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Inspection on 01/08/06 for Hillbrow Residential Home

Also see our care home review for Hillbrow Residential Home for more information

This inspection was carried out on 1st August 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.

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

Residents provision of care was recorded in an individual care plan including details of health requirements, personal and social care needs. Details of reviews had been completed but were in need of re-writing. Residents prescribed medication was all present and correct. Residents were able to access the local community facilities and the home supports access to religious and social activities. The residents receive a regular choice of food and could request alternative meals from the menu provided. Recruitment practice was good however there were some areas that could be improved. A high percentage of staff had attained NVQ level 2 training and overall the skill mix available for service users was good. Residents felt well supported by the home and they benefited from regular residents meetings and money being safely managed when needed. Residents had benefited from internal home improvements however the homes grounds required attention to ensure that safety was consistently applied

What has improved since the last inspection?

The statement of Purpose has been redesigned. The home had provided new baths and an electric shower to the ground floor bathroom, two new WC`s on the first floor, redecorated ensuite room on the fist floor, redecorated two rooms and replaced flooring, fitted new valves to radiators to ensure the correct water temperatures are maintained at around 43C, and replaced old signs this was an excellent achievement benefiting the residents at Hillbrow.

What the care home could do better:

The statement of purpose contains had been improved however continued to be without adequate information about the staff qualifications and skills available to new and existing as required and listed in Schedule 1 of the Care Homes Regulations (2001). This was the second time that this Requirement has not been met therefore a new timescale has been agreed. The Garden area was in need of improvement due to hazards such as unprotected corners on a stainless steel kitchen unit located in the garden area and old furniture and builders rubbish. This prevented the garden from reaching its full potential and two requirements were made relating to maintenance and health and safety. Recommendations made included the following: Original care assessments to be sought from the local Social Care Teams. For the registered manager to ensure that, statutory training, `The Safeguarding Vulnerable Adults ` is confirmed and that all staff attends. That the home consider the suitability and appropriateness of having and old kitchen sink unit situated in the back garden and to considered replacing this with something more suitable, possibly an outside tap and to considerreplacing the existing pond liner that had become discoloured with a new bitchumen liner. That all new staff provide their last employers reference or if appropriate, the last `long term` employer, not forgetting that there is a need to ensure the suitability of the staff member if they did not come from another `care` environment.

CARE HOMES FOR OLDER PEOPLE Hillbrow Residential Home Hillbrow 18 Mill Road Epsom Surrey KT17 4AR Lead Inspector Damian Griffiths Unannounced Inspection 10:00 1 August 2006 st 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 Residential Home DS0000061265.V302577.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 Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillbrow Residential Home Address Hillbrow 18 Mill Road Epsom Surrey KT17 4AR 01372 720633 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) Mrs Soomit Sumessur Mr Vinod Sumessur Mrs Soomit Sumessur Care Home 12 Category(ies) of Dementia (5), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (1), Old age, not falling within any other category (7) Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to seven (7) service users in the category Old Age (OP) may be accommodated. Up to five (5) service users in the category Dementia, aged over 65 (DE(E)) may be accommodated. Additionally one named service user (as per letter dated 13th August 2004) in the category Mental Disorder aged over 65 (MD(E)) may be accommodated. 21st June 2006 Date of last inspection Brief Description of the Service: The home is located near to Epsom Town Centre. The registered providers have managed the home since August 2004 and major renovation work has been completed in order to update the premises. The home is currently registered for twelve older people and cares for 7 residents. The accommodation at the home has four single and four double bedrooms. Two male residents share a room at present and there is ample space throughout the premises. The home is located near to Epsom Town Centre. Weekly Cost:£400.00pw. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by the registered manager Mrs Soomit Sumessur and her husband Mr Vinod Sumessur representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire from the home and notifications of significant events known as regulation 37. Comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page this Inspection report. The inspector was with staff and residents at Hillbrow for a period of 6½ hrs. This time was spent sampling resident’s care need assessments, care plans, contracts and talking to residents, staff and a Health Care Practitioner who was visiting the home to treat a resident. Staff files were inspected for evidence of good practice in the following areas: recruitment, allocation of staff skills, daily rotas and training. Five residents, three relatives and three Health and Social care practitioners completed CSCI Survey’s distributed prior to the inspection. Random sampling of the survey groups ethnicity and diversity revealed that residents were primarily of British origin. One resident thought this aspect of recording was ‘irrelevant’. The inspector would like to extend thanks to the residents staff and management at Hillbrow for their assistance and hospitality. What the service does well: Residents provision of care was recorded in an individual care plan including details of health requirements, personal and social care needs. Details of reviews had been completed but were in need of re-writing. Residents prescribed medication was all present and correct. Residents were able to access the local community facilities and the home supports access to religious and social activities. The residents receive a regular choice of food and could request alternative meals from the menu provided. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 6 Recruitment practice was good however there were some areas that could be improved. A high percentage of staff had attained NVQ level 2 training and overall the skill mix available for service users was good. Residents felt well supported by the home and they benefited from regular residents meetings and money being safely managed when needed. Residents had benefited from internal home improvements however the homes grounds required attention to ensure that safety was consistently applied What has improved since the last inspection? What they could do better: The statement of purpose contains had been improved however continued to be without adequate information about the staff qualifications and skills available to new and existing as required and listed in Schedule 1 of the Care Homes Regulations (2001). This was the second time that this Requirement has not been met therefore a new timescale has been agreed. The Garden area was in need of improvement due to hazards such as unprotected corners on a stainless steel kitchen unit located in the garden area and old furniture and builders rubbish. This prevented the garden from reaching its full potential and two requirements were made relating to maintenance and health and safety. Recommendations made included the following: Original care assessments to be sought from the local Social Care Teams. For the registered manager to ensure that, statutory training, ‘The Safeguarding Vulnerable Adults ’ is confirmed and that all staff attends. That the home consider the suitability and appropriateness of having and old kitchen sink unit situated in the back garden and to considered replacing this with something more suitable, possibly an outside tap and to consider Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 7 replacing the existing pond liner that had become discoloured with a new bitchumen liner. That all new staff provide their last employers reference or if appropriate, the last ‘long term’ employer, not forgetting that there is a need to ensure the suitability of the staff member if they did not come from another ‘care’ environment. 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. Hillbrow Residential Home DS0000061265.V302577.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 Residential Home DS0000061265.V302577.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): 1,3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose had been redesigned and was well presented however it still requires development. Residents had not received a comprehensive assessment however care plans were in place. Hillbrow does not provide an Intermediate Care service. EVIDENCE: The statement of purpose had been redesigned and included details of the registered mangers qualifications with the exception of all other staff. The Statement of Purpose must include details of ‘The number, relevant qualifications and experiences of the staff working at the care home’ as quoted from Schedule 1 of The Care Homes Regulations 2001. A new resident to the home was without a full assessment of need, however his care needs had been recorded and an active care plan was in place. All new residents must receive thorough and comprehensive assessment of need from the registered manager before becoming a permanent resident. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 10 The Registered manager had acknowledged this and there was evidence that a new and comprehensive assessment form was being developed. Potential new residents were able to take their time to adjust to the home and a statutory six-week trial period was in place. It was recommended that all residents original care assessments be sought from the local Social Care Teams. Please see the requirements and recommendations section of this report. Hillbrow Residential Home DS0000061265.V302577.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents provision of care was recorded in an individual care plan including details of health requirements, personal and social care needs. Details of reviews had been completed but were in need of re-writing. Residents prescribed medication was all present and correct. EVIDENCE: Six care plan folders were sample for evidence of assessed needs being put into practice on a daily basis. The folders showed evidence of daily routines in place and the help required being given. This was evidenced by sampling the daily records sheets compiled by staff that were in place. Risk assessments had been completed and reviews of care plans conducted, however, the new reviews had been hand-written and partially obscured the care plan record. It was recommended that the care plans be retyped, in the interests of clarity and for the promotion of good practice. Residents consulted confirmed that the staff were considerate and caring when providing the help they required. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 12 New residents to the home were receiving health care support from a range of practitioners relevant to their need. Comments received from a visiting health care practitioner confirmed that she had no concerns regarding the resident’s access to health care treatment and was confident that the home would always ask for advice when required. The home was aware of areas of risk such as diabetes treatment and skin care essential to ensure the wellbeing of the residents. Comments received from other Health care practitioners: confirmed that resident’s privacy was respected and they were treated within their own rooms. Residents’ medication was stored in a convenient part of the home that provided staff with privacy, security and a good work surface when using the Medical Administration Records (MAR). Residents did not take charge of their own medication which was stored appropriately and administered from prepacked containers. Each resident had his or her own record of prescribed medication noted in the appropriate manner and signed by the staff member administering the medication. A drug returns book was used to record all medication returned to the pharmacist. Residents commenting in the CSCI survey felt that they always received the medical support they needed. Resident sharing a room confirmed that they had adequate privacy in the room and could use the screens provided. Staff was observed knocking prior to entering residents rooms and would address them by the name of their choosing. A married couple confirmed that staff supported them adequately and respected their privacy. Hillbrow Residential Home DS0000061265.V302577.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to access the local community facilities and the home supports access to religious and social activities. The residents receive a regular choice of food and can request alternative meals from the menu provided. EVIDENCE: Religious preferences were respected and a Chaplin visited regularly say mass for the majority of Church of England residents. All resident had completed the CSCI section relating to ethnic origin and concluded that the home consisted of white British, Irish and Indian service users. Staff were from overseas and residents did not report any problems with language barriers or poor attitudes to care, throughout the consultation process. Comments noted on the CSCI survey regarding ‘ethnicity and diversity’ from one resident felt that this aspect of information gathering was ‘irrelevant’. The residents care plan folders sampled provided evidence that residents with dementia needs received written assessment of their interest, such looking at photos, DVD’s relevant to their past experience. A health practitioner visiting the home commented on the activity of the residents who were ‘usually busy playing cards or dominoes’ whenever she Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 14 visits. Some residents did not feel like going on outings and were contend with the activities available at the home. A day trip to Hastings had been planned later on in the month. Other residents enjoyed helping out with domestic chores at the home and another resident enjoyed shopping and smoking, there was a separate place available for smoking in located in the conservatory nearest the kitchen. Other residents attended the local day centre to practice their interest in arts and crafts. Choices of fresh fruit and vegetables were available daily on the menus provided and alternative meals were available if required. One resident enjoyed regular servings of kippers for breakfast. Residents confirmed that their families were welcomed to the home and they could visit in privacy if they so required. Comments from the CSCI Survey concluded that the residents always or usually enjoyed the activities, meals provided. Hillbrow Residential Home DS0000061265.V302577.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew who to make a complaint when necessary and the home was aware of the need to renew it’s training commitment to ensure staff knowledge of the ‘safeguarding of vulnerable residents’ in their care was regularly updated. EVIDENCE: Complaints policy and procedures on file could be found in the office and the complaints folder inspected. There had been no complaints recorded since tha last inspection. The visiting health practitioner stated that she visited the home regularly with her colleges and had not observed of heard any complaints against the staff. Policy on safeguarding adults, whistleblowing and a leaflet on the recognition and prevention of abuse was available in the home and the leaflet was prominately displayed. The registered manager has attended local authority training for safeguarding adults and has passed on this information to staff. The manager stated there were difficulties in accessing the local authority training as it had been cancelled but was committed to follow this up with renewed training for all staff. It has been recommended that the registered manager ensure that this training is confirmed to ensure staff receive up-dated and adequate training to safeguard service users from harm or abuse. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 16 Comments recorded in the CSCI surveys included: From Health and Social Care practitioners; an excellent service and satisfied with overall care and ‘Relatives’ had ‘no complaints and very pleased with the service’ : Residents felt that it was ‘ a very happy home’. Hillbrow Residential Home DS0000061265.V302577.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, 20,21,22,24,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents had benefited from internal home improvements however the homes grounds required attention to ensure safety was consistently applied. EVIDENCE: A full tour of premises was conducted and gardens at the back of the home could of provided a safe space for residents to walk. The lawns were in good order, but the borders contained builders rubbish and an old kitchen unit. The premises were greatly improved with new floors and carpets, two communal bathrooms had been refurbished and tiled and new floors fitted. Taps tested in communal areas had been fitted with automatic controls to reduce temperatures all within the 44c limit, as were resident’s rooms and the stair-lift was in good working order. A patio and pond had been constructed in the corner of the building next to the conservatory with appropriate garden furniture in place offering a pleasant sanctuary for resident who preferred to sit outside. Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 18 A stainless steel double sink unit had been placed in garden. It was plumbed into the cold water supply for the convenience of anyone using the garden the edges of the sink had not been finished off to the standard demanded to ensure the safety of the residents and a seat had been placed directly next to the hazard. A requirement was made to remove this sink unit or make safe and fit for purpose and for the safe disposal of all rubbish in the garden. It is recommended that the home consider the suitability and appropriateness of having and old kitchen sink unit situated n the back garden and to considered replacing this with a more suitable outside tap. It was recommended that the home consider replacing the pond liner that had become discoloured. The CSCI survey concluded that all the residents considered the home to be ‘fresh and clean’. Please see the requirements and recommendations section of this report. Hillbrow Residential Home DS0000061265.V302577.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practice was good however there were some areas that could be improved. A high percentage of staff had attained NVQ level 2 training and overall the skill mix available for service users was good. EVIDENCE: Five staff files were sampled to confirm the level of training received and skills available to the residents. Evidence that staff had received appropriate training was apparent due to certificates being in evidence for: Induction training, first aid, food hygiene: skin care, fire training, care of dementia, hydration, medication and health and safety. Training with the Surrey Multi-Agency procedure that is needed to ensure the safeguarding of vulnerable adults was being sought. A staff training programme was available and provided course dates and information. A review of evidence in the provider data set indicated the home had met the targets in the NMS for National Vocational Qualification. By having 57 of staff at this level. The GSCC Code of Practice was available for staff. Appropriate recruitment procedures were being observed by the home and a number of overseas staff were employed. All had two references but some of Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 20 the references did not reflect previous employment satisfactorily. A staff member’s employment history showed that they had accrued the majority their work experience from one employer however they had not provided a reference from this employer or an explanation for its absence. A new application form was required to be used requesting more details of the previous employee’s referee details and to emphasise ‘skills in care’ and it was also recommended that all new employees provide their last employers reference and the most relevant or long term work experienced. Please see the requirements and recommendations section of this report. Hillbrow Residential Home DS0000061265.V302577.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): 31,32,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents felt well supported by the home and they benefited from regular residents meetings and were satisfied with the way money was being managed. The rear garden of the home did not reflect the good standard of health and safety achieved within the home. EVIDENCE: The manager holds a NVQ level 4 in care and a Registered Managers Award and she had many years experience in the residential care field. Health Care Practitioners visiting experienced a relaxed and was always very relaxed and friendly, residents were treated with respect and the home was very organised. The homes manager had a good rapport with her team and was able to discussed health care concerns with the appropriate health or Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 22 social care practitioner. Staff and management at the home had a good rapport with the Health and social care practitioners visiting the home. It was observed that residents were confident when visiting the office and requests for help and advice was given by the manager and her staff throughout the day. Residents meeting regularly enabled access for comments about the home and the issues important to the residents. A questionnaire had been circulated following the last inspection to gauge residents’ satisfaction. Most residents managed their own money but the payment of a weekly allowance was in place as arranged by the home and the local authority funding the resident’s placement. This allowance was paid annually to the home and distributed weekly to the resident. There was evidence to show that the resident had signed all the transactions that were recorded in a receipt book. Health and safety policies and procedures were in place and a tour of the premises confirmed that the home promoted the safety of the residents. Insurances were in place: fire drills and extinguishers checked, equipment checked, COSHH, water temperatures physically checked and correct, training in place. There were no concerns or complaints reported regarding Health and Safety in the home. It was unfortunate that the rear garden was unable to present a hazard free environment for the residents due to: The stainless steel double sink unit’s edges had not been finished off to the standard demanded to ensure the safety of the residents and a seat had been placed directly next to the hazard. A requirement was made to remove this sink unit or make safe and fit for purpose and for the safe disposal of all rubbish in the garden and it is recommended that when positioning furniture throughout the home health and safety is considered. Hillbrow Residential Home DS0000061265.V302577.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 X 3 X X X 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 2 3 4 3 X 3 3 3 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 3 3 X 3 X X 2 Hillbrow Residential Home DS0000061265.V302577.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 4. (1)(c) Requirement Timescale for action 01/09/06 2. OP19 23(1)(a) (2)(B)(C) (0) 3. OP38 13(4) 23(0) The registered person must ensure that the statement of purpose contains information as listed in Schedule 1 of the Care Homes Regulations (2001). The timescale of 28/02/06 has not been met. This was the second time that this requirement has not been met therefore a new timescale has been agreed. 01/09/06 The registered manager must ensure that the physical design and layout of the premises to be used as a care home meet the needs of the residents and are of sound construction and in a good state of repair internally and externally and ensure that all parts of the home to which the residents have access are reasonably free from hazards. 01/09/06 The registered manager must ensure that ensure that all parts of the home to which the residents have access are reasonably free from hazards and external grounds are suitable, safe and well maintained. DS0000061265.V302577.R01.S.doc Version 5.2 Hillbrow Residential Home Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP18 Good Practice Recommendations It was recommended that original assessments be sought from the local Social Care Teams. It has been recommended that the registered manager ensure that this training is confirmed to ensure staff receive up-dated and adequate training to safeguard service users from harm or abuse. It is recommended that the home consider the suitability and appropriateness of having and old kitchen sink unit situated n the back garden and to considered replacing this with a more suitable outside tap. It was recommended that the home consider replacing the pond liner that had become discoloured. It was recommended that all new employees provide their last employers reference. It is recommended that when positioning furniture throughout the home health and safety is always considered. 3. OP19 4. 5. 6 OP19 OP29 OP38 Hillbrow Residential Home DS0000061265.V302577.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hillbrow Residential Home DS0000061265.V302577.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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