it is only used for storage. They stated, “Everyone has showers”. This arrangement does not allow service user to make an informed choice. Generally service users were satisfied with the level of personal care provided, although one service user said that “ they can be a bit rough sometimes”. Another service user said the pads that they were given “were too small” and often “there was not enough”. Service users stated that the manager has daily contact with everyone in order to discuss any issues they may have and to hopefully resolve these immediately. All service users are registered with a GP and weekly surgeries are held at the home. The Doctor may be called to the home on other occasions as and when required. The home has written policies on death and dying and staff said that all possible care is provided for service users and their families at such times. Medication was inspected and although there were no gaps or discrepancies found on the MAR sheet, a hand written medication sheet was discovered. This practice contravenes both the company’s medication policy and also the Royal Pharmaceuticals Societies guidelines. The ex by ex report stated; - Every resident I spoke to, without exception, said how good the carers are and how well they are attended to. All the residents I met were clean, well dressed, with tidy hair and several ladies wore jewellery. They appeared to be comfortable whether they were sitting in chairs with cushions, or in bed with padding for extra support. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 12 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 –15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current activities programme provided is excellent and meets residents’ needs and expectations. Service user choice is currently compromised by the poor standard of presentation and choice of meals. EVIDENCE: An excellent range of activities and leisure activities are provided. There are 60 hours per week, which are divided between a full and part-time worker who have a joint responsibility in implementing the agreed programme. The service is provided over a seven-day period. Activities range from Quiz’s Bingo, reminiscence sessions, late night scrabble, cookery club, church services held at the home, beauty days, hairdressing, board games, arts and crafts as well as a variety of planned celebrations including May day, VE day, Food Theme nights, Garden parties ‘Tea at the Ritz’. The activity workers also produce a monthly activity newsletter, which outlines a range of interesting facts about the respective months and describes events planned for the whole of the month. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 13 The activity staff should be commended on providing a first class activities programme for people living at Hill House and the commitment and enthusiasm in which it is delivered, which the inspector was fortunate to observe on her visit to the home. The ex by ex report stated that; - Each time I looked into the lounges they were unoccupied. There was an activities sheet, which the residents had a copy of in their rooms, stating that there were planned activities for the afternoon. I spoke with three people in the smokers’ room to establish their views. One gentleman said that he preferred to stay indoors rather than go out into the grounds. He was not interested in the activities as he was fed up with quizzes and bingo. When I enquired what would improve his life, he replied, ‘put a bar in the house’! One lady I spoke to goes to the activities and enjoys the exercises, saying they are fun. The young men on YPD South were not interested in activities but one spends quite a bit of time on his computer, which he enjoys. Two of these young men asked if I would look at letters and forms they had received from the DSS, which had to be completed and returned by a fixed date. They both needed help with advice with the filling in of the forms. I mentioned this to the Head of Care who said she would ask a Social Worker to call and see them. Both the inspector and ex by ex joined service users for lunch. There were two choices of main course, which some service users did not want. The alternative meal provided was poached eggs and chips or salad. The eggs were hard and grey and the chips cold and shrivvled. The chef was asked to join the lunch table and asked to explain the standard of the meal served to one service user. They stated “the eggs were soft when they were served up on the trolley”. However, no explanation was provided about the cold and wrinkled chips. Another service user stated that they would like more green vegetables, such as broccoli .The response from the chef was that “Broccoli was too expensive at this time of year”. The ex by ex report stated that: - The feedback I received from speaking to other residents suggested that all did not appreciate the food. Out of the 6 residents interviewed, either in their rooms or in the smoking rooms, they thought the food was good with the exception of one person who was bedridden. She commented that her food and drinks were not hot enough. She advised me that she had complained about this but was informed that it was ‘the best they can do’. One resident said he decided to stay on at the home after respite care, as he enjoyed the food. Three young men on YPD South told me that they thought that the food was terrible and often had take-always or other food brought in by visitors or family. They thought one chef was better than the other but that there was often a shortage in the kitchen of eggs, tomatoes, and cheese and there was limited choice of food. They considered that some of the food was unsatisfactorily prepared giving examples of baked potatoes that were often hard, scrambled eggs with the texture of rubber and unpleasant trifle. I joined some of the residents in the well-decorated, spacious Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 14 dining room for a lunch of tomato soup and chicken tikka on rice, which tasted good. The tables were well presented and there was a choice of juice or water to drink. Residents have to place an order for their main meals the previous night for their next day’s requirements. That day’s menu stated a choice of breaded fish or chicken tikka on rice with naan bread. Most of the residents were served fish cakes (not breaded fish as stated), mashed potatoes and diced mixed vegetables. Several dinners were left unfinished. I considered that the mashed potatoes along with fish cakes containing potatoes were rather heavy/stodgy. A sauce, such as a parsley sauce, would have given more moisture to the meal. One lady was served a salad but little of it was eaten. Another lady commented to the chef, who was speaking to residents at lunch, on how large the pieces of tomato were on the salad. When I enquired about having cherry tomatoes, which are smaller and sweeter, he mentioned the extra cost of this variety. There is little difference in the price of cherry and ordinary tomatoes and residents would not need to be served very many small ones. One gentleman was given an egg sandwich for his lunch as, I was told, and he prefers sandwiches. Jelly and ice cream was served for dessert but there appeared to be no other choice. I do not recall seeing any fresh fruit being available. One lady at the dining table told me that they have to take pot luck with the food and that they had been told there would be another chef, but they haven’t noticed much difference with the meals so far. The chef told me that each Monday they have what they call a ‘themed meal’, which takes the form of a resident choosing their favourite meal, and that is made available for everyone. The carers attended to the few residents that were unable to feed themselves carefully and quietly, in an unhurried manner. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that there is a complaints process that they can access, both formally and informally. Staff are not fully informed of policies in relation to protecting service users, which may leave some people at risk. EVIDENCE: There is an appropriate written complaints policy. Five complaints have been received since the last inspection took place. All of these complaints have been resolved to a satisfactory and mutual conclusion. There are written procedures in place for Safe Guarding Adults and a Whistle blowing Policy. However one member of staff spoken to during the inspection was unaware of the whistle blowing policy. Staff receive suitable and adequate Protection of Vulnerable Adults training. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. Generally the environment is maintained to a satisfactory standard although some internal re-decoration is required. There are inadequate bathing facilities, compromising service user health and welfare. EVIDENCE: Both inspectors carried out a complete environmental tour of the home and found a torn and badly stained armchair turned towards the wall, behind the service users sitting room door. A badly torn stool used in the service users lounge on the ground floor, and a badly ripped, stained chair in the main staff office. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 17 A tour of the first floor identified the bathroom that is used between seventeen service users was not in operation. This meant that service users had no choice but to have a shower in their room. Staff on duty confirmed that the bathroom was not in operation. The bathroom was also being used to store several hoists. Several hoists throughout the home were badly stained and required a thorough clean. The manager is responsible for the overall maintenance of the home, which is a constant challenge given the age of some parts of this building. Regular Quality Assurance audits are carried out on all areas of the home. Several areas of the home looked shabby and could benefit from being re-decorated. All fire checks have been carried out in accordance with health and safety legislation. The last fire drill was carried out on the 8/03/07.The last fire equipment checks were on the 22/3/07. Emergency lighting check last carried out on the 27/09/07.The last equipment check was carried out on the 20/09/07. Call points were checked on the 11/10/07. The ex by ex reported; - Most of the residents I spoke to were happy with their rooms and expressed a preference for remaining in them most of the day. All rooms seen on the day of the inspection had been personalised and appeared comfortable and homely. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 18 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): 27-30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate for providing care to the current service user group. The training programme for staff is structured and consistently maintained so that staff are sufficiently trained to meet peoples needs. Service users can be assured that the recruitment process is thorough and complies with legislation. EVIDENCE: The staffing provided on the day of the inspection was adequate to meet the needs of the existing service users. The staffing levels on the day were four trained nurses, fourteen carers plus the head of care and the registered manager, plus kitchen, domestic and activity staff. The standard of staff training is good and records proved that all staff are receiving the mandatory training required including, Dementia care, medication training, manual handling, safeguarding adults. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 19 Supervisions are carried out in line with the required standard and this was confirmed during discussions with staff members on duty. Full staff meetings and senior meetings are held on a regular basis. Robust recruitment practices are observed to offer protection to service users and in line with legislation; all documentation including CRB and written references are maintained on these files. The ex by ex report states; - One carer has been at the home for 7 years where she started as a cleaner, then attended university to train as a nurse and now looks after several residents. She was enthusiastic and sympathetic to the needs of the residents who were in her care. Another carer who looks after young people with disabilities has been working at the home for 5 years. She started training in January for the NVQ2. She has had in-house training of manual handling and personal care. The three service users on YPD South were very complimentary about the care they receive from carers, saying they thought they shouldn’t work such long hours and should get paid more. One carer has a Science Degree and this is her first job working with people. She said she enjoys the work and has received training in manual handling, food and hygiene and Personal Best. I spoke with the training co-ordinator, who was previously a trainer in a bank. She assists with residents in the dining room at lunchtimes. Documentary evidence was produced of training carried out at the home and passed to the Lead Inspector for her perusal. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 20 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 –38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and organisation of the home and its service adequately meets the needs of the people in residence. EVIDENCE: The current manager has been at the home for a period of just under two years. It was noted that several standards had fallen into adequate or poor outcomes for service users since the last inspection was completed in May 2007. The inspectors and expert by experience were concerned with the standards of food provision, issues relating to personal care, cleanliness, care planning and recording. Several requirements have been made as a result of this inspection. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 21 Staff and service users said that they were clear about most procedures within the home and that the manager and deputy were approachable and supportive. All fire records were accurate on the day of the inspection. Staff were aware that service users and families could access their records, subject to individual permission and the Data Protection Act. The home provides the CSCI with details of all significant accidents and incidents and with regular reports from Head Office staff visits. The homes carries out both internal and external quality assurance audits and also carries out service user/stakeholder questionnaires on an annual basis. The manager carries out a daily tour of the home to ensure that service users have the opportunity to discuss any issues directly with him, in order to resolve these at the very earliest opportunity. However, furniture that was damaged had not been identified or removed from use. Also as earlier stated in the report the standards of the meals caused residents concerns but this did not appear to have been addressed. Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 2 2 3 3 3 2 2 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 2 2 3 3 3 2 1 Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 23 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 OP8 OP37 OP38 Regulation 13(4)(c), 15(1) & (2) & 17(1) Schedule 3 and 4. Requirement All care plans must contain all the relevant information in order to ensure the appropriate care is provided to people e.g. individual risk assessments must be completed; pressure sore documentation must be accurate, including the size and the depth. Turn charts must be completed regularly. Night time records must be complete. To ensure residents safety individual risk assessments must be completed for each recliner chair used by service users. To ensure resident’s safety hand written amendments to service user’s MAR charts must not be made. The meals provided must meet the service users requests or needs. Those served were unsatisfactory, lacked flavour and were served cold. To ensure service users are kept safe all staff must be inducted and trained in the whistleblowing policy. All communal areas of the home DS0000019427.V352904.R01.S.doc Timescale for action 15/12/07 2. OP9 13(2) 15/12/07 3. OP15 16(2)(i) 15/12/07 4. OP18 13(6) & 18(c)(i) 23(2)(b) 15/12/07 5. Hill House OP19 15/12/07 Page 24 Version 5.2 6. OP14 OP21 12(1) & 23(2)(j) 7. OP26 13(3) & 23(2)(d) 8. OP32O P33 24 must be made safe from broken or damaged pieces of furniture. There must be adequate bathing 15/12/07 facilities provided to people living on the first floor of the home. Service users choice must be upheld as this is currently compromised due to the bathroom on the first floor being out of action. All areas of the home must be 15/12/07 maintained to an adequate standard of cleanliness in order to prevent the spread of infection. This includes the cleaning of all hoist and equipment. Adequate and effective 31/12/07 management systems must be in place to monitor all aspects of care provided in order to protect the health and welfare of service users. The current quality assurance systems must be improved to ensure the needs of the service users are heard and responded to e.g with a particular focus on service user meals and bathing arrangements. 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 Recomm Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area 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 Hill House DS0000019427.V352904.R01.S.doc Version 5.2 Page 26 - 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. 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