CARE HOMES FOR OLDER PEOPLE
Hill View 46 St Judith`s Lane Sawtry Cambridgeshire PE28 5XE Lead Inspector
Nicky Hone Key Unannounced Inspection 30th May 2007 09:00 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 View DS0000015106.V340324.R02.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 View DS0000015106.V340324.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hill View Address 46 St Judith`s Lane Sawtry Cambridgeshire PE28 5XE 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) 01487 831709 F/P 01487 831709 Oak House Homecare Limited ***Post Vacant*** Care Home 16 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (16) of places Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th July 2006 Brief Description of the Service: Hill View is registered to provide care to 16 older people including six older person with age-related mental health impairment. The home is set in its own gardens in a quiet location on the outskirts of the village of Sawtry and approximately five minutes walk from the village centre shops and public house. Huntingdon, Cambridge and Peterborough are within a radius of approximately 20 miles. Originally a domestic bungalow, the building has been extended to offer ground floor accommodation in single bedrooms all of which have en-suite facilities. The home is spacious and has a large lounge off the hallway at the front of the home, a dining room with an open plan kitchen, a conservatory and a separate dedicated office used by the manager and for meetings. The home has adequate bathing and washing facilities and is wellmaintained. Hill View has a neat and well kept enclosed and sheltered garden with ponds and flower beds. The weekly fees vary from £353 to £494. A copy of the latest inspection report is kept in the Service Users Guide which is provided to all service users and their representatives. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It was carried out by the field inspector Dragan Cvejic who also provided this report. This site visit lasted for 3 hours and the inspector spoke to three case tracked service users, to two more users, to a staff member and to the manager, Jennifer Telford, and operational manager who visited the home during the site visit. Documentation related to three case tracked service users was checked. A self-assessment form was filled in by the home and was used to inform this report. Three comments from external professionals involved in care process were also considered when the evidence was collected. Ten comment cards were returned to the CSCI giving direct anonymous comments from service users and their families. What the service does well:
“I chose to come here, as my wife was here. We were in rooms next to each other. She later moved to a nursing home. The staff are very good”, stated a case tracked service user. Another user commented: “They could not be better to me. I have been to 2 hospitals before I have got a place here, but this place is much better than any in Cheshire, where I came from. I cannot praise the staff enough. I like my room here. It’s much more than I expected.” Two staff helped a user during the site visit to come to the dining room. It took her a long time, but she was proud that she was able to do this independently, monitored by staff to avoid incidents. Staff were patient, they encouraged the user to move slowly, take a rest when she needed and showed great respect for the user’s dignity. New records were good. Medication process and records were exceptionally good. The home held 3 monthly Resident and Relative meetings which give the Service users and their Relatives an opportunity to get together and talk about how they may like their home life to change, improve, or what they would like to remain the same. Activities, meals and entertainment were usually the main topics at these meetings. Service users were encouraged to take part in the running of the home. They were consulted through quality assurance review, through informal chats with staff, the manager and operational manager during her visits. A suggestions box was located in the lounge area and provided an opportunity to make any comments or give suggestions. Visiting professionals had commented on the happy atmosphere Hill View has, how relaxed the environment was, yet how there was always something going on. A Community Outreach Worker provided the information for this
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 6 inspection when she was asked by the home and stated: “ Hill View is one of the nicest homes that I visit during my working week. The service users appear to be relaxed and happy and it is as if they are “at home with family” instead of in a residential home.” What has improved since the last inspection? What they could do better:
Despite the precise, accurate records of service users’ money held by the home, there was a chance to further improve the auditing system by adding the signatures of service users, when possible, for transactions, or at least after auditing and checking of balances. The home was encouraged during the site visit and after a user provided his comments, to introduce a free chiropody service for users with diabetes, as they were eligible for this service, in addition to private chiropodist visits, payable individually. Although the hot water taps were equipped with safety mixing valves to control water temperature, it was agreed that the records of temperatures were still to be kept, to reduce risk to users in case of potential faults with these devices. The home would need to ensure constant review of the staffing level, especially for the night shift, when only one staff member was on duty. At the time of the site visit, this was considered appropriate, but with potential gradual deterioration of users general health and increased needs, it was necessary to act preventatively and, if identified as needed, to increase the level of cover. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 7 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 View DS0000015106.V340324.R02.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 View DS0000015106.V340324.R02.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): 1,2,3,4,5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provided excellent information to service users allowing them to make an informed decision about their choice of home. They were fully assessed prior to admission, ensuring that their needs would be fully met, once they were admitted. EVIDENCE: The home stated in their self assessment: “We provide prospective service users with information regarding Hill View so they are able to make an informed decision about where they would like to live. This is our service user guide, which includes a copy of our statement of purpose outlining the services and facilities we have to offer. Also a sample copy of a contract, our latest inspection report and our complaints policy and procedure. We invite
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 10 prospective service users and their families to come to Hill View to see for themselves exactly what services we provide and the atmosphere / surroundings they are provided in. This also gives an excellent opportunity for them to meet our dedicated staff team.” Their service user’s guide was up to date. The home explained their admission process that included initial assessment: “All service users have a contract issued to them, or to their relatives if more appropriate. This details what is included in the fee they pay. A sample contract is available for their perusal before any agreement is made. Once signed, one is kept by the service user / relative and another is kept at Hill View on file. All permanent contracts include a 28 day trial period for both parties. Before admission a robust assessment is carried out by two senior members of staff. The care needs of the individual are assessed to ensure that Hill View is able to meet their needs fully. As well as the Prospective service users assessment form being filled in, a blank copy of the company care plan is taken along so as much information regarding the person is gathered before possible admission to Hill View. And of course, this helps us to help them to maximise their independence. If the prospective service user is funded by an authority then we would also receive a care plan from their social worker. This does not replace our assessment. Hill View encourages prospective service users to visit as much as possible before a decision is made on whether Hill View will become their new home. Day care and respite care is offered and encouraged.” Two service users spoken to confirmed these fact, as well as four checked files. A service user commented: “They cannot be better to me. I have been in two hospitals before coming here, but this is by far the best place.” The home explained how they improved the assessment: “On each assessment these are now taken together and we have improved on the amount of information gathered in the initial assessments. It is very important to all the staff to gain as much information before a prospective service user moves into Hill View as this will, we hope, make their settling in / adjustment period a lot more comfortable for them. A new information leaflet with colour pictures of Hill View has been devised giving information of services provided with sample photos of the facilities at Hill View.” Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offered excellent health care to service users with full respect for their privacy and dignity. Medication process was safe, well organised and ensured users were safe while their abilities to handle medication were promoted. The home exceeded these standards. EVIDENCE: A new format for care plans was used and all files were updated with this new format. The plan clearly instructed staff how to respond to each individually assessed need for each individual. Four service users files were checked and all had detailed, regularly reviewed care plans and risk assessments. Service users were involved in creating care plans to ensure their views and preferences were taken into account. Care plans were signed by the users. Healthcare needs of service users were appropriately assessed, reviewed and met. A service user with diabetes commented that he chose a chiropodist and was paying for this service. However, as a diabetic, he would qualify for free
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 12 chiropody service from NHS and the home would need to put him on their waiting list, in addition to existing private treatment. Another user had hearing problems and was on a waiting list for a hearing aid. The home stated in their self assessment how they ensure users get medical attention when it was necessary: “Wellside Surgery are very supportive of the needs of the service users. If we have any concerns regarding the service users health then we are able to call the practice and a Doctor will come out as soon as they are able that same day. Service users comment on the quick medical assistance they receive if they request it, or if it is evident that they require it. Wellside surgery also allow for us to talk to the Doctors on the phone for advice if a Doctors visit is not necessary. District Nurses are also very supportive and will visit Hill View if we have any concerns regarding the wellbeing of any service user. Service Users have their weight recorded monthly, if it is noticeable that a service user is losing weight then a care plan will be written to identify this and a course of action agreed, this may involve the Doctors.” In all checked files, the weight charts, visits of medical professionals and any potential risks were appropriately recorded. The home changed their medication supplier to Boots. Since the change, the medication process was significantly improved. Three records were checked and demonstrated that the system was very good. Medication carried over from sheet to sheet was recorded on a new sheet allowing for easy auditing. Only one service user was prescribed a controlled drug and the recording and procedure were accurate and safe. One user was self medicating with inhalers and also injected himself with insulin injection. A risk assessment was drawn up for this. A contact person from Boots commented: “Any changes in medication are always phoned through, so I can be aware when the monthly scripts arrive.” Although all staff received medication training, only three staff were administering medication, which significantly reduced the possibility for mistakes. This process and records exceeded minimum standards and offered extra safety to service users. Service users were treated with respect and dignity. A user spoken to stated that he did not mind having female carers helping him. The home demonstrated how they respected privacy: “All bedroom doors are knocked on and staff wait for a verbal come in before doing so. This also applies to the bathroom and shower room.” Terminal care was given essential attention and the home assessed it as very good: “Terminal care is given with the most respect ensuring that the service users dignity is intact at all times. Close work with the Doctors and district nurses take place to ensure that we are able to provide all that is necessary to enable us to care for the service user appropriately. Relatives are able to visit as often as they like whenever they like, provisions are made to allow for them to stay in the home overnight if they wish. Comments, cards and flowers are received by Hill View from relatives who have lost a loved-one, thanking the
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 13 staff for the kindness showed towards their relative whilst they were with us at Hill View.” Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users were pleased that they could decide on their daily life and routine. Their views were taken into account when activities were planned. The home exceeded these standards. EVIDENCE: Service users spoken to confirmed that the statement provided by the home about the activities, daily life and food was accurate. The home wrote: “We strive to meet all the recreational needs that the service users have. We understand that our service users are individuals and that their needs are ever changing. We aim to provide activities to suit the service users. Whether they are group activities or 1 to 1 activities. We organise fund raising events and barbeques that the residents all enjoy. We also celebrate national events throughout the years i.e. red nose day, football finals etc.
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 15 Service users views and suggestions are fully sought and listened to. This helps us to provide a service containing entertainment and activities that they will enjoy and benefit from. Activities and events are advertised throughout the home, service users and their families/friends are encouraged to join in, but their wishes are respected if they decline. We provide wholesome nutritional meals which cater for many dietary needs and choices. Staff will assist Service Users to write letters if they find it difficult, we will post them too. Hill View recieves visits from both the Methodist Church and also from the Baptist Church. If other ministers are requested then we will endeavour to arrange these. The Salvation Army also visit fortnightly. The service users are encouraged to continue to be involved in the Sawtry community and receive invitations to attend the Sawtry Feast and local infant school plays. We hold Spring, Summer, Autumn and Christmas Fetes to help to raise money for the resident comfort funds. In the summer we hold BBQs and cream tea afternoons, which are specifically for the Service users and their Relatives.” A service user was more than happy that the owner helped him buy a scooter and significantly improved his mobility. “I can go to the centre of village now”, he proudly stated. Comments cards received to the CSCI indicated that the food provided in the home was good. Service users spoken to stated that they were happy with food, choice and the opportunity to influence changes to the menu. The manager stated that home catered for a vegetarian service user and would cater for any other special dietary needs. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Dealing with complaints was appropriate, users were confident that they could complain if they wished. Users were protected from potential abuse, but the system could be improved by adding a users’ signature on records and users would be even better protected. EVIDENCE: There were no complaints since the last inspection. Service users spoken to and comments cards received showed that people were aware of the complaints procedure and would know how to complain if they wanted. The home introduced a book to record potential complaints, but no entries were made, as there were no complaints. Three users confirmed that they were taking part in recent local elections. However, one user stated that he was not on the voting register and the manager took up the task straight away to investigate why and rectify the situation. The home stated in their self assessment: “All staff have received POVA training and are all aware of whistleblowing. We have open discussions at staff meetings to raise awareness on these issues. Feedback from external agencies is complimentary as we have our own POVA key practitioner within the company.
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 17 Service users money is checked regularly to ensure balances remain correct, 2 staff sign when money is received and taken out to allow for a good audit trail.” Two service users’ records of money were checked. All entries corresponded to the receipts, but there were no service users’ signatures to confirm that they were aware of expenditure and balances. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a well maintained, pleasant, comfortable and clean environment where service users could use all their abilities to remain as independent as possible. EVIDENCE: The home provides a safe and secure environment for all service users. All rooms have en-suite facilities and are carpeted. Hill View is well maintained clean and comfortable. Service users are encouraged to have personal items in their room and two users spoken to showed their rooms with personal possessions. The home has all the necessary aids and adaptations throughout to meet the assessed needs of the service users and specialist equipment will be
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 19 purchased or hired if required to meet the needs of the service users. Equipment around the home includes hand rails, grab rails, raised toilet seats and hoists. The home was clean and bright at the time of the site visit. All staff are dedicated to providing a clean environment that is free from unpleasant odours and infection control procedures are adhered to. The home was inspected by the Environmental Health in April 2007. A gardener was emlpoyed since the last inspection and the garden provided a very comfortable and nice space for service users. A service user also mentioned his garden, an allocated part that he was tending to. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was constantly reviewing the staffing level to ensure that increased users’ needs would be answered, when they exceed the ability of the existing staff to respond to them in a timely manner. Service users trusted staff and felt well treated, respected and supported. EVIDENCE: “I cannot praise staff enough. They could not be better to me”, commented a service user on staff. Another user explained how the staff responded to calls at night: I call them, I do not normally need to wait. They come, they make me a cup of tea and I go back to sleep.” A staff member who had worked in the home for 3 years and was promoted to a senior position 9 months ago commented: “Staff are well organised and good communication is the key for the effective work. Our handovers are detailed and we always know what affected each individual resident.” The home had one staff member during the night, but their on-call system ensured that there would be more staff, if the situation demanded. In their assessment the home stated: “There are always senior members of
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 21 staff on duty between 7.30am and 10pm. There is always a senior member of staff on call 24hrs per day to provide assistance and advice if required Hill View has a team of steady, experienced and reliable staff enabling us to provide a standard of care to the residents that incorporates continunuity.” They also explained their situation related to the requirement from the last inspection: “When the inspection was carried out in July 2006 it was felt by yourselves that an additional member of night staff would be beneficial at Hill View. Under normal circumstances one member of Night staff is on duty between the hours of 10pm-7.30am and this is sufficient to our current service users needs. There is always an on-call member of senior staff on duty to provide advice or assistance at any time if needed. Our staffing levels will always be under review as our service users needs change.” Eight out of ten workers had their NVQ qualifications. The home strictly followed the organisation’s recruitment procedure, ensuring all new staff were properly checked before starting working with service users. Four staff files were checked and all had the required documents: two references, CRB disclosure, POVA disclosure, training records and supervision dates. One of the files without supervision records had a probationary review form, as the home did not supervise new staff for the first six weeks, but carried out a review of the probationary period instead. Staff training was also very good, especially the enhanced training for senior staff that was much more in-depth. The senior staff tried the equipment for themselves: hoist, turn sheet etc in order to better understand the feelings users had when the equipment was used to support them. The following was mandatory training: POVA, Manual Handling, First Aid, Food Hygiene, Fire Safety, Dementia Care; all mandatory training was updated yearly. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured service users were well protected by the safe working practices that were constantly monitored. EVIDENCE: The home was managed by the experienced, skilled and knowledgeable manager. The Visiting professional commented: “The manager is approachable and friendly and always available for discussion.” Another management approach was described in a letter from a GP who monitors service users in the home: “In my opinion, Hill View is well run. Their facilities are kept in good order, the staff are friendly with ourselves and caring of the service users.”
Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 23 Service users spoken to also commented on the good management of the home. The ethos of the home was praised in all 10 comment cards, in three letters from the external health professionals and from all service users spoken to during the site visit. The organisation’s quality assurance review was carried out once a year. This year’s questionnaires were planned to be send in June. However, the home constantly collected opinions and comments from relatives and external professionals, as well as from staff and service users at their 3-monthly meetings. The home commented on their dealing with users’ money: “Small amounts of money are kept for service users in the office safe. Each service user has a cash sheet which details monies in and out and two staff signatures are required. Balances are checked regularly.” When records were checked, all were signed by two staff and the amounts were accurate. However, there was no evidence that service users were aware of the balances, as they did not sign these records or auditing of their money. Staff supervision was regular and was provided 5 times a year, plus the appraisal meeting. Staff spoken to confirmed that the support for staff was excellent. Very good induction, induction reviews and initial training for all new staff ensured they could start work confident, trained and with good knowledge of service users. Health and safety was delegated to a staff member and thus the process was well monitored and all actions taken preventatively. The home had recently been inspected by environmental health and there were no major shortfalls. New mixing valves were installed to ensure safe hot water temperatures on taps. However, the home could further improve this safety measure if they start recording these temperatures. Safe working practices were in place. Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP27 Good Practice Recommendations The home should support service users with diabetes to gain access to free, NHS chiropody in addition to the existing private service. The home should record staffing level reviews to document that the level is determined by the existing users needs and that changes would be introduced if the need for that arise. The home should introduce service users’ signatures on the records of their money kept in the home to allow users to be aware of their balances. The home should start monitoring water temperature on hot water taps to ensure better protection of service users in case of mixing valves develop faults. 3 4 OP35 OP38 Hill View DS0000015106.V340324.R02.S.doc Version 5.2 Page 26 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
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