Inspection on 22/11/07 for Hillbro Nursing Home

This inspection was carried out on 22nd November 2007.

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

The inspector 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 12/09/06

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 Mary Bentley Unannounced Inspection 22 & 23 November 2007 10:00 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 Hillbro Nursing Home DS0000019896.V355211.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.V355211.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) Michael Stephen Berry Anita Anne Berry Mr Ian Watson 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.V355211.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. 12th September 2006 Date of last inspection Brief Description of the Service: The home has 42 places. It provides nursing care for people with dementia and people with mental illness. It is in the village of Baildon, on the outskirts of the city of Bradford. The home is close to the shops and other facilities in the village centre and there is a small car park to the front of the property. The home is accessible to people in wheelchairs by the side entrance and there is a passenger lift to the bedrooms and other facilities on the upper floors of the building. Bedroom accommodation is provided in both double and single rooms and the majority have en-suite facilities. There is one communal bathroom on the first floor. There is a designated smoking room for people living in the home. In November 2007 the provider told us the weekly fees ranged from £505.00 to £598.00. Hairdressing and private chiropody are available at an additional cost. Information about the home, including inspection reports, is displayed in the entrance area. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We did this inspection over 2 days and spent approximately 25 hours in the home. The first day of the visit was unannounced. During the visit we spoke to people living in the home, visitors, staff and management. We observed care in the lounge and dining areas, looked at various records, including some people’s care plans and looked around the home. Before the inspection we sent surveys (comment cards) to people living in the home, their relatives, some health and social care professionals such as GPs and social workers and staff working in the home. Surveys give people the opportunity to tell us what they think about the service. The information we get is shared with the home but we do not identify who has provided it. We received 12 surveys from a variety of people. The home completed a self-assessment form for us before the visit. It was sent back to us in good time. This report includes information from the self-assessment, the surveys, our records relating to the service and our site visit. What the service does well: We asked people what they think the home does well and these are some of the comments we received from relatives of people living in the home: • • • “The staff are friendly and caring, serve good food” “After visits I leave content that I have left her in very safe hands” “People are encouraged to be independent but help is always at hand if needed”. During the time spent in the home we found the staff to be friendly and pleasant. The home welcomes visitors at any time. The manager is very approachable and he said he wants people to be more involved in the running of the home. What has improved since the last inspection? Information about the home is more easily available to people, it is prominently displayed in the entrance area along with information about other organisations that people can get advice and support from. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 6 A hairdressing room has been provided; this means that it is no longer necessary to use someone’s bedroom for a communal activity. There is an ongoing programme of redecoration and new soft furnishings have been provided in many of the bedrooms. This has helped to give these rooms a more homely appearance. The home has just appointed an activities organiser. He had just started when we visited and was still getting to know people, however his appointment should mean an improvement in the way people’s social care needs are addressed. Changes have been made to the laundry systems and people said they have noticed an improvement in how people’s clothes are cared for. The manager acknowledges that more work is needed in this area. What they could do better: 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. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 & 5. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is information available to help people decide if the home is suitable for them and people’s needs are assessed before they move in. EVIDENCE: The home has a Residents’ Handbook, which incorporates the Statement of Purpose and Service User guide. Copies of this are available in the entrance area. People told us that in general they felt they had been given enough information about the home. One person said they had visited when looking for a place for their relative, they said they had been given an information pack and found the staff friendly. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 9 The home’s policy is to give everyone a copy of the terms and conditions regardless of how their care is funded. We saw signed copies of terms and conditions in some of the records. One person’s had not been signed; the home said that the person’s representative had declined to sign it. The home carries out assessments of people’s needs before they move in. This is done to make sure that the home will be able to meet people’s needs. We saw copies of pre-admission assessments in the care records. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Overall people’s personal and health care needs are met. However, people are not involved in drawing up their care plans and this means that needs may be overlooked and care may not always be given in accordance with people’s wishes. Some care practices do not promote people’s dignity. EVIDENCE: These are some of the comments made by relatives of people living in the home: • “Care and consideration shown to all patients above and beyond the call of duty” • “The care and empathy shown to myself and the family at the recent loss of my husband was second to none. He was able to pass away with peace, dignity, privacy, we could not thank them enough.” Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 11 Everyone living in the home has a care plan and we looked at seven, some in more detail than others. The care plans are based on a model that is mainly focused on physical care needs and this means that other areas of need are not always identified and addressed. Although the home specialises in the care of people with dementia and mental illness there is very little information about how people’s emotional and psychological needs will be dealt with. For example the care plan for one person with Schizophrenia said she would go to her room if it were noisy because she preferred this. There was no other information about how her illness might affect her day-to-day. In another example, staff told us of their concerns about one person who is constantly going into other people’s rooms and getting into their beds. They were clearly at a loss as to how to deal with this but there was no care plan to guide them or suggest ways in which this person could be diverted into other activities. In another person’s records we saw that restrictions had been placed on this person going out alone. There was no care plan to guide staff on what arrangements had been agreed to make sure this person could go out. There is no evidence that people, or those close to them, are involved in drawing up and agreeing care plans. There are risk assessments in place for areas such as falls, nutrition, continence, and pressure sores. It was not always clear how often these are to be reviewed. One person had a good risk assessment about going out alone and the home has arranged for him to have a Medi Alert because he suffers from Epilepsy. We saw evidence that people have access to a good range of NHS services including GPs, diabetes and tissue viability specialist nurses. No one living in the home manages his or her own medicines. There are suitable systems in place to make sure that medicines are managed safely. We saw that staff are friendly and pleasant in their interactions with people. However, they are not always mindful of people’s dignity. For example, we saw one carer using the same hairbrush for more than one person and we saw some underwear that was not named for individuals. One person told us they often find their relative wearing other people’s clothes. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides some activities. However, not enough attention is given to making sure that each person is treated as an individual; is supported in following their personal interests and is given opportunities to make the most of their abilities. EVIDENCE: These are some of the comments made by relatives of people living in the home: • • “Everyone is treated equally and special needs e.g. disability are well catered for” “Could be more entertainment and would like to see people going out more.” There is very little information about people’s cultural and spiritual needs, their past lives, and their hobbies and interests. Most people have social care plans but there is not much information about what people are interested in, how they like to spend their time, or how staff Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 13 should try to engage them in any form of social activity. For example, one person’s plan said they are not interested in joining group activities but did not say anything about what they are interested in. The daily entries in the care records tend to be repetitive and refer mainly to personal care needs, they do not give a picture of how people spend their time or how they are feeling. There are some organised activities, which include an entertainer about once a month. There were no organised activities while we were in the home. Staff spent time with people chatting, doing nails and reading papers and books. The television in one lounge was turned off and music was put on for people to listen to. During the morning a member of staff came and changed the music without acknowledging anyone in the lounge or asking if they wanted a change. The home has recognised this is an area that needs to be improved and has appointed an activities organiser. He had just started and was still getting to know people when we visited. People can go to their bedrooms during the day and some people prefer to stay in their rooms most of time. Visitors are welcomed at any time and there is a room where people can see their visitors in private if they don’t want to use their bedrooms. One person said, “The food could be better”. People do not know what they are having until it is served. The daily menu used to be displayed; the cook said it had fallen off. We observed lunch in both lounge/dining rooms. We noticed that some people who had been having breakfast at about 10.30am were served lunch at 12.30pm. There were no condiments on the tables in either area. Tablecloths were used in one room but not in the other. In the front lounge there were 3 staff helping people (whom they called “feeders”) to eat, which meant that 7 people were left unsupervised in the dining area for about half an hour. The meals in both rooms were served plated. We did not see anyone being offered an alternative hot meal; some people were offered sandwiches when staff noticed they had not eaten their meal. There was a fairly long wait for pudding to be served, we heard someone say it wasn’t ready yet. The food records show that people have a hot meal, such as pie and peas, most evenings. The cook said people have sandwiches at suppertime, (about 7.30pm) and people can have a hot or cold breakfast. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living in the home, or those close to them, know how to make a complaint. Complaints/concerns are looked into and action taken to put things right. People may not always be safeguarded from abuse because of a lack of awareness by staff of the different ways in which people may be put at risk. EVIDENCE: People who completed surveys for us said they know how to make a complaint. People who had raised concerns said the home had responded appropriately. Staff told us they know what to do if people have concerns about the service. The home has just started a complaints log. The information recorded is very basic and we discussed this with them during the visit. Complaints, concerns, and feedback from people using the service should be used to help improve the service. To be able to do this more information about the nature and the outcome of any complaint needs to be recorded. Since the last inspection we have received one complaint about the service, this was also referred to the Adult Protection unit. The matter was dealt with by the home. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 15 Two other matters were referred to the Adult Protection unit and these were also dealt with by the home. The manager has attended Adult Protection training and training is planned for all the staff. We were concerned that staff were not sufficiently aware of issues around the protection of people living in the home. Entries in one person’s care record indicated behaviour, which was putting other people at risk. This had not been identified as a possible protection (safeguarding) matter and had not been reported. We asked to manager to report these concerns to the Adult Protection unit and since our visit he has confirmed that this has been done. The home has started to address the issue of mental capacity to take account of the changes brought about by the introduction of the Mental Capacity Act earlier this year. The manager acknowledges that this is an area that needs more work. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is an ongoing programme of redecoration but more needs to be done to make sure that the home provides a pleasant, comfortable, and suitably equipped home for people to live in. EVIDENCE: There is a visitors’ lounge just inside the main entrance. This is nicely decorated and furnished. People living in the home can only use this lounge if they are with a visitor or staff; access from the main part of the home is restricted by a keypad. On the ground floor there are 2 lounge/dining areas. The standard of décor and furnishings in these rooms is satisfactory but we noticed an unpleasant odour as we came in from the front hall. One of the lounge/dining rooms has Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 17 patio doors giving access to the outside; this is the entrance for people using wheelchairs. On the first floor there is a conservatory (sensory room) and this has direct access to an enclosed garden area. One person told us they enjoyed spending time in this garden with their relative when the weather permits. Although not a smoking area the conservatory smelled strongly of tobacco smoke and the smoke/heat detector was hanging from the ceiling. We asked the owner to check this to make sure it was in working order. There is a designated smoking room for people living in the home. The room has mechanical ventilation however; there was a strong odour of tobacco smoke in the corridor near this room. There is one communal bathroom, which has a bath hoist. Most of the bedrooms have en-suite bathrooms or showers. However, the baths are all placed against the wall and are not easy for people with limited mobility to use. Several of the showers we saw were not in use, either because of broken connections or because they were being used for storage. This means that people have very little choice of bathing facilities. There are 2 communal toilets on the ground floor. At the time we visited one of these was being upgraded to improve disabled access. Generally the bedrooms are suitable to meet people’s needs. Most people had some personal belongings in their rooms. The home’s policy is not to provide carpets in bedrooms and this tends to give the rooms a rather “clinical” feel. If people want carpets they have to pay for them, one person in the home has chosen to do this. During our tour of the building we identified a lot of maintenance issues, which we discussed with the manager and owner. We were concerned that these issues had not been picked up by the home’s systems for dealing with routine maintenance. The bedroom doors have door locks but most of these are not the single action locks recommended for use in homes caring for people with dementia. Some doors still have “star” locks, which means that the door can be locked from the outside. Some, but not all, have been taken out of use. Recent changes to the laundry system have improved the way people’s clothes are cared for; one relative said clothes are now ironed before they are put away. We found this was not always the case particularly with underwear and nightwear, which we found untidily stuffed into drawers in several rooms. The manager is aware more work is needed in this area. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 18 The home has a 3 star (the best rating is 5 star) environmental health rating for the standards of food hygiene and safety. Hillbro Nursing Home DS0000019896.V355211.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are usually enough staff to make sure that people’s needs are met. The home is continuing to make improvements to staff training to make sure that they have the right skills and knowledge to care for people properly. EVIDENCE: These are some of the comments made by people using the service: • • “Very caring attitude by all members of staff” “The new manager has put great emphasis on staff training”. People living in the home said staff are usually available when they need them. There are usually 6 care staff on duty, including a senior, in the morning and afternoon and 4 care staff from 5.00pm until 9.00pm. There is also a nurse on duty. Overnight there are 4 staff, one of which is a nurse. The manager works Monday to Friday and is supernumerary. The home employs separate staff for housekeeping, catering, administration, and maintenance. Some staff said they did not think they had enough time to spend on leisure activities with people. The company has just employed an activities organiser Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 20 and he will be spending 2 to 3 days a week at Hillbro. He will also be working in another home owned by the company. 30 of care staff have achieved an NVQ (National Vocational Qualification) at level 2 or above and 5 more are working towards this qualification. There are 3 other care staff waiting to start on the course. Staff told us they get lots of training. The records show that as well as training on safe working practices such as infection control and moving & handling staff have received training on the Mental Capacity Act and palliative care. Some staff have had training on dementia care and the manager is planning to do more training on this in January 2008. We looked at the files of 4 newly appointed staff. Three files showed that all the required checks had been completed before staff started work. In one case there was only one reference and the person had started work before the PoVA (Protection of Vulnerable Adults) check had been returned. Two written references and a PoVA and CRB (Criminal Records Bureau) check must be done before new staff start work to make sure that people are protected. Hillbro Nursing Home DS0000019896.V355211.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The manager is clearly committed to continuing to improve the service and to making sure that people using the service experience good quality outcomes in all aspects of the service. EVIDENCE: The registered manager is an experienced mental health nurse and has been at the home for just over a year. Staff said they get a lot of support from the manager. Questionnaires are sent to people four times a year. The results are analysed and displayed, in a graph format, on a notice board in the hall. Questionnaires Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 22 for relatives and visiting professionals are available for people to pick up at any time in the entrance area. The manager audits various aspects of service and has done an action plan for himself which he reviews regularly to monitor progress. The area manager has left and one of the owners is going to do monthly visits to the home to monitor the quality of the service. The home does not hold meetings for people using the service; the manager said a lot of informal consultation takes place. A more structured approach to consultation is needed to make sure that everyone is included. Some relatives told us they felt involved in the care but others told they didn’t really know anything about how their relatives are cared for and have never been consulted about how their care needs will be met. The home does not have staff meetings but uses the shift handover time to have discussions with staff and the manager sees staff individually if necessary. The home issues surveys to staff twice a year. The manager is aware that staff supervision and appraisals need to be done and is working on plans to deal with this. The home manages money for 5 people. There are suitable systems in place to make sure that money is properly accounted for, there are records of all transactions, and receipts are kept for any purchases made on people’s behalf. There is a system for monitoring accidents and the manager said any untoward events, such as unexplained bruising, are investigated. Our records show that we have not been notified of any events in the home since May this year. We discussed this with the manager and owner. The owners confirmed that weekly checks on the fire alarm system are carried out. However, the recording of these checks has lapsed, and the most recent entry in the fire log was dated July 2007. The remainder of the records relating to health and safety and maintenance were up to date. Hillbro Nursing Home DS0000019896.V355211.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 3 3 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 2 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Hillbro Nursing Home DS0000019896.V355211.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 OP7 Regulation 15 Requirement The care plans must set out in detail how people’s personal, health and social care needs will be met and provide evidence that people, or those close to them, have been involved in drawing up the plans. This is to make sure that all people’s needs are identified and addressed and to make sure that care is given in accordance with people’s wishes. Timescale for action 31/03/08 2 OP10 12(4) Previous timescale of 31/10/06 not met. Care must be given in a way that 31/12/07 respects people’s dignity and individuality. As a minimum People must not be depersonalised by the use of terminology such as “feeders” The use of communal hairbrushes, underwear, and other similar personal items must stop. People must be able to wear their own clothes. People’s personal clothing including underwear must be DS0000019896.V355211.R01.S.doc Version 5.2 Page 25 Hillbro Nursing Home properly cared for. 3 OP12 16(2) (m) & (n) People’s personal interests must be recorded and people must be given opportunities for stimulation, through leisure and recreational activities that suit their preferences and capacities; particular consideration must be given to those people with dementia. Previous timescale of 31/12/06 not met. Staff must be given training to make sure that they understand all the different ways that people can be put at risk of abuse and/or neglect. This is to make sure that people are safeguarded from abuse. The smoking areas must be properly ventilated to prevent unpleasant odours and to protect other people from the affects of passive smoking. There must be an effective system for dealing with routine maintenance so that people can live in a home that is safe and in a good state of repair. To take account of the fact that there is only one communal bathroom the provision of baths/showers in en-suite bathrooms must be reviewed and where necessary upgraded to make sure that people are able to use them. The Commission must be notified without delay of any event that has an adverse effect on anyone living there. This is to assist us with the ongoing inspection process and to enable us assess how the home is safeguarding the well being of the people living there. DS0000019896.V355211.R01.S.doc 28/02/08 4 OP18 13(6) 28/02/08 5 OP19 23(2)(p) 28/02/08 6 OP19 23(2)(b) 28/02/08 7 OP21 23(2)(j) 31/03/08 8 OP37 37 31/12/07 Hillbro Nursing Home Version 5.2 Page 26 Previous timescale of 31/12/06 not met. 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 OP15 Good Practice Recommendations The way that people are supported in having a choice of meals and the way meals are served should be reviewed to make meal times a more pleasurable experience for people. Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillbro Nursing Home DS0000019896.V355211.R01.S.doc Version 5.2 Page 28 - 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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