Inspection on 09/01/07 for Hillcrest Care Home

This inspection was carried out on 9th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillcrest Care Home 28/01/09

Hillcrest Care Home 05/02/08

Hillcrest Care Home 04/07/07

Hillcrest Care Home 17/08/06

Hillcrest Care Home 07/11/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hillcrest Care Home 106 Thorpe Road Thorpe Norwich Norfolk NR1 1RT Lead Inspector Mr Jerry Crehan Key Unannounced 9th 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 Hillcrest Care Home DS0000065216.V327230.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 DS0000065216.V327230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest Care Home Address 106 Thorpe Road Thorpe Norwich Norfolk NR1 1RT 01603 626073 01603 765100 hillcrest@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited 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) Position Vacant Care Home 52 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (20) of places Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2006 Brief Description of the Service: Hillcrest is a care home providing care for up to 52 older people including service users with dementia. There are 37 single rooms en-suite, 3 single rooms without en-suite facilities and 6 double rooms with en-suite facilities. The home is situated within walking distance of the centre of the city of Norwich and its facilities. The detached property is set in its own grounds; the garden areas have flowerbeds and a terraced patio. There is parking space to the front of the premises. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection compromised an unannounced visit to the home that took place over 9.5 hours on 9th January 2007, and is the second key inspection at the service within the last five months. The inspection included a full pharmacy inspection undertaken by a specialist pharmacy inspector. The reason for this inspection was to assess the home’s medicine management practices following a recent referral to the Norfolk Adult Protection team and to investigate alleged poor management of medicines, which put the health and welfare of a resident at risk. Opportunity was taken to tour the premises, look at care records and policies, and communicate with the home’s service users, visiting relatives, staff and manager. The inspection report reflects regulatory activity since the last inspection and evidence from inspection of Key Standards. Comment cards from service users, relatives and others were not sought prior to this inspection visit. However, comment cards received prior to the home’s last inspection in August 2006 gave broadly favourable comments about the service provided by the home, though expressed some concern about staffing levels. Hillcrest is one of several homes in Norfolk owned by the proprietors. The range of weekly fees for the home is from £338 upwards. What the service does well: What has improved since the last inspection? • There are improvements to service user’s care plans and the availability of service user’s ‘life history’ information to inform a more personalised approach to the care of individuals. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 6 • • • Although some environmental improvements are noted, further improvements are required to provide a comfortable and safe standard of accommodation for service users. Service users or their representatives are provided with terms and conditions in respect of accommodation to be provided. Staff training and awareness of adult protection has improved, and the home has made appropriate referrals following agreed local protocols. What they could do better: • There are serious shortfalls in the home’s ability to safely manage medication practices, which places the health and welfare of service users at risk. The full detail of this is available in the (separate) pharmacy inspection report, along with a number of relevant requirements and recommendations. The standard of meals at the home is variable and sometimes poor, with a lack of care in preparation and limited choice to add dietary interest for service users. There are concerns about the home’s record keeping as it has not been able to provide individual service user records, nor account for why they are missing from the home. Improvements to the home’s environment and fixtures and fittings are required, including carpeting, redecoration of some areas, replacement furniture and an attention to the strong and unpleasant odour on the first floor corridor in the dementia care side of the home. There are still insufficient numbers of dementia and NVQ trained staff despite requirements made at the last inspection and reassurance that this would be addressed. Training in medication handling and administration is evidently not sufficient. There are insufficient numbers of staff on duty to meet service user need. A programme of formal supervision for all staff at the home must be established. There are four repeated requirements in this report, which is evidence of non-compliance requirements made at the last inspection. There are management failures at the home, some of which may be indicative of a wider organisational culture, and therefore not able to be addressed by the manager alone. • • • • • • • • 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 DS0000065216.V327230.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 6 Quality in this outcome area is good. New service users are admitted on the basis of a full assessment, and are issued with a statement of terms and conditions of residence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The most recent inspection report and ‘Statement of Purpose’ was available in the reception area of the home alongside other information about the home and its services. Sample contracts are in place for newly accommodated service users. Those seen included information required in the Standard, including costs for care and additional services. There was evidence that relatives of service users had signed contracts. A review of sample service user files provided evidence of good pre-admission assessments and post admission assessment carried out by the manager. They included relevant health and medical histories, dependency assessments, dementia assessments, and personal care needs. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. There are improvements to service users care plans and the availability of life histories to inform care. However, there are serious shortfalls in the homes ability to safely manage medication practices, which places the health and welfare of service users at risk (see separate pharmacy inspection report). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sample service user files were reviewed. Records for service user’s included comprehensive pre-admission assessment and assessment by the placing authority One such service user’s records indicates that they ‘had a few falls recently because of low blood pressure which the GP does not feel can be stabilised any more’. Their notes also indicated a sensitivity to Aspirin. This information had been translated into the care plan, which had been reviewed with input from a relative. The care plan also included relevant risk assessments, in particular a falls risk assessment. However, this felt short of identifying the particular risk associated with the service users low blood Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 11 pressure, despite the identification of a risk of falling on standing upright (see Requirement 1). The pharmacy inspection highlighted the need to develop care plan guidance that gives clear instructions on the use of PRN psychoactive medicines prescribed for the management of psychological agitation, it also notes that information concerning a sensitivity to Aspirin had not been included in medication profile information available. (see pharmacy inspection report). Other files reviewed were satisfactory. There was evidence of the carrying out of life story work for service users. The home’s activities coordinator has undertaken the majority of this information. It is recommended that this information be included in the service users care plan file in order that it is accessible for all care staff (see recommendations). The manager described that she is undertaking training with care staff concerning the gathering of further life history information. This will include talking to the service user and their relatives, reminiscence activity, exploring interests, hobbies and occupations, and is part of the overall package of dementia care training to be delivered. The management of the home do need to take urgent action to ensure that the care planning standard is met as the inspection history of the home indicates that this standard has never been met since the National Minimum Care Standards were introduced. A pressure pad was seen on the floor in the doorway of a service users bedroom. The service user likes their bedroom door open but suffers disturbance from other service users at times. The pressure pad provides staff with warning when the service user may have been disturbed. Staff were observed responding to this at the time of the inspection. On the first floor of the dementia care side of the home several service users in their own bedrooms and in communal areas were observed without shoes, slippers or socks on their feet (see requirement 2) A specialist pharmacy inspector undertook a full pharmacy inspection at the same time as the general inspection of the home. The reason for this inspection was to assess the home’s medicine management practices following a recent referral to the Norfolk Adult Protection team. This was to investigate alleged poor management of medicines placing the health and welfare of a resident at risk. The outcome for residents in relation to the medication Standard is poor because the home’s medicine management practices are placing the health and welfare of residents at risk. This judgement has been made on evidence available during this inspection and the preliminary outcome of the home’s investigation into alleged medicine practices shared by the home during the recent Adult Protection meeting. (see pharmacy inspection report). Service users spoken to indicated that they find care staff helpful. Service users spoken to during the inspection indicated that their right to privacy is respected at the home, and that visitors are made welcome and can be seen in private. Service users were reasonably and appropriately dressed except for several without footwear. There is telephone access, including access to a cordless Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 12 phone on both sides of the home in order that service users may make or receive calls in private. Hillcrest Care Home DS0000065216.V327230.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. The overall quality outcome for these standards is adequate. There are social and recreational options available that satisfy the known needs of service users. Contact with friends and relatives are supported by the home. The standard of meals at the home is variable and sometimes poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a new activities coordinator at the home and a published weekly programme of activities. Service users recently enjoyed celebrating ‘a VE Day’ event. There were photographs and themed artwork in evidence. PAT dogs visit the home every Thursday. There were no group activities observed at the time of the inspection visit, however, service users spoken to said that there were things to do. Discussion with service users provided evidence that the home supports their contact with relatives and friends, enables service users to manage their own affairs if desired, and to bring and keep their own possessions with them. Fluids were available to service users throughout the home. The manager stated that finger foods are usually available to service users, though they were not at the time of the inspection visit. Service users are offered tea and Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 14 coffee at various times of the day. The morning tea trolley on the dementia care side of the home did not include a biscuit or other snack for service users. In the afternoon a biscuit tin was available on the tea trolley, the tin was full though only offered the choice of one variety of plain biscuit. A complaint received prior to the inspection referred among other matters to the poor nutritional quality of the ‘cheap’ food at the home. The main meal options at the time of the inspection visit were shepherds pie with mixed potatoes and green beans, or cheese and potato pie with the same vegetable choice. The shepherd’s pie seen did not look appealing. It did not contain a proper gravy and was extremely watery. The cheese and potato pie option was a tray of mashed potato with a little grated cheese on top. Anecdotal feedback from service users and staff suggested that food is usually of a better quality. The manager stated that the usual chef was not at work on the day of the inspection (see requirement 3). The teatime option was assorted sandwiches, tomato soup and a selection of cakes. Hillcrest Care Home DS0000065216.V327230.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. There are arrangements in place to deal with complaints that service users and relatives are aware of. Service users are not fully protected by the home’s health and medical care practices. The home has not been able to provide individual service user records, nor account why they are missing from the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was confirmed in discussion with service users that if they had a concern or complaint they would speak with the manager or with the administrator. A summary of the complaints procedure is available in the reception area alongside other information about the service offered at the home, including the ‘Statement of Purpose’. The Commission received a complaint by a relative concerning the care of a service user in dementia side of the home. This was concerned with general poor care and dementia care, failure in health and safety and staffing. It was passed to the provider to investigate who concluded that the complaint was largely substantiated. The complaint (and another complaint) was dealt with within the required timescale and outcome records kept at the home. There have been four referrals made through the local adult protection protocol. Three referrals were correctly made by the home, though ‘no further action’ required by the lead agencies for adult protection (Social Services and Norfolk Constabulary). The fourth referral was made by the N&N hospital over Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 16 the care for a service user admitted to hospital from the care home with heart attack symptoms, and is the subject of ongoing adult protection enquiry. The enquiry has called for the proprietor to undertake a full investigation into the alleged failure to provide proper care, and to investigate why records relevant to aspects of the service user’s care are not available at the home. At the time of the inspection visit these records had still not been located, nor were they located at the conclusion of an investigation into their whereabouts undertaken by the proprietor shortly after the inspection visit (see Requirement 4). There was evidence through discussion with staff, training taking place at the time of the inspection visit, and training records of training for staff in adult protection, and in particular recognising types of abuse. Appropriate adult protection and ‘whistleblowing’ policies are in place. Relevant staff demonstrate and awareness of the content of these policies and know what immediate action to take if necessary. Hillcrest Care Home DS0000065216.V327230.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is poor. Although some improvements are noted, further improvements are required to provide a comfortable and safe standard of accommodation for service users. Offensive odours are noticeable in parts of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and presented externally and has accessible patio areas at the front. Replacement windows for those that had become misted have been installed. Two further windows in similar condition have been identified for replacement. Blinds have been fitted to the conservatory dining area on the dementia side of the home, and the area was comfortably warm on a cold day. The manager advised that window restrictors would be fitted to the conservatory in order that the area can be ventilated in the summer months. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 18 Lockable storage facilities for service users are now in evidence throughout the home. The standard of furniture in parts of the home is poor, furniture on the first floor of the dementia side of the home particularly so. Chairs in the activities area where some service users also take lunch were torn with foam coming through. Decoration in a number of bedrooms is poor. The manager indicated that quotes have been obtained for redecoration. The first floor hall carpet on the dementia side of the home is very worn and dirty in appearance, particularly in the area leading to the main service users lounge (see Requirement 5). The main bathroom on the first floor on the dementia side of the home has a new bath fitted, however, the bath chair does not work and the bath therefore not in use (see Requirement 6). The manager explained that service users have used other bathing facilities on the other side of the home. It is recommended that a complete review of bathing facilities and there appropriateness and accessibility to service users be carried out. The first floor had a very high and unpleasant odour at the time of the inspection visit. Again, this was particularly evident in the area near the lounge, where many service users are served their lunch (see Requirement 7). The general standard of the premises has been the subject of requirements since November 2005 and now needs urgent attention. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. There is still insufficient numbers of dementia and NVQ trained staff despite requirements made at the last inspection and reassurance that this would be addressed. There are insufficient numbers of staff on duty to meet service user need. Staff recruitment practices protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 49 service users accommodated at the home at the time of the inspection visit, 31 of whom were living on the dementia side of the home, 18 on the residential side. There is a total care staff compliment of 26 staff and the manager. From information provided by staff rotas and the manager there are usually 8 staff on duty during the morning shift and 6 staff during the afternoon. This was evident at the time of the inspection visit. Usual staff deployment on the residential side of the home is 3 staff in the morning and 2 in the afternoon. In the dementia care side it is 5 staff in the morning with 2 staff upstairs, 2 staff downstairs and a senior carer, with 4 staff on duty in the afternoon across the two floors. There is an allocation of 4 night staff. The Commission would expect one member of staff to every five residents throughout the waking day for people who have some type of dementia illness as they are reliant on staff to generate meaningful activity. The current provision at Hillcrest is slightly Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 20 less in the morning if one includes the senior carer, who argulably should be managing the shift and only one to eight in the afternoons. Shortfalls in care indicated in this report and in the report from the pharmacy inspection indicate that this is not a sufficient staff allocation to safely meet the needs of the service users living at the home (see Requirement 8). Out of the care staff complement of 26, 2 care staff have achieved training at NVQ level 2 or above. The manager stated that a further 20 care staff are registered to undertake this training (see requirement 9). Sample staff files provided evidence that service users are protected by safe recruitment practices for new staff. Information provided by the manager and training records provide evidence that there are currently four care staff with dementia care training. The manager is awaiting training materials in order to deliver suitable training to all staff from 5th February (see repeated Requirement 10). There are seven staff who have had training in first aid. Training for further staff has been booked for the first week in February according to the manager. There is evidence of other appropriate training for care staff. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38. Quality in this outcome area is poor. There are management shortcomings that compromise the health safety and welfare of service users. However, the manager is well thought of by both service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been in post for seven months and is a Registered Nurse. She has extensive experience of working in a senior professional capacity within hospital settings. She also has experience as a trainer. She has enrolled to undertake the Registered Managers Award programme, and has begun the process of application for registration with the Commission. Both service users and staff spoken favourably about the manager and said that she is approachable. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 22 There are continuing deficits in the care provided to service users with dementia at the home. At the last inspection of the home in August 2006, a requirement was made that the manager and proprietor should allocate a person in charge of dementia care at the home who has an enhanced level of knowledge and training of dementia in order that they may properly train and supervise other staff. This had not been implemented at the time of this inspection visit (see repeated requirement 11). However, the manager has explored relevant training via the Alzheimer’s Society, and one of the Team Leaders has completed a relevant dementia care-mapping course. The undertaking of questionnaires that are provided to both service users and their relatives supports the views of service users. There is evidence of staff meetings being undertaken, of internal monthly audits, and external monthly audits undertaken by the proprietor, these include reports provided to the Commission and required by Regulation. Due to the poor outcomes for service users indicated in this report, the proprietor will be required to provide an improvement plan setting out the methods by which, and a timetable to which, the registered persons intend to improve the services provided in the care home (see requirement 12). Service users financial interests are safeguarded by the home; their relatives manage the vast majority of service users financial affairs. It was apparent from care staff and from personnel records that formal staff supervision is still taking place only sporadically. Given the findings of the pharmacy inspection supervision should also cover monitoring of competence of staff authorised to handle and administer medicines. Discussion with the manager confirmed that there is not yet a coordinated approach to providing supervision at the home (see repeated Requirement 13). The health, safety and welfare of service users are compromised though failures to safeguard healthcare for service users, missing care records, environmental shortfalls and staff training shortfalls, which are the subjects of requirements in the pharmacy report and in this report. Hillcrest Care Home DS0000065216.V327230.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 1 1 Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that care plans set out the action to be taken to address identified risk. The registered person must make suitable arrangements to ensure that the home is conducted in a manner which respects the dignity of service users. The registered person must provide suitable, wholesome and nutritious food which is varied and properly prepared. The registered person must maintain in respect of each service user a record which includes the information documents and other records specified in Schedule 3 relating to the service user. The registered person must ensure that premises are kept in a good state of repair and reasonably decorated. This Requirement Is Repeated The registered person must ensure that equipment provided DS0000065216.V327230.R01.S.doc Timescale for action 26/01/07 2. OP8 12(4)(a) 26/01/07 3 OP15 16(2)(i) 26/01/07 4 OP18 17(1)(a) 17(1)(b) &17(3)(b) & Schedule 3 23(2)(b) & 23(2)(d) 26/01/07 5. OP19 02/02/07 6 OP19 23(2)(c) 19/01/07 Hillcrest Care Home Version 5.2 Page 25 7 8. OP26 OP27 16(2)(k) 18(1)(a) 9. OP28 18(1)(a) 10. OP30 18(1)(c)( 1) 11. OP31 18(1)(a) 12 OP33 24A(1) 13. OP36 18(2) for service users at the care home is maintained in good working order. The registered person must keep the care home free from offensive odours. The registered person must ensure that there are suitably qualified, competent and experienced persons working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person must ensure continued progress toward meeting a minimum ratio of 50 NVQ 2 (or above) trained staff. The registered person must ensure that all staff receive training appropriate to the work they are to perform. This Requirement Is Repeated The registered person must ensure that there are suitably qualified and competent and experienced persons responsible for dementia care delivery and supervision working at the care home. This Requirement Is Repeated The registered person must produce an improvement plan setting out the methods by which, and the timetable to which, the registered persons intend to improve the services provided in the care home. The registered person must ensure that care staff at the home are appropriately supervised. This Requirement Is Repeated 02/02/07 02/02/07 30/04/07 31/03/07 31/03/07 16/02/07 26/01/07 Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 26 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 OP7 OP19 Good Practice Recommendations It is recommended that life story information be included in the service users care plan file in order that it is accessible for all care staff. It is recommended that a complete review of bathing facilities and there appropriateness and accessibility to service users be carried out. Hillcrest Care Home DS0000065216.V327230.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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