Inspection on 13/04/07 for Hill House Nursing Home Limited

This inspection was carried out on 13th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Nursing Home Limited 03/11/05

Hill House Nursing Home Limited 02/06/05

Hill House Nursing Home Limited 11/01/05

Hill House Nursing Home Limited 07/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Hill House Nursing Home Limited Hill House Nursing Home 48-50 Park Road Kenley Surrey CR8 5AR Lead Inspector Michael Williams Key Unannounced Inspection 13th April 2007 9:45am 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 Nursing Home Limited DS0000019029.V332737.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 Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hill House Nursing Home Limited Address Hill House Nursing Home 48-50 Park Road Kenley Surrey CR8 5AR 020 8660 9336 020 8668 0210 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) Hill House Nursing Home Limited Mrs Elana Pamela Follwell Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (0), Terminally ill (10) of places Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 10 service users in the category of Terminally Ill aged over 40 years. Eight intermediate care places provided in rooms 102, 108, 110, 111 and 112. A variation has been granted to allow day care to be provided for one specified service user. 18th April 2006 Date of last inspection Brief Description of the Service: Hill House provides personal care, including nursing care, for older people but does not provide care in other categories such as dementia care or people with mental illness. Its services include Intermediate Care and care of the Terminally ill. Both of these specialist services are supported directly by the relevant Health Authority agencies. The hotel-style home comprises 35 single rooms and 15 shared rooms. There are 4 dayrooms plus bathrooms, showerrooms and there are toilets sited throughout the home. There is a library, a hairdressing salon plus the usual facilities, including a laundry, offices and staff rooms. There is a garden to the rear and an enclosed courtyard plus off-street parking to the front of the home. Fees as at April 2007 were £600 to £950. Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. To monitor all aspects of care the Commission ‘tracked’ the care provided to a sample number of residents and cross checked the information by examining the documentation supporting care, observing the meals provided, checking the arrangement for medication, for handling money, records of complaints and accidents. Staff providing care were interviewed, and where possible the inspector met with relatives as well as interviewing or observing the residents themselves. Questionnaires were also distributed and we received written comments from 3 residents, 5 relatives, 5 members of staff, 2 doctors, 1 physiotherapist and 1 palliative care social worker. All commentators agree Hill House provides satisfactory care and some respondents describe the home as “excellent”, an outcome for residents that the Commission would not disagree with. What the service does well: What has improved since the last inspection? What they could do better: A small number of points requiring improvement have been noted. Each resident must have contract and/or a copy of the agreement between the home and the placing authority. Residents must be offered the choice of bedroom door lock unless a risk assessment in their care plans indicates this Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 6 would be unsafe. Bedrooms doors must risk-assessed in respect of self-closing devices. 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 Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 7 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 Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 8 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): NMS 2, 3 and 6: Quality in this outcome area Good. This judgement has been made using available evidence including a visit to this service. New service users are being admitted only on the basis of an assessment undertaken by people trained to do so. This involves the service user or, in some cases, their representative so they will be assured that their needs will be met. The home has in place facilities to support residents preparing to return to their own homes. The Primary Care Trust has not always been providing contracts or agreements in respect of patients placed by them so neither the home nor service users are clear about what conditions apply to them. EVIDENCE: The home has revised its Statement of Purpose and is in the process of updating its Guide so as to ensure that the information provided is easy to understand, clear and accurate. Residents in this home often arrive from hospital or are admitted to the home directly so as to avoid hospitalisation. Nurses, Doctors and other health professionals are therefore involved in assessing most residents’ needs prior to admission. The home also has its own very detailed assessment formats. Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 9 The manager explained that a number of residents are placed by a local PCT (Primary Care Trust) and some of these patients do not have an individual contract or an agreement. The Care Home Regulations were recently amended to strengthen residents’ rights and ensure everyone entering a care home has clear information in a legally binding agreement. Without such a contract or agreement neither the home nor the resident is clear about the conditions for their residence and in particular whether the home can veto placements, or discharge residents, that are outside their registration category. Despite the problem of contracts such placements endorse the home’s capacity to meet the needs of residents with complex clinical needs and demonstrates a confidence in nursing and care staff to provide high standards of care. Areas of strength are the detailed assessments that take place prior to admission, the accessibility of the home for prospective residents to visit and evaluate services prior to admission and the information provided by the home at the time of admission. However, one vital matter requiring improvement is the need to ensure all residents have a contract or agreement. This section, about choice of home, is therefore assessed as good. Hill House Nursing Home Limited DS0000019029.V332737.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): NMS 7, 8, 9 , 10 and 11: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning, the provision of health care and the procedures for dealing with medication are not only satisfactory in this home but in many instances achieved to a very high standard - this ensures the often complex social, and health care needs of residents can be met. EVIDENCE: The home has a strong ethos of involving residents in all aspects of their life. All residents have a robust care plan. The home has effective systems in place to ensure care plans are reviewed and updated regularly and arranges additional reviews when changes take place. Feedback and involvement is a continuous ongoing process; the inspector confirmed that staff spend time with individual residents to ensure they understand their needs, although some feedback indicates staff are often very busy. However, contrary one observer’s impression, there are no restrictions on staff engaging with residents for example by sitting and chatting to them in the lounge. The care plan is used as a working tool and is understood by all staff. It is a standardised, colourcoded format written in clear language and could be used in an emergency by people who are not familiar with its content. Each care plan includes a Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 11 comprehensive risk assessment. Management of risk takes into account the needs of residents balanced with their aspirations for independence and choice and this is particularly true of residents undertaking rehabilitation before returning home. The home operates to well developed and efficient medication policies, procedures and practice guidance. The manager routinely observes staff attitudes and approach to privacy and respect and constantly seeks and values residents’ views and experiences. The homes policies, procedures and guidance support and inform practice. This home provides care to residents who often have complex clinical needs and a number of such residents were ‘case tracked’ including examination of case records, interviewing residents themselves and talking to family and to staff. It is to the credit of Hill House that a number of residents arrive in the home with an expected life span counted in weeks or days but in fact their health and quality of life improves and it is not unusual for their life span to be extended considerably longer than anticipated. The wishes of individual residents about dying and terminal care, and the arrangements they want after death are openly and sensitively discussed with both the residents and their family during the development of the care plan. This home is one of small number of care homes in the area involved in the end of life programme. They have implemented the ‘Liverpool Care Pathway’ to ensure a resident’s last days are sensitively and well managed and this consultation with the resident, their family and staff to ensure a coordinated approach at this critical time. These strategies are clearly recorded, respected and known to the staff delivering the care. The home has a detailed policy, procedure and practice guidance to help staff when handling terminal care and death. All staff receive in house training and practical advice in caring for these residents, and have continuous support and opportunities to discuss any areas of anxiety and concern and this was confirmed a palliative care social worker in her feedback to the Commission. Facilities are provided to allow relatives and friends to stay with the resident and to assist with their care if the residents want this. Areas of strength include the home’s capacity to provide high standards of care, social and clinical, in complex cases. There are no matters identified as requiring improvement so this section, about health and personal care, is assessed as excellent. Hill House Nursing Home Limited DS0000019029.V332737.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): NMS 12 to 15: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from limited only by their own choice or incapacity. The home has sought the views of residents and visitors and has considered their varied interests and abilities when planning meals and the routines of daily living and arranging activities. Routines are very flexible, within the constraints of large establishment, and residents can make choices band exercise control in major areas of their life. The routines, activities and plans are resident focussed, regularly reviewed, and can be quickly changed to meet individual residents needs. EVIDENCE: The home has an activities coordinator who is responsible for creating meaningful activities and experiences both in the home and the wider community. On the day of the inspection visit residents were in the main lounge enjoying a quiz and they spoke very highly of the programme of activities provided by the home. The system in place and the practice and attitude of the staff team give service users the opportunity and support to remain independent particularly when residents are planning to return home. However it is inevitable that in many instances residents are far too frail to be independent and are in fact very Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 13 dependent upon staff for all aspects of their care. But in such circumstances the home seeks to ensure residents are stimulated and kept mentally active, one excellent example is a resident who by the blink of an eye can now make her wishes known and is keen to listen to the radio channel of her choice. Other residents still get out and about despite frailty and disabilities. Family and friends were on site to advise us that they are welcomed into the home and can either meet residents in the communal areas, in private areas such as the library or in resident’s own bedroom. Food is recognised as very important and meal times considered a social occasion. The cook in the home is qualified and experienced in cooking for older people, is an important member of the care team and is well aware of the recorded dietary and cultural needs of each service user. He is committed to involving service users in menu planning and making sure that they are able to enjoy the food they prefer and like and frequently makes extras meals for residents who dislike or choose not to have the main choices. The menu is varied, balanced and nutritious. It has a number of choices including a healthy option, and includes a variety of dishes that encourage service users to try new and sometimes unfamiliar food. Food is served to meet the needs of all residents including those who have swallowing or chewing difficulty. Staff give assistance to those service users who need help to eat, and when doing so they are discrete and sensitive. Mealtimes are relaxed, staff are patient and helpful, and allow service users the time they needed to finish their meal comfortably, encouraging them to serve themselves. Residents appreciate the good quality food they are served and being able to have a drink when they wish and the availability of snacks. They also enjoy being able to eat in their own room when they wish. Whilst the home does not have kitchenettes for residents to prepare their own meals some residents do have food storage facilities in their room and can shop for their own choice of food and meals. One or two comments were made to us about the meals such as the temperature of some vegetables at the point of service and whether ‘extras’ were allowed; these comments were passed onto the chef. Areas of strength include the very popular activity programme, the comfortable environment and the very good catering and as no matters requiring improvement arise this section, about daily living, is assessed as excellent. Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 14 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): NMS 16 and 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear and simple procedure for dealing with complaints so residents are confident their concerns will be dealt with promptly and effectively. To ensure service users are safeguarded from abuse the home has a comprehensive training programme as well as written policies and procedures. EVIDENCE: The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It can be made available in a number of formats to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is widely distributed, and has a high profile within the service – even so a number of feedback forms indicate that not everyone knows what the complaint procedure is. But when we spoke to residents and their visitors in was clear they had a good understanding of how to make a complaint, to whom and they are were very clear about complaints are handled. It was the impression of some that very local and immediate complaints could be dealt with quickly but sometimes issues such as maintenance problems took some time to resolve. The home contends that unless there are exceptional circumstances the service always responds to complaints within the agreed timescale – although some practical problems may take time to fix. The policies and procedures regarding protection of residents are of a high quality and are regularly reviewed and updated. The service is clear when Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 15 incidents need external input and who to refer the incident to and since the previous inspection there have been four occasions when the system for making such referrals has been used. Training of staff in the area of protection is regularly arranged by the home. The outcomes from any referral are managed well and issues are usually being resolved to the satisfaction of those involved. This includes disciplining staff where lapses in conduct have been identified. Residents and others associated with the service state that they are very satisfied with the service provision, they tell us that they feel very safe and well supported by Hill House staff and Directors. The promotion of the individual’s rights is central to the aims and objectives of the service and is spelt out in their charter that is on display in the home. Policies, procedures and the home’s documentation reflect the rights of the individual. Advocates are used to help residents understand their rights, and to also ensure that they can access places of worship or community facilities of their choice. We met one such advocate to confirm this is the case. Staff are skilled and understand the importance of actively promoting individuals rights, for example they understand residents’ rights to privacy, to direct their daily lives, to make choices (within the limitations of their abilities and disabilities) and to accept or reject treatment and support as they wish. Areas of strength include the willingness of the home to listen to concerns and complaints and act upon them. It has demonstrated a clear understanding or the procedures for protecting vulnerable adults. Matters requiring improvement include the need to publicise more widely the complaints procedures that apply in this home. This section, about complaints and protection, is assessed as good. Hill House Nursing Home Limited DS0000019029.V332737.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): MNS 19 and 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the home and the manner in which it is being maintained means ensures that this is a safe, comfortable and suitable environment for the service users. The premises are being kept clean, hygienic and free from offensive odours and systems are in place to prevent the spread of infection. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live with many bedrooms rooms that meet the national minimum standards including en-suite facilities in many instances. Where rooms are shared it is only by agreement, and screens provided for privacy. Residents are given the choice to move into a single room when one becomes vacant. They have the choice to bring small personal items of furniture into the home. The homes fixtures and fittings meet the needs of the residents and can be changed if their needs change and in one example the Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 17 bedrooms has been refitted to provided extra over-head storage space for personal possessions. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy, in the library for example, or in their own bedrooms. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. Residents say that there is plenty of hot water and the temperature in the individual bedrooms can be adjusted upon request. The home is well lit, clean and tidy and free of offensive odour. The management has a good infection control policy. They seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. Residents commend housekeeping in Hill house. A rolling programme of renewal and replacement is in place and recently carpets have been laid on the ground floor. Inevitably some areas need attention including areas where chairs cause superficial damage to walls, doorways and tiles (a point noted in the feedback to us). Not all bedrooms doors have a door lock and not are all self-closing. It is advised that both points are addressed. This may require risk assessment and consultation with the local Fire Safety unit. Areas of strength are comfortable surroundings in which residents live, the home is clean and tidy and well equipped to cater for residents with mobility problems. Amongst those matters needing attention is the minor damage to the fabric of the building and the bedroom doors (locks and self closing devices). So this section, about the environment, is assessed as good. Hill House Nursing Home Limited DS0000019029.V332737.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): MNS 27 to 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home which ensures that their needs are being met. The required procedures are in place to ensure recruitment of staff protects service users. The home has a staff induction, training, support and supervision regime in place so service users can be assured that staff are competent in their jobs. The recruitment, training and support of staff will ensure service users are ‘safe in their hands’. EVIDENCE: Residents have confidence in the staff that care for them, often describing them as very caring and thoughtful. Rotas show well thought out, making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. This includes moving key staff from one floor to another as overall dependency levels alter. Management encourage staff members to undertake external qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. For Nurses this means maintaining their qualifications and skills through recognised training and practice sessions throughout the year. The service clearly defines the roles and responsibilities of staff, nursing, caring and ancillary, through accurate job descriptions and specifications. Residents Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 19 report that staff working with them are very skilled in their role, and are consistently able to meet their needs. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. Feedback to us from external trainers confirms the staff not only undertake relevant training but are enthusiastic and keen to learn. The service has a good recruitment procedure that clearly defines the process to be followed. A number of staff were examined and staff interviewed to confirm this procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. There is little use of any agency or temporary staff Areas of strength are the number, qualifications and skills of staff and as no matters requiring improvement arise in this section, about staffing, it is assessed as good. Hill House Nursing Home Limited DS0000019029.V332737.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): NMS 31, 33, 35, 37 and 38: Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The owners and manager are registered with the Commission as persons competent to run this Hill House in accordance with its stated aims and objectives and so in the best interests of the service users. The home is well managed, including its finances, and is safe and viable for the benefit residents. EVIDENCE: The manager has the required qualifications and considerable experience making her very competent to run the home. The Manager works closely with the Directors, who themselves are closely involved in the day to day running of their care home, to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is residentfocused and leads and supports a strong staff team who have been recruited Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 21 and trained to a high standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. The home has sound policies and procedures, which the management team periodically review and update. The manager is regarded highly by other professionals as affirmed in their feedback to us; one visiting professional described the home as “excellent”. Staff are positive in their approach to translate policy into practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that they receive feedback on their work. The home works to a clear health and safety policy, all staff are given a copy, and regular random checks take place to ensure they are working to it. The home has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. A range of records were examined during the inspection visit including residents’ case files; staff files; food records; money records; medicine records; complaints; accidents and so forth. Where issues have been identified, for example, in care plans, these have been acted upon successfully to ensure residents care is not compromised. Residents are aware of safety arrangements and have confidence in the safe working practices of staff. The Directors evidently have the skills and ability to deliver good business planning, effective financial controls and provides a quality assurance and monitoring processes. They confirm that the home remains financially viable. Insurance cover in place to enable it to fulfil any loss or legal liabilities. If they wish and are able to, residents are helped to take responsibility for managing their own money and some do. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for resident’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. A sample of money records were checked to ensure these records are maintained with probity and efficiency. Areas of strength are the overall management of the service as confirmed by feedback to us and as observed during inspections and information sent to the Commission. Matters requiring improvement are listed under other sections, such as the needs to provide contracts or agreements to all residents and the need to confirm the current bedroom doors meet safety and privacy standards; so this section, about management and administration, is assessed as excellent. Hill House Nursing Home Limited DS0000019029.V332737.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 X 2 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 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 4 X 4 4 3 X 4 3 Hill House Nursing Home Limited DS0000019029.V332737.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. Standard 1 OP2 Regulation 5, 5A and 5B. Requirement Contract or Agreement: Each resident must be provided with a written contract or agreement in accordance with the revised regulations to ensure they know their rights. Bedroom doors: The home must fit suitable locking mechanisms on bedroom doors for the privacy and dignity of residents unless a care plan risk assessment indicates one should not be fitted. Fire safety: For the protection of residents the home must risk-assess bedroom doors in accordance with the revised care home regulations and the Regulatory Reform (Fire Safety) Order 2005 and fit suitable self-closing devices where required. Timescale for action 30/07/07 2 OP19 23(4) and (4A) 30/03/08 3 OP19 23(4) and (4A) 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hill House Nursing Home Limited DS0000019029.V332737.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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