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Inspection on 24/01/07 for Hillbrow House

Also see our care home review for Hillbrow House for more information

This inspection was carried out on 24th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to provide a clean, safe and comfortable home for the residents. It provides prospective residents with good information to help them make a decision about whether they want to live in the home. Staff are caring and well trained, they are able to recognise bad practice and would feel confident that issues would be dealt with. Care plans are formulated from good assessments and contain detailed information that helps staff meet the needs of the residents. Healthcare needs are monitored and appropriate action taken to involve healthcare professionals. Medication is securely stored and administered in line with the home`s policies and procedures.There is a good system for obtaining the views of residents and their relatives on the quality of care provided by the home. Residents are consistently offered choices about their everyday lives, including whether they participate in the activities on offer, where they eat their meals and what they have to eat. Food provided is of a high standard and residents were happy with quality and quantity that was served. Good relationships were observed between staff and residents who were enthusiastic about each other. Relatives were happy with the care their relatives received and comments received included, `I am very happy with the care in this excellent home`, `My mother has recently come to Hillbrow and finds everything to her liking and is extremely happy here`. There is a clear and simple complaints procedure and residents and relatives were confident that any concerns would be dealt with appropriately.

What has improved since the last inspection?

Staff are now consistently following the policies and procedures relating to medication. There are risk assessments available for all aspect of the building and the general environment. Care plans have been expanded to include more information on the resident`s social needs.

What the care home could do better:

No requirements were made at this inspection. However, three recommendations were made. These were that staff should receive formal and recorded supervision at least six times a year, to ensure the staff continue to feel supported and any issues relating to their performance can be addressed. Suitable locks should be fitted to resident`s bedroom doors to ensure their privacy is maintained. The home should be more pro-active in enabling residents to self-medicate even if this is only in a small way.

CARE HOMES FOR OLDER PEOPLE Hillbrow House Hillbrow 1 Park Road Crediton Devon EX17 3BS Lead Inspector Sue Dewis Unannounced Inspection 24th January 2007 09:30 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 Hillbrow House DS0000036439.V321776.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. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillbrow House Address Hillbrow 1 Park Road Crediton Devon EX17 3BS 01363 773055 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) hillbrow@shears.eclipse.co.uk Hillbrow Residential Care Home Ltd Mrs Rosemarie Joan Olive Heard Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Hillbrow House is based in an original two-storey 18th century building with a modern ground floor extension. It is situated in a residential area towards the outskirts of the town, and on a main bus route. GP surgeries and other services are reasonably close by, and the shops are within one mile. The older part of the building has one double bedroom on the ground floor and seven single bedrooms on the first. There is a shaft lift between floors. The older part of the building also contains one of the lounges and the dining room. The extension has fifteen single bedrooms and a lounge. Both of the lounges and the dining room have been decorated to a high standard. On the ground floor there is a step down into the dining room with grab rails at either side. There is also a step between two parts of the corridor, which has been ramped. There is an attractive, well-maintained and sheltered garden to the rear of the building with flowerbeds and pond. A patio area has been paved and a small fountain added. A new paved area has been created to the side of the home. There is also a good-sized car park. Fees for the home are £400 per week. A copy of the latest CSCI inspection report was displayed in the entrance hall. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours on the 24th January 2007. The inspector was accompanied by a social work student, who was part of the inspection only as an observer. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. During the inspection 3 residents were case tracked. This involves the inspector looking at the residents’ individual plans of care, and speaking with the resident and staff who care for them. This enables the Commission to better understand the experience of residents living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. As part of this, questionnaires were sent out to 10 residents, 8 health and care professionals (including GPs and care managers), 10 relatives and 8 staff. At the time of writing the report, responses had been received from 3 residents, 8 health and care professionals, 8 relatives and 3 staff. During the inspection the inspector spoke with 3 residents individually and six in a group setting, as well as observing staff and residents throughout the day. The inspector also spoke with 3 staff and the manager and the owner. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. What the service does well: The home continues to provide a clean, safe and comfortable home for the residents. It provides prospective residents with good information to help them make a decision about whether they want to live in the home. Staff are caring and well trained, they are able to recognise bad practice and would feel confident that issues would be dealt with. Care plans are formulated from good assessments and contain detailed information that helps staff meet the needs of the residents. Healthcare needs are monitored and appropriate action taken to involve healthcare professionals. Medication is securely stored and administered in line with the home’s policies and procedures. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 6 There is a good system for obtaining the views of residents and their relatives on the quality of care provided by the home. Residents are consistently offered choices about their everyday lives, including whether they participate in the activities on offer, where they eat their meals and what they have to eat. Food provided is of a high standard and residents were happy with quality and quantity that was served. Good relationships were observed between staff and residents who were enthusiastic about each other. Relatives were happy with the care their relatives received and comments received included, ‘I am very happy with the care in this excellent home’, ‘My mother has recently come to Hillbrow and finds everything to her liking and is extremely happy here’. There is a clear and simple complaints procedure and residents and relatives were confident that any concerns would be dealt with appropriately. What has improved since the last inspection? 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 Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillbrow House DS0000036439.V321776.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 Hillbrow House DS0000036439.V321776.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents or their representatives are provided with sufficient information with which to make an informed choice as to whether they wish to move into the home. Prospective residents are safeguarded by having knowledge of the contractual arrangements of the home. Prospective residents are encouraged to visit the home and an assessment of the support they require, ensures that the home can appropriately meet their care needs. The home does not provide intermediate care. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 10 EVIDENCE: Three resident’s files were looked at, including that of the most recent admission to the home. Two of the three contained signed contracts, the third was that of the most recent admission and the home was waiting for a copy to be returned to them. The contracts ask that the resident list any specific social or cultural needs be specified, so that the home can make arrangements for these needs to be met. The manager clearly explained the admission procedure, which includes the resident visiting the home (where possible) and the staff discussing whether they can meet the resident’s needs. The home has a detailed assessment form that they complete, as well as obtaining a care management assessment if applicable. When the home has determined that they can successfully meet the needs of the prospective resident, they write to the person to confirm this. A copy of the home’s service user guide is also sent at this point along with any of the home’s policies that relate directly to the resident. Two residents confirmed that they had received the service user guide and had visited the home prior to their admission. A third resident said that their relative had dealt with everything and though they had not visited the home, their relative had. The home does not provide intermediate care. Hillbrow House DS0000036439.V321776.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet resident’s health needs. Care needs are well met in an individual manner by caring and informed staff and residents are treated with dignity and respect. The health care needs of residents are well met with evidence of good multidisciplinary working taking place where necessary. The systems for the administration of medication are good with clear and comprehensive arrangements in place. However, more encouragement to enable residents to self medicate would enhance procedures. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three care plans were inspected, including that of the most recently admitted resident. Care plans are produced from the assessments made before admission and adjusted as residents’ needs change. Two of the three plans showed that they had been reviewed regularly and that the resident had been involved in drawing up their plan. The third plan was that of the most recently admitted resident whose plan had not yet been reviewed due to their short time at the home. The manager and owner said that the home sometimes receives referrals for people with high care needs. They were clear about the need for careful assessment and balancing the needs of existing residents, as well as the skills and capacity of the staff team. The plans contain pressure assessment charts and weights and bowel movements are regularly recorded. There was some discussion between the manager and the inspector as to whether these were needed on a regular basis as the inspector felt they only need to be recorded when a concern has been raised. More information on residents’ social history and needs is now being kept. The manager said that the home was well supported by the local surgeries, and records were maintained showing the involvement of healthcare professionals. It was possible to see where a health concern had been raised by staff and a visit from the GP requested. One resident was visiting the hospital that afternoon for a routine check up. Medication was securely stored and MAR (Medication Administration Record) charts were looked at, they were well completed with no gaps and staff who administer medication receive training in line with the recommendations of the National Minimum Standards. Records are now available to show that medication had been checked and booked in when received. However, residents are not routinely encouraged and enabled to look after their own medicines. Risk assessments tend to focus on why the resident should not self medicate, rather than looking for ways in which they may be supported to selfmedicate, even if only in some small area. Residents were spoken with individually and in small groups, both in communal areas and in residents’ own rooms. They spoke about how they were treated with respect by staff. For example, by staff knocking on doors before entering and calling them by their chosen names. Residents also said that help with having a bath and going to the toilet was given in a way, which respected their Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 13 privacy and dignity. Staff were seen offering personal care in a discreet manner, and spoke with residents in a friendly and respectful way. All toilets and bathrooms have suitable locks fitted to the doors to ensure residents’ privacy. However, bedroom doors do not have locks fitted to them. The owner will fit locks to the bedroom doors if requested. During the inspection the owner again asked residents if they would like locks on their doors and one resident said that they would. The owner said that they would arrange for this to be fitted as soon as possible. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with visitors and the community are good, giving opportunities to support and enrich residents’ social life. The home offers a suitable range of activities and entertainments to stimulate and occupy residents. The meals in this home are well presented and nutritious offering both choice and variety. EVIDENCE: A total of nine residents were spoken with either individually or in a group setting, all said that enjoyed the lifestyle at the home and were well supported and assisted by the care team. Residents are given the opportunity to join arts and crafts groups in the home and a poster was displayed for a ‘Potting Up’ plants and seeds session. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 15 Arrangements are made for residents to have access to religious services if they wish and there are regular trips out when the weather permits. Residents told the inspector that they could have a visitor at anytime, and comments received on cards indicated that visitors were made to feel welcome whenever they visited. One commented ‘Hillbrow is a fantastic home, very well run, with the owner always in evidence, I think the standard of care far outweighs what most homes provide. We always feel most welcome, problems are addressed at once. My mum is so happy there, 10 out of 10 !’. Another commented ‘…staff and management are friendly and helpful’. Staff were heard offering choices to residents on what they wanted to do and where they wanted to spend their time. Residents confirmed that they were able to spend their day as they chose, participating in activities or sitting in their rooms as they wished. One resident commented on their card that though activities were provided ‘ I rarely take part, but that is my decision not to do so’. Residents are asked daily about what foods they want to eat and where they would like to have their meals served. A wholesome balanced diet is provided and a choice is always available to residents, they are also offered fortified wine with their main meal of the day. Residents said that the food provided was to their liking and was of good quality with portions served to their choice. The meal served on the day of the inspection was of good quality and was clearly appreciated by the residents. The ‘Resident’s Survey of Hillbrow Services 2004, 2005, 2006’ indicates a high level of satisfaction in all areas relating to food. The cook and the kitchen assistant demonstrated a detailed knowledge of the likes and dislikes of residents, and could evidence that a range of food is served to residents. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that residents and relatives feel that their concerns will be listened to and acted upon. Residents are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: The home has a clear and simple complaints policy and procedure that is readily available with a copy is displayed in the hall of the home, and included in the Service User guide. Residents that were spoken with were unsure of the formal complaints procedure itself, but were confident that if they raised a concern it would be taken seriously and quickly dealt with to their satisfaction. Visitors’ comment cards said that they were aware of the home’s complaint procedure. Staff told the inspector that they all try to deal with any complaints as they arise, but if they can’t then they pass them to the owner or the care manager. No complaints have been received by the Commission since the last inspection and none were received during the inspection process. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 17 The three staff that were spoken with said that they have received training in recognising and dealing with abuse. Staff were able to describe a variety of differing kinds of abuse, including physical, verbal and mental. Staff were also aware of the correct procedures for reporting any suspicions to someone within the home and said that they would involve other agencies such as the police if they felt they needed to. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a clean, safe, comfortable and homely place to live. EVIDENCE: A partial tour of the building was made, and several bedrooms were looked at. There are several communal areas around the home for the use of all residents, and while some have their favourite areas, some move between them. The communal areas are homely, with many ornaments and pictures around them. They are decorated and furnished in a comfortable manner and to a high standard that meets the needs of the residents. Residents said that they were very happy with the standard of the décor and they all appeared relaxed in their environment. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 19 There is level access to the garden area and a small courtyard. Residents said that they enjoyed sitting out, when the weather permitted. There are three communal bathrooms, two with assisted baths and one with a walk in shower, which also has facilities for the hairdresser. Two in particular have been refurbished to a very attractive level. There are five en-suite rooms, and the remaining rooms have wash hand basins and the use of a number of communal toilets throughout the home. At the time of the inspection, the double room was being used as a single. Residents said that they were very happy with their rooms and one said that they had been asked what colour they wanted the room decorated in, before their admission. The rooms are light and bright and residents are encouraged to bring in some personal objects to make them feel at home. The home is clean and well maintained throughout with high standards of hygiene evident, and no offensive smells in any area. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of staff available throughout the day and night are sufficient to meet the needs and numbers of the current residents. The procedures for the recruitment of staff are robust and offer full protection to residents. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. A full training programme ensures that staff are competent to meet the needs of residents. EVIDENCE: The staffing levels for the home remain at their previous level ensuring that there are sufficient carers to ensure that residents’ needs are appropriately met. On the day of the inspection, four care staff were on duty in the morning, including a senior, three care staff were on duty in the afternoon until 8pm and then there are two waking night staff. The manager and the owner were also present, plus domestic and kitchen staff. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 21 The home has robust recruitment and selection procedures. Three staff files were inspected including that of the most recently appointed. All three contained the required documents including two written references and a satisfactory CRB (Criminal Records Bureau) check. All staff had received an in depth induction prior to them working unsupervised. Three staff were spoken with during the inspection, they were well aware of the individual care needs of the residents and were able to describe these and how they are met on a day to day basis. Staff spoke with enthusiasm about the residents and their work with them. There is a clear record of staff training, which enables the manager to audit the skill mix of staff and to highlight where training needs to be refreshed. Staff described how they felt training was encouraged, and told the inspector (certificates were also seen) that they had received training in POVA (Protection of Vulnerable Adults), Moving and Handling, Basic Food Hygiene and Fire Precautions. Six staff have NVQ level 2 (Care qualification), with two of these also having level 3. Three more staff are working for level two, one other for level 3 and a another is doing the NVQ assessors course. The care staff said that they did not feel rushed at any time and had time to spend chatting to residents. Residents told the inspector that there were always staff available if they wanted anything, and that they did not have to wait for help. There was a relaxed and unhurried atmosphere around the home, with staff meeting the needs of residents in a quiet and competent manner. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of the residents, though more formal supervision of staff would enhance this. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents and relatives. EVIDENCE: The registered manager of Hillbrow has worked in the care sector for many years. She has obtained the registered managers award and throughout the Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 23 inspection she demonstrated a detailed knowledge of the residents, staff and all aspects of the service provided. Residents and staff expressed confidence in the management processes of the home. Staff said that they felt encouraged to do a good job and that they are always given plenty of praise and feedback about their work. As well as the general enquiries made by staff, to ensure residents’ needs are met, the home also conducts a formal quality assurance process. Twice a year residents and their relatives are asked for their opinions on the service provided by the home. The results are displayed in the entrance hall of the home. The residents that were spoken with said that staff always put the needs of the residents before the routines of the home. The inspector was told that all residents (or their relatives) manage their own personal allowances. Staff told the inspector that they received yearly appraisals and regular supervision. However, though records are kept they are not detailed and do not routinely show any further action that may be needed and who would be responsible for it. The pre-inspection questionnaire provided evidence that Hillbrow complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. Fridge and freezer temperatures are checked daily, though there is no indication of the range of acceptable temperatures that would help staff easily identify if a problem occurred. So that the risk of burning from hot surfaces is minimised, all radiators within the home are being covered, there is just one in the main lounge to be done. All windows above ground floor level are now fitted with restrictors, in order to minimise the risk of any resident falling from these windows. Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP10 OP36 Good Practice Recommendations Medication policies and procedures should support and enable residents to self medicate Suitable locks should be fitted to all residents’ bedroom doors in order to ensure their privacy and dignity is maintained You should ensure that supervision sessions are recorded in detail and with specified outcomes in order that there is an accurate record of the sessions Hillbrow House DS0000036439.V321776.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Hillbrow House DS0000036439.V321776.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!