Inspection on 12/09/06 for Hillbro Nursing Home

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 22/03/06

Hillbro Nursing Home 01/09/05

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 West Yorkshire BD17 6RZ Lead Inspector Stevie Allerton Key Unannounced Inspection 12 September 2006 11:30 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 Hillbro Nursing Home DS0000019896.V302107.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. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillbro Nursing Home Address Holden Lane Baildon Shipley West Yorkshire BD17 6RZ 01274 592723 01274 532699 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) Mr Ronald Berry Mrs Doreen Berry, Michael Stephen Berry, Anita Anne Berry Care Home 42 Category(ies) of Dementia - over 65 years of age (41), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (41), Physical disability (1) Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the category of MD be used only for the persons named in connection with the variation applications That the category of PD be used only for the person named in connection with the variation application. 22nd March 2006 Date of last inspection 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. It is owned by the Berry family, who are also registered providers for two other care homes, and is currently managed on their behalf by Mr Ian Watson. At the present time the home provides care (including nursing) for forty-two residents diagnosed with Alzheimer’s 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 older part of the 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 original building. The home is accessible to residents/visitors in wheelchairs (side 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. Current care fees are £531 - £634 per week. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of a day and a half, comprising two visits. The recently appointed Manager, Ian Watson, was on duty on both days and made himself available to answer questions and supply care records, etc. Michael Berry, one of the registered providers, joined the Manager and was given feedback by the inspector on the findings of this inspection at the end of the second day. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, reports from other agencies, i.e., the Adult Protection body, and information supplied by way of an annual questionnaire. This information was used to plan the inspection visit. The inspector case tracked four service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspectors assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspector spoke with identified service users and relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with relatives and external professionals to obtain their opinions about the quality of services provided at the home. The inspector would like to thank everyone who took the time to talk to her and express their views. What the service does well: The home provides a valued community resource, with many of the service users having local connections. There is a warm and bustling feel to the home, with many visitors coming and going, who say that they are made welcome by the staff. The newly appointed Manager has extensive experience in Mental Health Nursing, which complements the skills of the existing nurses. He has already Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 6 identified areas of the service that he feels need improving and has come up with a simple plan for supporting staff to achieve better standards in these areas. Service users receive a high standard of health and personal care from the nurses and the care staff; everyone spoken to expressed their satisfaction with the attitude of the staff, saying they felt well cared for. The housekeeping staff provide high standards of cleanliness and hygiene throughout the home. What has improved since the last inspection? What they could do better: There are still a number of shortfalls in the service. These are detailed at the end of this report. The planned refurbishment must continue in order to provide better, more comfortable facilities for the service users. Care plans could improve by being weeded out and the superfluous material archived. This would make the care plan documents easier to access for staff as well as service users and/or their relatives. Care must be taken to ensure that established “custom and practice” does not impinge on service users’ rights, for example, the use of a bedroom for hairdressing purposes. The provider needs to look at ways of improving social and leisure opportunities for service users, particularly for those with dementia; care planning must include this aspect of care. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 7 The home may be selling itself short, by not making public the results of quality audit/inspection, i.e. internal Investors in People audits or CSCI inspection reports. This makes it difficult for service users and their relatives to find out what the standards should be, how well the provider achieves the standards, or what action is intended to address any shortfalls in the service. 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 DS0000019896.V302107.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Prospective service users and their relatives are given a good standard of information regarding the home and the process of admission, the Welcome Pack being particularly informative and helpful. However, the absence of a copy of the home’s Statement of Purpose, or a copy of the latest CSCI inspection report in the reception area, means that the information is incomplete. Those people who may not know about the existence of these documents and their rights to access them, would be unlikely to ask to see them. EVIDENCE: There are various documents outlining what the home can provide and what prospective service users and their relatives can expect during the process of moving in – the brochure, the Statement of Purpose and the Welcome Pack, which either goes to the service user, or their relative if they are not able to comprehend. The Statement of Purpose was not on display, so people would have to ask for it. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 10 The case file for a service user recently admitted contained a copy of the home’s terms and conditions document, which outlined what services are provided for the fees and where the contributions towards those fees were coming from. The file copy was signed by a relative on behalf of the service user. There was evidence in the case files that the assessment process is thorough, the initial information, from hospital or through social services assessment, is backed up by the home’s own assessment documentation. Hillbro Nursing Home DS0000019896.V302107.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Care plans are excessively detailed in some areas and there is duplication, making it difficult to extract current information on care needs. Not all care plans are being evaluated at the appropriate intervals. Staff have a tendency to concentrate their efforts around nursing care for physical and mental health needs and not take an holistic view. Medication is managed appropriately by the nursing staff. The practice of using a bedroom to provide hairdressing services to others compromises privacy. EVIDENCE: Four service users with a range of care needs were selected for case tracking. Their files were examined in depth and cross-referenced with other documents, and their care was discussed with the home staff and the service users themselves, where possible. Some visitors and the visiting hairdresser were also spoken with. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 12 Written care plans are in place for each service user. Some of these are extremely detailed, even for areas assessed as low in risk. Care plans mainly concentrate on physical and mental health and welfare, with very little about social care needs. Some of the risk assessment tools, specifically the pressure care assessment tool, are now out of date and have been superseded by more up to date models, as advised by the local Primary Care Trust, so some of the care plans contain a lot of duplication. There was some good recording seen regarding specific events and the care notes reflected the involvement of other health and social care professionals. However, some records of a significant conversation with a relative had not been dated and there was no evidence of any follow-up or action taken in response to this relative’s request. Some care plans had been able to be signed by the service user. It was found that some care plans were not being evaluated regularly enough, for example, no evaluations of a social care plan for 6 months. The relatives and the service users spoken to felt that the standards of personal and health care were good and that they were looked after well. The hairdresser also made comment that she felt that people were well cared for at this home. Two comment cards were returned by GP practices, with positive feedback. Medication systems were seen in operation, with good practice in evidence. Those service users who are being cared for in their own bedrooms have their drugs stored there in locked cabinets, so that they are easily accessible for the nursing staff. The Deputy Manager takes the lead with ordering prescriptions and there is a pre-dispensed system in place, administered by Boots’. The Manager and Deputy have requested medication reviews by GPs and have reduced some of the drugs people were being prescribed, with some success. One of the service users who was case tracked has Parkinsons Disease and the records showed that he has drugs prescribed at specific times to manage his symptoms. The nurse confirmed that these were given at the appropriate times and that the service user himself was actively involved in managing his symptoms and liaised closely with the nurses regarding the timing of drugs. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Families and friends provide a valuable source of stimulation and social opportunity for service users, but for those without regular visitors, the home could be providing more in this area. Care planning does not focus on social care and opportunities to take action to improve this area of care for specific service users appear not to be given much importance. Food is of a satisfactory standard, but will be improved with the introduction of new menus that increase choice. The cook may benefit from some additional training in the nutritional needs of older people. EVIDENCE: Some service users are fortunate enough to have families and friends actively involved and the home positively encourages them to continue whatever level of involvement they had in the past. It could be shown that that does happen for some people, with regular pop-in visits from family living nearby, bringing them the morning paper each day, for example. Another family continues to take their relative out for walks in the countryside and lunch in the pub. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 14 Some activities are arranged by the home, for example, music & movement sessions, dominoes and other board games; this was confirmed by relatives. An outside entertainer had been booked for the day of the first inspection visit. Staff had established which service users enjoy this kind of entertainment and which ones prefer to be in a quieter environment. One service user said that he missed being able to go on outings, as he was a wheelchair user and the home’s transport is not accessible for him. On the day of inspection the home felt busy with visitors coming and going and the Manager said that the home’s open house culture was clearly understood by staff and visitors alike. The hairdresser was working in the home on the day of inspection. She said she had become used to providing a service to people with dementia and coped with occasional restlessness by trying to distract the person, with a magazine, for example. The home does not have a specific area or room for a salon, so she uses a bedroom – one was empty on that day, but sometimes it is someone’s room that has to be used. Care records contained evidence that some relatives have voiced their concerns to staff about the lack of stimulation, but no action could be seen in following this up. The new Manager said that he too had identified that more should be done to develop activities. Food provision was discussed with the Manager and with the cook and a lunchtime meal was observed. The home is introducing new menus, which are to give service users more choice. It was noted on the records of food served that there are often processed items, such as chicken nuggets, which may not be as nutritious as home-made foods. Individual preferences, likes and dislikes are accommodated without problem, e.g., vegetarian meals and blended meals. Presentation of the blended meals was appropriate, each element done separately. The Manager is keen on hydration, ensuring that service users have plenty of drinks. The cook was asked how the staff keep track on who has had drinks at the appropriate intervals, when some of the service users are in their own rooms and others may be wandering - the kitchen whiteboard is used to good effect to communicate to staff. Night staff can access the kitchen and stores to make people drinks and snacks if they are awake during the night. Service users said they were satisfied with the food provided. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 the home. Service users are protected by a robust complaints policy and procedure. The open culture allows relatives, and other people visiting the home, to say if they are not happy about anything. Staff have a good level of awareness of Adult Protection issues. EVIDENCE: The provider has demonstrated their ability to investigate complaints thoroughly and to involve other agencies where appropriate, such as Alzheimers Society advocates, the Police and Adult Protection. The Manager has a good level of knowledge and experience regarding the Mental Health Act and how this impacts on the decisions that service users and their relatives can make. Relatives spoken to said they felt confident to raise any aspect of care with the nurse in charge or the Manager. The hairdresser also said that she was very happy with the attitude of staff and the caring they show to people they look after. She said that she would tell the Manager if she saw or heard anything that made her feel worried. There is information in the entrance hall about the complaints procedure, and also in the staff policies file. The local Adult Protection “No Secrets” policy is available for reference. Some staff have had training in Adult Protection, although new staff have not yet taken part in this. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 16 The system for managing money on behalf of service users who cannot manage this themselves, is robust and protects their interests. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19, 23, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The majority of bedrooms have en-suite facilities. Some areas of the home are in need of upgrading, but these have already been identified and action is being taken to address these within the next few months. This will improve the accommodation and facilities for service users. Laundry and cleaning systems are of a high standard. EVIDENCE: The provider advised that the planned refurbishment was halted after the previous Manager left, but has recently re-started with new curtains, headboards and bedding to the bedrooms on the ground floor. The service users & relatives spoken to in some of these rooms were very pleased with their new furnishings. Soft furnishings are on order for the remaining rooms and the plan is for all bedrooms to have been upgraded within the next 6 – 8 months. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 18 The majority of bedrooms have vinyl floor-covering instead of carpet; however, there were no unpleasant odours detected and the surroundings were of a good standard of cleanliness. The main lounge/dining area was about to be repainted and new floor-covering put down. The Manager is keen that tablecloths are used in the dining rooms; this was not in evidence on the first visit, but was the following day. The senior housekeeper went through the laundry system in place, along with the domestic routines. She said that the care staff and housekeeping staff worked much more closely as a team than previously. Observation of staff indicated that they were working to the described standards. Service users said that the standard of cleaning was to their satisfaction. Many of the service users have dementia and wander around their surroundings, so there are restrictions in the form of key pad entry/exits between floors, and between certain areas of each floor, to try to maintain a safer environment. There is safe access to outside patio areas on both floors, which provide pleasant surroundings for sitting out or walking around. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. 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 the home. Staff of varying roles within the home demonstrate good levels of knowledge about their work and how this impacts on the care of service users. The new Manager has already identified areas of training need and has taken steps to resource the appropriate training. Recruitment and induction procedures for new staff are sound. EVIDENCE: Nursing staff, care staff, housekeeping staff, and the cook were all spoken to during the inspection visit. All were happy to talk about their roles and showed enthusiasm and a good level of knowledge about their work. A new starter had been linked with one of the very experienced care staff for “shadowing”; this was discussed with the experienced member of staff, who described the importance of demonstrating good care standards to new workers. There were also 2 nurses from Eastern Europe, working towards their adaptation to RGN qualification, who work at the home for 3 days each week, being mentored by one of the Deputy Managers. The staffing rota shows that there are appropriately qualified nursing staff on every shift, along with a team of care and other workers, encompassing a wide range of ages and cultural background. There are currently some care staff vacancies, caused by individuals leaving to start college courses, etc., although some are to continue to be retained on bank. Potential care staff were in the Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 20 process of being vetted and selected, the process described by the Manager confirming good practice in this area. The use of agency staff is a rare occurrence in this home. The new Manager is an experienced NVQ (National Vocational Qualifications) Assessor and is keen to promote NVQ training for care staff. 6 have been registered to start this autumn. Some of the care staff have also been booked onto a Dementia Care course with Age Concern later in the year. The Manager said that he had also put in place some “protected learning time”, every Thursday between 2 – 3 pm, which can be used for group meetings, discussion topics, etc. The care staff described how the day was organised, from handover in the morning, checking diaries and other records for appointments and events; staff are assigned to each floor so that there is responsibility for the care of a smaller number of service users and their well being and whereabouts can be more closely observed. Staff also confirmed the mandatory training they had had, such as Infection Control, Fire Safety and Moving & Handling. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The home has the required policies and procedures in place and record keeping is generally of a good standard. Service users’ finances are safeguarded by the robust accounting systems in place. There is good attention to health and safety in the home. The home sells itself short by not making public the results of quality audit/inspection, i.e. internal Investors in People audits or CSCI inspection reports. This makes it difficult for service users and their relatives to find out what the standards should be, how well the provider achieves the standards, or what action is intended to address any shortfalls in the service. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 22 EVIDENCE: Due to the unexpected absence of the Area Manager, who manages most of the records linked to Health & Safety, e.g., maintenance & repair, and accident records, these were not available for inspection. However, it could be observed from care plan records and the practices in place, that good attention is given to risk assessments and health and safety matters. A second visit was made to examine financial records and some staff records, which are held in the provider’s administrative office. Other records seen included service users’ care plans, accident records, medication records, food records, staff rotas and fire safety records. All of the records seen were informative and appeared to be accurate and up to date, apart from the fire safety records, which showed that alarm testing and fire practice was not being done frequently enough. The provider must ensure that all incidents required to be notified to CSCI under Regulation 37 are notified as soon as possible after their occurrence. The new Manager has yet to apply for registration with CSCI. He is a very experienced Mental Health Nurse with an active interest in staff training. It could be seen from a document introduced at the most recent staff meeting, that he has already identified areas of weakness within the home that need to be improved, and how the staff will be supported to achieve these higher standards. Staff supervision is to be given more structure and the role of the unqualified key workers developed. The Manager is supported by two nurses as Deputy Managers, each with an area of responsibility, and another RGN who takes the lead on wound care and was said to have improved practice in this area. The Manager appears to have a good rapport with staff, who said that his style of management had initially taken some adjusting to, as it was very different from the previous Manager. The provider organisation holds the Investors in People award. Quality audits are carried out to ensure that the home continues to perform at the required standard in specific areas; however, the results of these audits are not publicised. There are no CSCI Inspection Reports available for visitors to see, nor is the Statement of Purpose readily available. Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 23 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 X 3 2 Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5(1) Requirement The providers must make a copy of the home’s Statement of Purpose available, to current and prospective service users and their relatives. A copy of the most recent inspection report must also be made available. Care plans must detail the action to be taken by staff to ensure that all aspects of health, personal and social care needs are met; also reviewed at least once a month and updated to reflect current objectives. The providers must take steps to ensure that the privacy of service users is respected, in particular with regard to the use of one of the bedrooms as a salon for the visiting hairdresser. The providers must ensure that service users’ interests are recorded and that they are given opportunities for stimulation, through leisure and recreational activities that suit their preferences and capacities; particular consideration must be DS0000019896.V302107.R01.S.doc Timescale for action 31/10/06 2. 3. OP1 OP7 5(1) 15 31/10/06 31/10/06 4. OP10 12(3) & (4) 31/12/06 5. OP12 12(2)(m) & (n) 31/12/06 Hillbro Nursing Home Version 5.2 Page 25 6. OP15 12(2)(i) 7. OP19 23(2) given to those people with dementia. The providers must ensure that the menus reflect the wishes and preferences of service users and that due regard is given to maintaining good nutrition. The registered providers must provide the Commission with a new schedule of planned refurbishment work. (Outstanding requirement from previous inspections) The registered providers must ensure that at least 50 of the care staff team achieve a NVQ at level two (or equivalent). (Outstanding requirement from previous inspections) 31/12/06 31/10/06 8. OP28 18 31/03/07 9. 10. OP31 *RQN 8 11. OP38 The newly appointed Manager must apply to CSCI for registration. 37 The provider must ensure that all incidents required to be notified to CSCI under Regulation 37 are notified as soon as possible after their occurrence. 23(4)(c) & The provider must ensure that (d) fire alarm tests and fire practices are carried out at the required intervals. 31/12/06 31/10/06 31/12/06 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 Hillbro Nursing Home DS0000019896.V302107.R01.S.doc Version 5.2 Page 26 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 DS0000019896.V302107.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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