Inspection on 01/09/05 for Hillbro Nursing Home

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillbro Nursing Home 22/11/07

Hillbro Nursing Home 12/09/06

Hillbro Nursing Home 22/03/06

Hillbro Nursing Home 17/12/04

Hillbro Nursing Home 21/06/04

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

CARE HOMES FOR OLDER PEOPLE Hillbro Nursing Home Holden Lane Baildon Shipley BD17 6RZ Lead Inspector Steve Marsh Unannounced 1 September 2005 st 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 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. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillbro Nursing Home Address Holden Lane Baildon Shipley BD17 6RZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 592723 01274 532699 Mr Ronald Berry Mrs Cherokee Flame Needham Care Home with Nursing 42 Category(ies) of Mental Disorder Over 65 (41) Dementia Over 65 registration, with number (41) Mental Disorder (1) of places Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: That the category for MD be used for the person named on the notice that accompanies this certificate Date of last inspection 17/12/04 Brief Description of the Service: Hillbro Nursing Home is situated in an elevated position in the village of Baildon, which is located on the outskirts of the city of Bradford. At the present time the home provides care (including nursing) for forty-two residents diagnosed with Alzheimers Disease (or other types of dementia), or a functional mental illness. The home is close to the shops and other facilities in the village centre, and there is a car park to the front of the property. The original building is imposing and dates back to the nineteenth century, retaining many of its original features. More recent extensions to the property have been added in a sympathetic manner and complement the existing building. There is a planned programme of refurbishment and renewal at the home and it is anticipated that the majority of bedrooms will have been refurbished by the end of 2005 in line with the agreed timescales. The home is accessible to service users/visitors in wheelchairs (not main entrance), and there is a passenger lift available to the bedrooms and other facilities on the upper floors of the building. Bedroom accommodation is provided in both double and single rooms the majority having en-suite facilities. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection visit for the year 2005/06, and was carried out by one Inspector over a period of approximately eight hours. The last inspection of this service was in December 2004 and the main purpose of this visit was to assess the homes progress made in meeting the requirements and recommendations made at that time. The methodology used in this inspection included the examinations of records, observation of work practices, discussion’s with residents, visitors and staff and a tour of the building. Due to their illness (dementia/mental health) some residents were unable to express their views and/or opinions about the home, however those that were able felt that the staff team provided a very good standard of care. Comment cards were also provided, for residents and/or their relatives to enable them to share their views of the service with the Commission. Comments received in this way will be fed back to the registered manager of the home without revealing the identity of the respondent. The Inspector has visited Hillbro Nursing Home over a period of about two years and therefore drew on information already known about the home when completing this report. Requirements and recommendations from this inspection are detailed at the end of the report. (People living at the home said that they preferred to be referred to as residents and not service users in this report) What the service does well: The home continues to provide a safe and comfortable environment for the residents, and the manager and staff team are approachable, and appear to have a genuine understanding of their needs. The admission process is thorough and the manager will not admit residents unless she feels that the staff team are able to provide the level of care and/or support they require. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 6 The resident’s healthcare needs are met and any problems are identified and dealt with at an early stage. The care planning system in place is comprehensive and risk assessments and/or protocols are completed for specific areas of concern. Members of staff encourage the residents to make as many decisions as possible in relation to their daily lives, and activities/outings are organised in line with their wishes. The staff recruitment and selection procedures are robust, and there is a commitment to provide staff training both to meet the needs of the residents and for personal development. What has improved since the last inspection? What they could do better: The manager needs to ensure that the refurbishment programme gains momentum and is completed within the agreed timescale. Additional requirements relating to the environment highlighted in this report must be addressed, and the manager needs to ensure that staff are more vigilant, and do not leave bedrooms in a state of disarray and/or soiled/stained sheets on beds. Additional members of care staff need to be encouraged to study for a National Vocational Qualification (NVQ) at level two (or equivalent,) as the home is very unlikely to meet the deadline of having at least 50 of the staff team NVQ trained by the end of 2005. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,5 Residents are provided with sufficient information to enable them and/or their relatives to make an informed decision about the home. The admission process is good and includes per-admission assessment visits, introductory visits and trial periods if appropriate. EVIDENCE: The manager confirmed that there had been no changes to the homes statement of purpose and service user guide, which are available to both existing and prospective residents. The records examined provided evidence that pre-admission assessment visits are carried out to see prospective residents either in their own home or temporary place of residence, and the needs identified during this visit are reflected in their initial care plan. In addition to the pre-admission visit all prospective residents and/or their relatives are invited to visit the home prior to admission to view the Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 10 accommodation, meet the other residents and staff and stay for a meal if they wish to do so. Service users are also able to move into the home for a trial period to enable them and/or their relatives make an informed decision about their long-term care. It is however acknowledged that for some residents diagnosed with dementia, the above options may not always be appropriate as they may actually become more confused and/or disorientated. Relatives spoken to confirmed that the manager and members of staff had been helpful when they had initially visited the home, had shown them around, answered any questions asked, and provided general information about the care/services provided. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Records and reports completed show that the resident’s healthcare needs are met and any problems are identified at an early stage. The care planning system in place is comprehensive and is reviewed on a regular basis in line with the changing needs of individual residents. EVIDENCE: Care plans have been completed for all residents and there is sufficient evidence in the documentation to show that the residents and/or their relatives are involved in the care planning process. The care plans reviewed were comprehensive, easily understood and contained both the healthcare and social needs of the residents, as well as a good life history. Care plans are reviewed on a monthly basis or sooner if the needs of individual residents change significantly. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 12 In addition to the care plans, risk assessments are completed for individual residents highlighting specific areas of concern, and moving and handling assessments are completed if required. All residents are registered with a general practitioner and have access to the full range of NHS services. The home has established good working relationships with other healthcare professionals and any concerns are identified at an early stage and advice sought. Relative spoken to on the day of the visit confirmed that prompt medical attention was always received by the residents if they were ill, which they found very reassuring. Relatives also said that they were kept informed of any changes in the resident’s general health and were given the opportunity to meet other healthcare professionals involved in their care if they wished to do so. All medical examinations are carried out in the resident’s own bedrooms, and it was obvious through observation, and discussion with the residents that they are treated with respect, and staff maintained their dignity when assisting them with personal care. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The home offers a range of social and leisure activities, and residents are encouraged to make informed decisions about their lifestyle within the limitations of their illness. Meals appear nourishing and take into account the likes and dislikes of the residents. EVIDENCE: The manager confirmed that the daily routines of the home are flexible and based around the needs of the residents. The interests and hobbies of individual residents are recorded in their care file and they are encourage to pursue them for as long as it is practical for them to do so. The home employs a part time activities co-ordinator who is responsible for arranging activities and outings for the residents in line with their wishes. The home is fortunate to have access to a mini bus and weather permitting weekly trips are organised to places of local interest, which the residents confirmed they thoroughly enjoy. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 14 The day prior to the visit, an entertainer had also visited the home, and the manager confirmed that in–house entertainment continues to be arranged for the residents on a monthly basis. The manager confirmed that residents are encouraged to follow their own religious beliefs and arrangements can be made for individuals to attend places of worship if they wish to do so. A local priest also holds a service at the home on a monthly basis. The manager has in the past attempted to hold regular resident/relative meetings to keep people informed of forthcoming events, however as these meetings were poorly attended the home has now started to produce a monthly newsletter. Residents are able to see visitors either in their own room, one of the communal areas or the designated visitors room, and the relatives spoken to, confirmed that they were always made to feel welcome when they visited the home and offered light refreshment. The manager confirmed that since the last visit the home has stopped purchasing pre-packed frozen meals and all food is now freshly prepared on the premises. This will without doubt provide the residents with a more varied and balanced diet, and enable the cook to more easily cater for the likes and dislikes of individual residents. On the day of the visit the meals provided at both lunch and teatime looked appetising, were well presented and appeared to be enjoyed by the residents. It was noted that residents requiring assistance/prompting to eat their meals received the support and assisted they needed in a discreet and sensitive manner. Hot and cold drinks are freely available to the residents both day and night. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Robust complaint and adult protection policies and procedures ensure that the residents are listened to and protected from any form of abuse. EVIDENCE: The home has a complaints procedure and the manager confirmed that there had been no formal complaints received since the last inspection visit. Relatives spoken to confirmed that they were aware of the complaints procedure, but felt that if they had any concerns they would be dealt with immediately by the staff without them having to make a formal complaint. Policies and procedures are in place at the home in relation to the protection of vulnerable adults, and the manager ensures that all members of the staff team receive appropriate training. The manager and staff have also learnt lessons from a recent incident at the home involving a member of agency staff, and have changed some procedures, and implemented others, to safeguard the residents. Members of staff spoken to confirmed that they were aware of the homes policy on “whistle blowing” and their responsibility to protect the residents from any form of abuse. The manager is aware of the Protection Of Vulnerable Adults register and the implication this has had on the homes staff recruitment, selection and disciplinary procedures. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,24,25,26 There continues to be an ongoing programme of refurbishment and renewal at the home, which is due to be completed by December 2005. The manager must however ensure that the maintenance issues highlighted in the body of the report are addressed with some urgency, and bedrooms are not left in a state of disarray with soiled/stained sheets left on made beds. EVIDENCE: There is a planned programme of refurbishment and renewal at the home and over the past two years considerable work has been carried out to improve the environment for the residents. It was however disappointing to note that since the last visit to the home in December 2004 only an additional eight more bedrooms had been refurbished, which appears to indicate that timescale agreed for the completion of the work December 2005 will not be met. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 17 All the communal areas with the exception of the conservatory are situated on the ground floor of the home and were refurbished in the autumn of 2003. The conservatory is situated on the first floor of the property and has direct access to a purpose built and secure sensory garden area. There is also a second secure patio/garden area, which is accessed through the lounge/dining room situated on the ground floor of the property. Smoking is not allowed in the communal areas but there is a small smoke room located on the ground floor, which can be used by both the staff and residents. Bedroom accommodation is provided in both double and single rooms on both floors of the property, the majority having en-suite facilities. The rooms that have been refurbished are bright and airy and provide pleasant and comfortable accommodation for the residents, however there is a marked difference in the rooms still waiting to be refurbished. In particular it was noted that a double room on the ground floor of the building is in need of urgent refurbishment, as in addition to the décor, cupboard doors were damaged/hanging off and the front cover was missing from what appeared to be an unused air conditioning unit. Staff had also left stained/marked sheets on both beds in the room, one having being made with the bottom sheet stained with two large rings of dried urine. In addition the bedroom in general had been left in a state of disarray with clothing hanging out of draws etc. Following a discussion with the manager it became evident that she had already identified through the homes quality assurance monitoring systems that a member(s) of staff was/were not following the homes policies and procedures and was addressing the matter. Outstanding requirements relating to the refurbishment of the home are highlighted in this statutory requirement section of this report, and the home are still within the agreed timescale for completion of the work. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents are supported and protected by a robust staff recruitment and selection procedure, which includes Criminal Record Bureau (CRB) checks. Staffing numbers and the experience/skill mix within the staff team ensures that the needs of the residents are met in line with their care plan. There is a genuine commitment to staff training, however the manager must continue to promote NVQ training. EVIDENCE: A staff rota for the week of inspection was taken which showed that sufficient care staff are employed to meet the needs of the residents, however the home are presently recruiting for an additional qualified nurse to work part time on night duty. The manager is also presently advertising for a principal senior care assistant, a newly developed post, which carries additional responsibilities to the role of care assistant. There appears to be a good mix of skills and experience within the staff team and it was noted on the day of the visit that recently employed members of care staff were working alongside experienced members, and were supported by the qualified nurse on duty. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 19 Relatives spoken to said that they felt that the staff were doing a good job and feedback from the residents was positive regarding the ability of the staff to meet their needs. The manager confirmed that the home continues to use some agency staff to cover for leave and/or sickness, however wherever possible the same staff are employed to ensure the residents receive continuity of care. Cleaning and catering staff are employed in sufficient numbers to ensure that the resident’s dietary needs are met, and the home is kept clean and free from unpleasant odours. The homes recruitment and selection procedures are thorough and the manager confirmed that all new members of staff receive induction and foundation training. There is also an expectation that members of the care staff team will then go on to achieve a National Vocational Qualification (NVQ) at level two (or equivalent), although at the present time no member of the care staff team holds this qualification. Two members of staff are however currently on the course, and the manager herself a NVQ assessor, is looking to provide additional opportunities for NVQ training in line with the National Minimum Standards. The manager has also recently carried out a full staff training audit to highlight any gaps in the training needs of individual members of staff, and ensures that training is provided both to meet the needs of the residents and for personal development. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38 The manager is competent, provides good leadership to the staff team and ensures that the residents are protected and cared for appropriately. Comprehensive policies and procedures are in place to ensure the health and safety of the residents and safeguard them from harm. EVIDENCE: The registered manager Ms Cherry Needham is a First level Registered General Nurse, who has also achieved a number of other academic qualifications including a National Vocational Qualification at level four in management. Ms Needham appears to communicate a clear sense of direction and leadership to the staff team, and staff spoken to, confirmed that she has an open and approachable management style. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 21 Members of care staff also confirmed that they felt well supported by the manager and/or qualified nursing staff team, and all staff worked as a team to ensure resident’s needs were met. The manager ensures clear channels of communication within the home by holding regular staff meetings, and one-to-one supervision is supervision is carried out with individual members of staff on at least a two monthly basis in line with the National Minimum Standards. In addition, recognised quality assurance systems are also in place, and the manager confirmed that the home continue to actively seek the views and opinions of the residents, their relatives and visiting professionals, as part of the quality assurance monitoring process. Policies and procedures are in place to ensure the health and safety of the residents, visitors and staff, and the manager confirmed that they are reviewed on a regular basis or in light of changes in legislation. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 2 x 2 2 2 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 4 4 4 3 x x 3 x 3 Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? 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 OP22 Regulation 23(2) Requirement Timescale for action 31/12/05 2. OP24 16 3. OP25 23(2) The registered manager must ensure that grab rails are fitted to all en-suite facilities as part of the refurbishment programme. (Still within the agreed timescale 31/12/05). 31/12/05 The registered manager must ensure that appropriate door 30/11/05 locks are fitted to all bedroom doors as part of the refurbishment programme. (Still within the agreed timescale 31/12/05). Ground floor double bedroom (identified to manager) -- broken furniture requires repairing or replacing. A cover must be provided for the air conditioning unit or the equipment removed if obsolete. The registered manager must 31/12/05 ensure that the heating can be regulated in the bedroom accommodation as part of the refurbishment programme.The lighting in the bedroom accommodation requires replacing as part of the refurbishment programme. (Still within the agreed timescale 31/12/05). Version 1.30 Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Page 24 4. OP26 16 5. OP28 18 The registered manager must ensure that staff are more vigilant when making beds to ensure stained/marked sheets are removed and laundered. The registered manager must ensure that at least 50 of the care staff team have a NVQ at level two (or equivalent) by the year 2005. Immediate as agreed on day of inspection 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP32 Good Practice Recommendations The registered manager should ensure that the views and opinions of stakeholders in community are included in the quality assurance monitoing process. Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Hillbro Nursing Home 20050901 Hillbro UN Stage 4 S19896 V214007 J52.doc Version 1.30 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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