Inspection on 02/10/07 for Hillcrest House Limited

This inspection was carried out on 2nd October 2007.

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

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

Other inspections for this house

Hillcrest House Limited 30/10/06

Hillcrest House Limited 28/11/05

Hillcrest House Limited 07/06/05

Hillcrest House Limited 01/12/04

Hillcrest House Limited 15/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Hillcrest House Limited Hillcrest House Barbican Road East Looe Cornwall PL13 1NN Lead Inspector Elaine Bruce and Mandy Norton Unannounced Inspection 2nd October 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 House Limited DS0000046312.V347750.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 House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest House Limited Address Hillcrest House Barbican Road East Looe Cornwall PL13 1NN 01503 263489 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) sharon@hillcrestlooe.co.uk www.hillcrestlooe.co.uk Hillcrest House Limited Ms Sharon Jane Keast Stephen Phillip Jones Care Home 88 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (38), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (38), Old age, not falling within any other category (57), Physical disability (57), Physical disability over 65 years of age (57) Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th October 2006 Brief Description of the Service: Hillcrest House offers care and accommodation to service users in need of care by reason of old age. The home has two units, the General Unit that provides nursing care for up to 57 people and Trevena which provides care for up to 31 older people who have mental health problems or dementia. The home is situated on the outskirts of Looe and has scenic views over the surrounding countryside and sea. There is a small group of shops nearby. The home is a modern building, purpose built prior to the implementation of the Care Standards Act to provide care and accommodation. There is a large car park to the front of the home. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection at Hillcrest House took place on the 2nd October 2007 between the hours of 0930 and 1630 with two inspectors. Prior to the inspection a completed Annual Quality Assurance Document was received as were seven staff surveys and six people surveys. The inspectors had the opportunity to meet and talk to a number of people in the home, the staff on duty, the registered managers and the owner. The premises were inspected, as were the standard of the meals at the home, the medication arrangements and all the care files/records related to a number of people being case tracked. Random staff files were also inspected as were a number of important policies and procedures. All the people spoken to during the course of the day expressed positive comments on the standard of the care that they are receiving at the home. One person said: “ I like all the staff, I go out on trips, I go to bed when I want and I like living at the home”. The survey reports from the people in the home also indicated a satisfaction with the standard of the care that they are receiving for example: “my wife is well cared for”. The home is able to offer respite care stays as well as long stay care and placements take place in one of two areas of the home depending on the assessed needs of the person being admitted. The two separate areas of the home are staffed by a nurse in charge at all times. A secure area is provided in the Trevena unit for the safety and well being of the people in that area of the home. The weekly cost of care ranges from £300 to £602. What the service does well: A number of staff at the home are long standing employees and there are currently no staff vacancies at the home at this time. Staff on duty on the day of the inspection presented as very professional and capable. They were motivated, enthusiastic and smart in their uniforms. The home has worked hard since the last inspection to establish from the people in the home and their representatives what they could be doing better. Following the questionnaire feedback attention has been given to Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 6 improvements where they have been indicated, especially in relation to meeting social care needs. Positive comments were made on the recent dog show that recently took place at the home. What has improved since the last inspection? What they could do better: The care plans in the home are comprehensive and detailed in information. It is though essential that reviews of the care plans are evidenced as taking place monthly to ensure that care needs are being met at all times. The home is registered to provide care to people with a dementia and or mental disorder. Trevena unit could be improved to meet the more specialist needs of the people in this area of the home. For example more visual information/aides could be provided to guide people to their bedrooms and toilets when required. Hard floor surfaces in a number of the bedrooms present as stark and clinical and some of the bedrooms furniture requires updating in this area of the home. Fire drill training is overdue for all staff at the home and this must be undertaken as a priority to ensure the well being and the safety of the people in the home at all times. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 7 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 House Limited DS0000046312.V347750.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 House Limited DS0000046312.V347750.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough and comprehensive procedures prior to admission ensure that the people and their relatives/representatives can be confident that their needs will be met. EVIDENCE: The service user guide is available to visitors to read in the reception area of the home. The document is regularly updated to ensure that prospective admissions (and their representatives) to the home have the correct information on the services provided. Each person and their representative has been provided with a copy of this document. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 10 New admissions to the home take place following a full assessment undertaken by one of the registered managers of the home. The assessment is undertaken in hospital, the persons home or on a visit to the home. This information forms the basis of the persons’ individual plan of care. Evidence was also available in files of assessment information gathered from health care/social care professionals. Assessments of care needs can sometimes take place by the manager and an assistant member of staff if care needs are more complicated. The assessment process is thorough to ensure that the home will be able to meet the needs of the person coming to the home. A number of people come to the home from hospital and therefore the responsibility of choosing and viewing the home rests with the family/representative of that person. The home is able to offer a respite care facility if required. One completed survey from a relative of a person in the home said: “the home offers an excellent pre admission service and information. A guided tour is provided with no area left out, all questions are answered and explained”. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people in the home can be confident that they will be treated with respect and that their personal and health care needs will be met. EVIDENCE: A qualified nurse draws up the plan of care for each person in the home. Two nurses have the main responsibility for care planning in the two separate areas of the home. The care plans incorporate the health, personal and social care needs of the people in the home. The care plans evidence the involvement of the person in the assessment process with a signature in place. If the person is not able to do this a representative is asked to be involved. In the general area of the home care plans were evidenced as having been reviewed monthly but in the dementia unit two care plans were noted to be out of date for Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 12 reviews. This should be addressed to ensure that care needs are being met at all times. Daily records support the care plans. Comprehensive information is included in the care plans to include for example dietary requirements, weight monitoring and nutritional assessments, pressure sore prevention, continence assessments, moving and handling assessments and falls risk assessments. The home has good working relationships with the local Primary Health Care team members. All the people in the home are registered with one of the general practitioners at the local surgery. This does mean for some people they may have to change their general practitioner, but there are three general practitioners who visit the home weekly. A case tracking audit took place for four people in regard to the medication administration at the home. The medication administration records for the four people were found to be completed correctly. Each floor of the home has it’s own medication trolley and the medicines are dispensed from blister packs with bottles and items prescribed in between deliveries being kept separately in the trolleys’. The medication fridge is kept in the kitchenette on the floor. Consideration should be given to moving the fridge to a more convenient position off the floor. The manager advised that they were waiting for a thermometer to be able to read and record the temperature of the fridge every 24 hours. Controlled medication was found to be appropriately stored and recorded. The homely remedy list is up to date and kept in the medication file. The autoclave that is situated in the general area of the home should be removed as it is not required. The staff were observed to treat the people in the home with respect. Observations of people in the home suggests that they are comfortable and well cared for. One staff survey said: “the residents are treated well and given good care”. Hillcrest House Limited DS0000046312.V347750.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines in the home are relaxed, relatives and friends can be confident that they are welcomed and social activities are arranged. The dietary needs of the people in the home are well catered for with a balanced and varied selection of food that meets the peoples’ tastes and choices. EVIDENCE: Considerable progress has been made since the inspection report of the 30th October 2006 in meeting the social care needs of the people in the home. Some staff changes have been made and a new post created to ensure that two staff members have time to access social events/activities and can spend time with people in developing their interests and meeting their individual needs. In the month of September 07 two trips out from the home have taken place. One to Hannafore and one to the Tamar View nursery. Photographs are taken Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 14 of the trips out from the home and displayed nicely in a photograph album for all to see. Communion took place in September (and does every month) and the St Germans singers also visited the home. Music takes place monthly. A clothes show is booked for the month of October. The home has recently carried out an audit of opinion on the activities that people would like to join in with or observe. Where the people living in the home have not been able to complete the questionnaire this has been completed by their relative/representative. The home has considered this information and addressed the points raised to improve the daily life at the home. A basic preference form is in each file and a list of “likes and dislikes” to ensure that people have choices about how they are spending their days at the home. A “committee” has been formed to include two people living at the home. Meetings with the committee take place monthly. A monthly letter is sent out to everyone and this gives information to people on the planned events for the month. The newsletter is also available in the reception area of the home. Visiting to the home is encouraged and welcomed. The people in the home maintain contact with family/friends as they so wish. All visits are recorded and all visitors to the home are greeted by the reception staff member and asked to sign into the home in the visitors’ book. There are a number of communal areas in the home where visitors can be received as well as private accommodation areas. The staff ask the people in the home what they would like to eat prior to the meal on the same day. There is always a choice of meal. The menus are on a six weekly rolling programme. The catering manager has budget responsibilities and orders all the food for the home. Quality products are purchased and a good supply of dry stock is held. Local services are used for meat. The catering manager explained that special diets are catered for and supplements are available as required. Pureed/liquidised food was seen being served at lunch time from a heated trolley, each item had been pureed separately so the meals retained the colours of the original food. Records are in place as required to include temperature charts, and the district council requirements for “safer food, better business”. An inspection of the kitchen took place in January 2007. The catering manager has line management responsibilities for a number of staff. These staff members receive regular staff supervision and appraisals. One person spoken to said “I like living at the home the food is good, I like egg and cheese salad, and the chef does this really well”. Hillcrest House Limited DS0000046312.V347750.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people in the home can be confident that any concerns or complaints that they may have will be treated seriously and that they will be protected from abuse. EVIDENCE: The home has in place a clear complaints policy and procedure in place. All policies and procedures are kept in accessible files in the two separate areas of the home. The two surveys received clearly indicate that the people in the home (and their representatives) know how and whom to complain to if required. There are clear policies and procedures in the home regarding whistle blowing and adult protection. Staff files evidence that staff have received internal adult protection training and six members of staff have attended external training (Cornwall County Council) to enable them to cascade adult protection procedures information to the rest of the staff. The staff survey forms indicate that the staff know what to do if any one in the home has concerns about the home which may include adult protection issues. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Hillcrest House live in a pleasant, well maintained home that is comfortable, warm and clean. EVIDENCE: Hillcrest House is situated on the outskirts of Looe. The home is purpose built prior to the Care Standards Act. Good car parking is available at the home. Many rooms have very pleasant views over the valley and of the river. The home is divided into two separate areas, one for the people who have general nursing needs and one for the people who have a dementia/mental health needs. This area of the home is referred to as the Trevena unit. Each Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 17 area of the home has communal space to include dining room tables and chairs and comfortable lounge chairs. Each area has bedrooms either on the ground or first floor which can be accessed by a shaft lift. Access is available from each area of the home into the gardens which are pleasant and have been provided with seating in a patio area. A safe external area is provided for people from the Trevena unit. Improvements in visual aides could be made in the Trevena unit for the people to be able to recognise their bedrooms and the toilet areas. Improvements could also be made to the flooring in a number of bedrooms which present as stark and cold with hard flooring. Consideration should also be given to removing baths that are not being used and improving the facility with a walk in shower arrangement. Trevena is a locked unit where access is gained by a numbered key pad. Some of the bedroom furniture in the Trevena unit is shabby and would benefit from replacement. It is noted that suitable equipment is in place to meet needs for example beds and mattresses’. Three maintenance staff members are employed by the home and on the day of the inspection work was taking place in the grounds of the home. There are two cats who live in the home and cat flaps have been fitted for them on doors to the building. There is a rota for feeding the cats and the litter trays are cleaned out as necessary. It was noted on the day of the inspection the home was very clean. A staff member is employed daily for cleaning duties and a total of seven full time domestic staff are employed with a domestic supervisor in charge. Alcohol solution is provided at the entrance to all areas of the home to reduce the risk of infection. The whole home is vaccummed each day and other jobs are allocated as required such as carpet cleaning and deep cleaning rooms. The domestic supervisor has responsibility for ensuring that the cleaning at the home is of a good standard. A part time staff member is employed for laundry duties at the home. The laundry has two washing machines and driers in place, all laundry is undertaken at the home. When washed the laundry is delivered to the rooms by the carers who sometimes have to put a load of washing on in the evening. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Hillcrest House are cared for by motivated, knowledgeable, capable and caring staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment procedures protect vulnerable people. EVIDENCE: Each shift of care delivery is managed by a qualified nurse and there is always a qualified nurse on duty in each unit area of the home. A number of staff at the home are long standing employees and the home has no vacancies for any new staff members at this time. During the course of the inspection the staff were observed to be interacting well with the people in the home, they presented as professional during their interactions with the inspectors and looked smart in their uniforms with their name badges. A number of ancillary staff are employed for example laundry, housekeeping, administration, maintenance, catering. The home operates a thorough recruitment procedure which includes completed application forms, two written references and a criminal bureau check. Random staff files were inspected (in relation to staff on duty), these Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 19 were found to be completed well with the exception of one where there was only one reference in place, this staff member had though previously worked at the home. All staff are issued with a contract of employment detailing the terms and conditions of their employment. Staff are encouraged and supported to undertake NVQ training. Statutory training to include moving and handling training and first aid was found to be up to date. Two staff are trained to deliver moving and handling training but one staff member generally takes these responsibilities. It is recommended that the length of the certificates for validity is established. Fire drill training is due for all staff and it is appropriate for this to take place as a priority. A different staff member has been given responsibility for evidencing and organising all the training that is taking place in the home. She has worked hard to organise her systems and collate all the information together for a large number of staff. Four members of staff have undertaken dementia care training with plans for more to attend this course. The nursing staff undertake regular training to ensure that their skills are kept up to date, for example wound care and catheter care. Four student nurses from Plymouth are regularly placed at the home as part of their training course, although there were no student nurses at this time. The McMillan nurses provide training to the home as required. The inspectors observed that the staff team presented as motivated and enthusiastic in their work. New staff members employed at the home receive an induction that complies with the Skills for Care Council. The management team expressed some concerns as the Home Office are now not reviewing Phillipino work contracts which may have an impact on staffing in the future. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Hillcrest House live in a well managed home. The management and staff team strive to provide a stimulating, safe environment where people are respected and rights are upheld. EVIDENCE: The registered manager has been at the home since 1987, she is a registered nurse and has obtained the registered managers award qualification. She is supported in her duties by another registered manager who is a registered mental health nurse and has a level 4 qualification in management. He has Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 21 responsibilities for the standard of care in the Trevena unit of the home. There are plans for another senior staff member to also become a registered manager. The management team present with clear strong leadership where duties and responsibilities are clearly identified and delegated to appropriate staff members as required. A staff survey form stated that “management can always be spoken to with any concerns that you may have”. The owner of the home spoke with the inspectors during the course of the day. He is very involved in the running of the home. A yearly annual quality assurance takes place where surveys are sent out and results are then collated and converted to percentages of responses. Any actions taken are recorded on the back of the form and these are kept for future reference. The home has worked hard recently to obtain the views/opinions of people/representatives/visitors to establish what if anything they could be doing better. The manager and the accounts manager explained that they try not to be involved with the peoples’ finances. Bills are sent out (newspapers and hairdressing for example) to the relatives or the representatives looking after a persons finances. Receipts are in place of financial transactions. Secure facilities are available in the home for the safe storage of money and person items of value. Policies and procedures are in place for cleaning spillages and infection control. Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 22 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 x 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 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 x x 3 Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP19 Good Practice Recommendations To ensure that at all times the reviews of care plans are up to date. To consider the position of the medication fridge and removing the autoclave To improve the environment in the Trevena unit to include providing visual clues to areas, replacing some shabby furniture and removing hard flooring surfaces in bedrooms. All staff members should received fire drill training as a priority. 4. OP30 Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillcrest House Limited DS0000046312.V347750.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!