Inspection on 09/12/08 for Hillcrest Care Home

This inspection was carried out on 9th December 2008.

CSCI found this care home to be providing an Adequate service.

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

Hillcrest Care Home 24/08/10

Hillcrest Care Home 07/07/10

Hillcrest Care Home 19/10/09

Hillcrest Care Home 19/03/08

Hillcrest Care Home 21/03/07

Hillcrest Care Home 05/07/06

Hillcrest Care Home 06/12/05

Hillcrest Care Home 02/08/05

Hillcrest Care Home 22/03/05

Hillcrest Care Home 30/09/04

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Turret Villa Retirement Home

Moor House

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Beaconsfield Court Care Home

Little Sisters Of The Poor

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Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2009.

CARE HOMES FOR OLDER PEOPLE Hillcrest Care Home Wear Street Jarrow Tyne And Wear NE32 3JN Lead Inspector Alan Baxter Unannounced Inspection 9th December 2008 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 Hillcrest Care Home DS0000000234.V373261.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. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest Care Home Address Wear Street Jarrow Tyne And Wear NE32 3JN 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) 0191 489 0200 0191 428 6343 Hillcrest Care Homes Limited Jacqueline Karen Wallace Care Home with Nursing. 49 Category(ies) of Dementia (49), Old age, not falling within any registration, with number other category (49) of places Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 49 2. Dementia - Code DE, maximum number of places 49 The maximum number of service users who can be accommodated is: 49 19th March 2008 Date of last inspection Brief Description of the Service: Hillcrest Care Home is a purpose built three-storey building located within the busy town centre of Jarrow. The building has 49 single bedrooms all of which have an en-suite bathroom. Access around the building is made easier by a passenger lift or there are two staircases, which are located at either end of the building. There are a number of communal areas, such as lounges, dining rooms and quiet areas. A fireplace with surround and easy chairs is located in the corridors of both the first and second floor and provides a popular place where service users can choose to spend their time. A staff call system, which is accessible to the service users, is provided in all parts of the home. The laundry and staffroom are located on the second floor of the home. There is a garden to the rear of the home and parking facilities are available for the convenience of visitors. The home is registered to provide care to 26 people who have varying degrees of dementia and 23 people who are elderly. The home is registered to provide nursing care. A place at this home costs £395 - £541.73p per week. Additional charges are made for toiletries, newspapers / magazines, and hairdressing. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 19th March 2008. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 9th December 2008. It took approximately seven hours. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The quality of the care plans used to meet residents’ needs is improving. Nutritional assessments have been introduced, so residents’ diets are better monitored. There has been an improvement in the accuracy and the recording of the administration of medicines. There has been a significant improvement in the range and frequency of social activities and other social stimulation. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 7 New carpets have been laid in lounges and corridors, and some armchairs replaced. 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. Hillcrest Care Home DS0000000234.V373261.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 Hillcrest Care Home DS0000000234.V373261.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): 3 and 4. People who use the service experience good quality in this area. The home makes sure that all the needs of any potential new resident have been fully assessed before the person is admitted to the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home obtains copies of the detailed needs assessment drawn up by the referring agency, to see whether it is an appropriate referral. In addition, the home’s manager (and, where appropriate, a qualified nurse) carries out a comprehensive assessment to be sure that the home can meet all the person’s assessed needs, before he/she is admitted to the home. This includes assessment of need in the following areas: skin integrity, handling Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 10 and falls risks, nutrition, social and psychological needs, and dependency ratings. It was a requirement of the last inspection report that staff must be kept informed of the assessed needs of individual residents, including any changes in need. This has been carried out. All five staff who returned surveys said that they are always given up to date information about the needs of the residents. One commented, “Everything I need to know about a resident is in the care plans”. It was a requirement of the last inspection report that the responsible individual must make sure that there are effective strategies of support at the home, which follow current good practice, and maintain the rights, dignity, skills and lifestyles of all the people who live there. This has been carried out. Care plans reflected the expectation that staff will encourage and maintain the independence of the residents, respect their privacy and dignity, and treat them as individuals. Hillcrest Care Home DS0000000234.V373261.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. People who use the service experience adequate quality in this area. Residents’ personal care and health care needs are not being fully covered in their care plans, and some care plans are not always being followed. This means the home cannot fully show that it is meeting every need identified. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was a requirement of the last inspection report that the responsible individual must make sure that care plans are sufficiently detailed to guide staff practice in meeting service users care and lifestyle needs and record the work they currently undertake. This is in the process of being carried out. Most care plans now have reasonable detail, and there is evidence that they being regularly reviewed, and amended, where necessary. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 12 There is a good match between assessed needs and corresponding care plans. Care plans are also numbered and listed, and daily recordings are against specific plans. It was a further requirement of the last inspection report that the manager must make sure that all support for people with dementia follows current best practice and this is recorded in each persons care plan. This has not been fully carried out. In one example, a person recently admitted for nursing care with Dementia did not have a specific mental health care plan. This requirement is repeated in this report. It was a further requirement of the last two inspection reports that care plans must include details of significant behavioural needs, and clear guidelines for staff, so that individual people receive consistent support to help them manage this area of need. This has not been fully carried out, and this requirement is repeated in this report. There were also examples of where behavioural needs have been properly identified (with, for example, a need for food and fluid charts to be completed, or more frequent night staff checks to be undertaken), but where the ongoing daily/nightly records clearly show that the clear guidelines for staff are not being followed. It was a requirement of the last inspection report that nutritional assessments must be in place, up to date and reflect the nutritional needs of the people who live here. This has been carried out. Detailed nutritional assessments are now in place. Other health care assessments carried out include skin integrity, psychological condition, risk of falls, and dependency levels. The healthcare arrangements are accessible to all service users regardless of their needs. All service users have their choice of GP following admission into the home and the district nurses, chiropodist, dentist and optician visit regularly to carry out treatment and to address any medical issues that staff raise as a concern. Other healthcare professionals are brought into the home when they are required and staff escort Service users who have to attend hospital appointments. Of the six residents who returned surveys, four said they always receive the medical support they need; two said that they usually do. It was a requirement of the last inspection report that the manager must make sure that accurate administration of medication takes place at the home. This has been carried out. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 13 The Medication Administration Records (MAR) was fully completed, with no unexplained gaps. It is pre-printed by the supplying pharmacist to reduce the scope for errors, and any handwritten amendments are signed and dated. Medicines are checked and signed for on receipt. There is a photo of each resident attached to the relevant page of the MAR, again to minimise mistakes. Controlled drugs were checked and the records were accurate. It was also a requirement of the last inspection report that the responsible individual must make sure that records accurately reflect the total levels of medication held and administered at the home. This has been carried out. The home’s manager or line manager undertakes monthly audits. This takes the form of a detailed questionnaire that identifies any errors or omissions, and follows up with a detailed action plan to make good any deficits. Hillcrest Care Home DS0000000234.V373261.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. People who use the service experience good quality in this area. Social stimulation has improved significantly since the last inspection, and residents enjoy a good range of activities and choice as to how they spend their day. The food is good, but some further improvements are needed in enhancing the dining experience. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was a recommendation of the last inspection report that residents accommodated on the first floor should be offered equal opportunities to access the rear garden area. This has been carried out. They are now offered equal access to the garden. The home employed an enthusiastic and very capable activities co-ordinator in March this year. He has established a good rapport with the residents, and there has been a significant increase in the frequency, variety and quality of the activities programme, which is drawn up weekly, in conjunction with the Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 15 residents. There is a mixture of group and individual activities. Group activities include ball games, singing, board games, crafts, dancing, ‘pamper’ sessions and trips out. Residents confirmed that there are activities for them to join in. There is a reasonable degree of contact with the local community, and visitors are encouraged. A local church minister visits every Sunday to bring Communion. The manager operates an ‘open door’ policy to residents and their families, and she works one evening every two weeks and part of a weekend every month, so that she is available to those who cannot visit during office hours. Residents are encouraged to make decisions as to how they spend their day. They have choice as to when they rise and retire, what to wear, what to eat, whom to see, etc. The home advertises an independent Advocacy service on notice boards in the home. It was a requirement of the last inspection report that dining arrangements must be reviewed so that dining tables are set with equipment needed when taking a meal and so that service users are treat with dignity and respect. This has only been partly carried out. This requirement is repeated in this report. Dining tables still lacked tablecloths (although some tables had silk flowers in a vase) and although there were salt and pepper cruets in the dining room, they were not put on the tables until this lack was queried. The persistent noise of nearby carpet vacuuming detracted from the pleasure of the meal. Service was a little slow. Portions were of a good size, and residents were asked their choice of meal at the time of eating, which is good practice. Hot and cold drinks were available. Residents needing assistance were given this in an attentive manner, and were not rushed. The food appeared appetising. Residents spoken with said they liked the food, and this was confirmed in a survey, where four residents said that they always enjoy the food; one said he/she usually did (one did not answer this question). One relative commented, “Meals are very good, always plenty for them. They are well fed”. A notice was seen on the door into the dining room that encouraged residents to speak to staff if they were hungry or wanted a snack, at any time. This is good practice. Hillcrest Care Home DS0000000234.V373261.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. People who use the service experience good quality in this area. The home takes any concerns or complaints seriously, and these are well recorded and are properly looked into. The home also takes seriously its responsibility for protecting its residents, and reports any allegations appropriately. We have made this judgement using available evidence including a visit to this service. EVIDENCE: All five staff who returned surveys said that they knew what to do if a resident, relative or anyone else has any concerns about the home. All six residents who returned surveys said that they are listened to by the staff, who act on what they say. All six also said they knew who to speak to if they were unhappy or wanted to make a complaint. There have been five complaints in the past year. One, a detailed complaint from a former member of staff, was still in the process of being investigated. Part of this investigation was the sending out of a questionnaire to be completed anonymously. These are currently being collated and studied. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 17 Concerns and complaints are taken seriously, and are logged carefully. Investigation details are recorded, statements taken, where appropriate, and the complainant’s degree of satisfaction with the outcome recorded. Other parties, such as care managers, are involved where necessary. The manager says she errs on the side of caution when reporting ‘safeguarding’ issues. In the past year three safeguarding referrals have been made, one regarding alleged staff misconduct, and two about alleged inappropriate behaviours by relatives towards residents. It is recommended that all safeguarding recordings be kept on a central file. Hillcrest Care Home DS0000000234.V373261.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, 22, 24 and 26. People who use the service experience adequate quality in this area. Residents live in a safe, well-maintained, clean and hygienic environment, with sufficient lavatories and bathing facilities, but there are storage and privacy issues outstanding from previous inspections. We have made this judgement using available evidence including a visit to this service. EVIDENCE: All bedrooms have en-suite facilities and are pleasantly personalised. The lack of discrete storage space for continence products noted in previous inspection reports continues to be a problem There is a designated smoking room for residents. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 19 Bathrooms, though well equipped, are functional, and have little in the way of décor or homely touches to make the bathing experience more enjoyable for the residents. There is a pleasant and secure garden area for the use of residents. It was noted that new carpets have been fitted in the lounges and in some corridors since the last inspection, and that new armchairs have also been purchased. It was a recommendation of the last inspection report that residents’ wheelchairs and other individual mobility equipment should be stored in the respective resident’s own bedroom rather than in communal bathrooms. This has not been fully carried out, with some wheelchairs still in situ, as well as bathrooms being cluttered with laundry bags, weighing equipment and other items. This recommendation is repeated in this report. It was a recommendation of the last inspection report that blinds should be considered for those first floor bedrooms that can be seen from the main road, in order to ensure the privacy and dignity of the people using those rooms. This has not been fully carried out. The manager said that residents and their families have been asked if they wished to have blinds fitted but that no one had wanted this facility. It was agreed that blinds should be fitted as a norm for all new admissions, where the bedroom is overlooked. Consideration will also be given to having blinds fitted in those lounges overlooked by the public. It was a requirement of the last two inspection reports that continence equipment and protective equipment must not be left out on display in bathrooms and toilets. This is to ensure the dignity of residents, and also to protect equipment from possible cross-contamination. This has not been carried out. Such equipment is still being routinely stored in these areas. This recommendation is repeated in this report. Five of the six residents who returned surveys said that the home is kept fresh and clean; one said that it usually is. On the day of inspection, the home was very clean and tidy, and there were no unpleasant odours noted. Hillcrest Care Home DS0000000234.V373261.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. People who use the service experience good quality in this area. There are enough staff to meet the needs of the current resident group. A large proportion of staff hold a qualification, and most, but not all, training needs are being met. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The staff complement was one deputy care manager, four senior carers and fifteen care staff (with three more care staff starting soon). Nursing care is overseen by four RGN’s, three RMN’s and one dual qualified nurse. Staffing levels at the time of this inspection were one senior carer and two carers on the ground floor, and one nurse, one senior carer and three carers on the first floor (nursing). From 8pm to 8am, there are one nurse, one senior, and three (soon to be four) carers. Ancillary staff include a full time handyman, an activities co-ordinator (25 hours), two cooks, two kitchen assistants, a housekeeper, two domestics and one laundry person. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 21 Staffing levels reflect the numbers and dependency levels of the resident group. Of the five staff who returned surveys, one said that there was always enough staff to meet the individual needs of the residents; two said there usually is; and two said there sometimes was enough staff. All five staff did, however, feel that they had the right support, experience and knowledge to meet the different needs of the residents. Four of the six residents who returned surveys said that that staff always available when they need them; two said staff were usually there when they needed them. Nineteen of the twenty-two staff (excluding the registered manager and qualified nursing staff) hold National Vocational Qualification (NVQ) level 2 in care. This is a high percentage, and one that exceeds the minimum 50 required. Three of these have gone on to achieve NVQ level 3. Study of the recruitment records of recently appointed staff showed that all the required information is gathered and appropriate checks carried out, before an appointment is confirmed. The home’s line manager is currently carrying out a full audit of all staff files, to confirm that this was also the case under previous ownership. All five staff who returned surveys said that their induction covered everything they needed to know to do the job when they started. They all said that they are given training that is relevant to their; that helps them understand and meet the needs of residents; and that keeps them up to date with new ways of working. However, study of staff induction workbooks showed that some had not been completed. A requirement is made regarding this issue in this report. The staff-training matrix showed some gaps in the mandatory training scheme, but there was evidence that this had been already noted, and appropriate training arranged for staff in January to March 2009. This will be given by the company’s own trainers, ‘in-house’. There was evidence for both individual resident-focussed training and for staff personal development training. Hillcrest Care Home DS0000000234.V373261.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. People who use the service experience adequate quality in this area. The home has an experienced and qualified manager. Systems are in place for checking the quality of the service being provided, but staff are not receiving sufficiently regular supervision or fire safety training. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home’s registered manager, Jackie Wallace, has twenty years experience in the care sector, including ten years in management positions. She holds the required National Vocational Qualification (NVQ) level 4 in management, and is studying for the NVQ 4 in care. She is also an NVQ assessor. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 23 Lines of accountability seem clear, with qualified nurses carrying out all nursing assessments. A questionnaire regarding the quality of care being provided is sent out to families annually. Internal quality audits are carried out regularly. Areas covered by such audits include care plans, staff files, medication records, finances and operations. There is also a monthly visit and audit by the home’s line manager. Written records are kept. Examples quoted of improvements to the service, as a result of the above questionnaires and audits, included improved socialization of residents, with improved social activities, more trips out, and the purchase of a mini bus for the home, improvements to the environment, including the tiling of dining room floors. Money is currently kept for approximately 36 residents, at their request (or that of their families). Records are generally well kept, with two staff signatures for each transaction, and a monthly external audit undertaken. Receipts are kept. Four of the five staff who returned surveys said they meet with their manager regularly (one said ‘often’). Supervision records showed, however, that staff receive supervision, on average, only four times each year, rather than the expected minimum of six times. A requirement regarding this issue is made in this report. It was a requirement of the last inspection report that the manager must make sure that fire doors are not wedged open. This is to make sure that people are protected in the event of a fire. This practice was still evident at the beginning of this inspection, but door chocks were removed immediately, and an assurance given that they would be taken from the building and not replaced. This requirement is repeated in this inspection report. The manager was made aware that any repetition would mean that the Commission would consider taking enforcement action. Health and safety assessments were in place, as were Control of Substances Hazardous to Health (COSHH) assessments. There are monthly audits and a health and safety forum also meets monthly, with the aim of identifying issues that need to be addressed. The accident book was well recorded. The fire logbook showed that all the required checks and tests of fire equipment were being carried out at the necessary intervals. However, the logbook did not show that the required inhouse fire instruction was being given to staff at the prescribed intervals Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 24 (three-monthly for night staff, six-monthly for day staff). A requirement regarding this issue is made in this report. Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 25 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 26 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 12 Requirement The manager must make sure that all support for people with dementia follows current best practice and this is recorded in each persons care plan. (Previous timescales of 01 October 2007 and 01 July 2008 not met) Care plans must include details of significant behavioural needs, and clear guidelines for staff, so that individual people receive consistent support to help them manage this area of need. (Previous timescales of 01/10/07 and 01/07/08 not met). Dining arrangements must be reviewed so that dining tables are set with equipment needed when taking a meal and so that service users are treated with dignity and respect. (Previous timescale of 01/07/08 not met). Timescale for action 31/01/09 2. OP7 15 (2)(b) 31/01/09 3. OP15 12 31/01/09 Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 27 4. OP30 18(1) All new members of staff must be given induction training to National Training Organisation specification within six weeks of appointment to their posts, and this must be fully documented. Care staff must receive formal supervision at least six times per year. In-house fire safety instruction must be given to all staff at the frequencies set down by Tyne & Wear Fire and Rescue Service. 31/01/09 5. OP36 18(2) 31/01/09 6. OP38 23(4) 31/01/09 7. OP38 23 The manager must make sure 10/12/08 that fire doors are not wedged open. This is to make sure that people are protected in the event of a fire. (Previous timescales of 01/10/07, 01/03/08 and 01/07/08 not met) Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 28 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 OP22 Good Practice Recommendations Residents’ wheelchairs and other individual mobility equipment should be stored in the respective resident’s own bedroom rather than in communal bathrooms. Continence equipment and protective equipment must not be left out on display in bathrooms and toilets. This is to ensure the dignity of residents, and also to protect equipment from possible cross-contamination. Blinds should be considered for those first floor bedrooms and lounges that can be seen from the main road, in order to ensure the privacy and dignity of the people using those rooms. 2. OP26 3. OP24 Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hillcrest Care Home DS0000000234.V373261.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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