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Inspection on 24/08/05 for Hillcroft (Morecambe) Nursing Home

Also see our care home review for Hillcroft (Morecambe) Nursing Home for more information

This inspection was carried out on 24th August 2005.

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

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

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

What the care home does well

Both the General Manager and the Home`s manager are committed to making sure that the needs of the residents are met and the standard of care and the home is kept at a high level. There is an ongoing commitment to provide training to everyone who works at the home, with the home employing a named person called the Clinical Supervisor to make sure all staff get a range of training to do their work better. A number of staff have achieved National Vocational Qualification Levels II and III and staff are continuing to do these qualifications which are recommended by the Commission for Social Care Inspection. There is an ongoing redecoration and refurbishment programme which means that the home is clean and tidy and provides an excellent environment for people to live in. The home has used the interest a number of relatives have in the care that is provided by the home by starting a support group which meets on a monthly basis. As mentioned in this report, this group not only provides support to others who may be finding it difficult to accept their relatives have dementia or are now needing the care provided by the home, but also provides advice and information. The company pays for a place for the group to meet, along with food and drink. From talking with the nurses in charge and the staff on duty they know the residents at the home very well with care being provided on a very individual and caring basis.

What has improved since the last inspection?

What the care home could do better:

Overall, the care provided at the home was confirmed by both residents and relatives as being very good indeed. From this inspection it is recommended that the range of social and other activities in the home need to be developed further to ensure the residents who have dementia have meaningful and stimulating activities to do.

CARE HOMES FOR OLDER PEOPLE Hillcroft (Morecambe) Nursing Home Woodlands Morecambe Lancashire LA3 1LZ Lead Inspector Joy Howson-Booth Announced 24 August 2005 10:00am th 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 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. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hillcroft (Morecambe) Nursing Home Address Woodlands Morecambe Lancashire LA3 1LZ 01524 858599 01524 858699 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hillcroft (Morecambe) Limited CRH Care Home 54 Category(ies) of DE Dementia 24 OP Old Age 30 registration, with number of places Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service shall at all times should employ a suitably qualified and experienced manager who is registered with the CSCI 2. To accommodate 2 named people under 65 years of age within a maximum of 54 people Date of last inspection 22nd February 2005 Brief Description of the Service: Hillcroft Nursing Home (Morecambe) Limited is registered to provide residential and nursing care to up to 54 people of either sex. This home is one of a group of three homes, all operated by the Hillcroft Company, which has a Board of Directors who are reported to by the General Manager. The General Manager oversees the three nursing homes, each having their own named Registered Manager, registered with the Commission for Social Care Inspection. Hillcroft (Morecambe) is situated in a quiet residential area in the west end of Morecambe and is reasonably close to local shops and amenities. The home is built over two floors, with two separate units – one for those people who require nursing care and the other for those people who require more specialist dementia care. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced so the General Manager, manager of the home, staff, residents and relatives were aware of the visit. The inspection lasted for most of the day and included looking at care pathways, other documents and talking with the manager and staff on duty. A small number of residents were talked with although staff were also observed at work and interacting with the residents. The inspection was carried out against the National Minimum Standards for Older People. Because of the needs and capacity of the residents at the home, only a small number were able to express an opinion over the care provided. The direct observations of staff provided a good opportunity and showed that residents were treated with dignity and respect and the relationships with staff were very positive. Residents spoken with said they felt well looked after. Unfortunately, no relatives or healthcare professionals returned any comment cards and only one relative/friend was visiting the home during the inspetion but they declined to speak to the inspector. Comment cards obtained by the home indicated that relatives were satisfied with the care provided and these included – “carry on with the excellent way you and your staff look after my relative and all the residents. My relative is now more lucid obviously very content. Everything from tidiness, cleanliness of the home to excellent care of my relative”. Another feedback card stated “thanks again for the care and attention J received during her stay”. The home is divided into three units – one for people with dementia, and two others over the two floors in the home and caters mainly for those requiring nursing input. Observations of residents confirmed they looked comfortable and relaxed in their own environment, with a range of comfortable seating. What the service does well: Both the General Manager and the Home’s manager are committed to making sure that the needs of the residents are met and the standard of care and the home is kept at a high level. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 6 There is an ongoing commitment to provide training to everyone who works at the home, with the home employing a named person called the Clinical Supervisor to make sure all staff get a range of training to do their work better. A number of staff have achieved National Vocational Qualification Levels II and III and staff are continuing to do these qualifications which are recommended by the Commission for Social Care Inspection. There is an ongoing redecoration and refurbishment programme which means that the home is clean and tidy and provides an excellent environment for people to live in. The home has used the interest a number of relatives have in the care that is provided by the home by starting a support group which meets on a monthly basis. As mentioned in this report, this group not only provides support to others who may be finding it difficult to accept their relatives have dementia or are now needing the care provided by the home, but also provides advice and information. The company pays for a place for the group to meet, along with food and drink. From talking with the nurses in charge and the staff on duty they know the residents at the home very well with care being provided on a very individual and caring basis. What has improved since the last inspection? The manager has been in place now since February 2004 and feels now that the home is settling down following a number of changes. These have included: Changes to the shift patterns. Previously staff worked a 12 hour shift but these have now been shortened. Staff spoken with all confirmed they preferred these shorter shifts and feel much less tired. In addition to this, staff are now deployed throughout the home so that staff know about other residents in the home. A number of new staff have been recruited and are being trained. The care supervisor for the three homes has provided a lot of input with tried and tested ideas which has meant some changes to working practices but making improvements by reinforcing good care. Training of staff – current training includes a moving and handling update as the home now has a no lifting policy in place. The care pathways (which detail individual resident’s care needs and how the staff at the home are to meet these) continue to develop with initial gremlins Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 7 being ironed out. The home is looking to the local College to enable their care pathways to be officially recognised as a way of writing about care needs. The work of the relatively new Head Chef shows that the meal provision in the home is much better and with the range of meals on offer, the quality and quantity means that residents have much better meals to eat. 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. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 The system for assessment of prospective residents in the home is very comprehensive and provides excellent information to enable a judgement to be made as to whether the home can meet identified needs. EVIDENCE: The company has recently introduced a new assessment and care planning system called “Care Pathways”. This means that following the initial enquiry from either Social Worker, Health professional or relative the manager will undertake a person visit to meet the prospective resident and complete a “care menu”. The care menu is in the format of a comprehensive list of identified needs, including – Leisure/Social, Mobilising, Elimination, Personal Hygiene/Dressing, Eating/Drinking, Skin Care, Physical Health, Communication, Sleep, Mental Health, Personal Safety and Pain Control. Each of these major areas is then Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 10 subdivided into specific needs relating to the main area and covers identified need, desired outcome and nursing intervention. This system not only provides a method of prompting for assessment but means that individual and specific needs can be added in as needed. In addition to this there is evidence of healthcare professional and Social Services assessments. Where a resident has been admitted from the specialist assessment hospital there is the arrangement for the residents place to be kept open for 12 weeks. Support and guidance is available from the specialist consultant and, before a final decision to discharge is taken, a review of the placement is made to ensure the resident has settled and the home is able to meet the identified needs. Two recently admitted resident’s care pathway initial assessments were seen and evidenced the initial assessment menu, dependency score, administration and financial information, nurse admission sheet to be in place. It was also seen that from this initial information a care pathway had been requested and put in place. This home does not provide an intermediate care facility. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 The are comprehensive and clear care planning systems in place which means the needs are of the residents are met in a consistent, professional and caring manner. The staff have a good understanding of the residents needs and provide care in a way that protects the residents privacy and dignity. EVIDENCE: As mentioned previously, a new care pathway system has been introduced into the home and, following the completion of a care menu at the time of assessment, a care pathway will be set up for the new resident. Care pathways have also been introduced for existing residents. The system means that identified needs in the care menu are transferred into a working document or care pathway. Either monthly or as residents needs change, this system enables any changes to be immediately incorporated into a new care pathway document . This was seen for one resident who had developed a skin care need – an updated care Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 12 pathway was requested, put in place and then changed once the skin care problem had been healed. Five care files were examined, with two residents being case tracked and their care looked at in more depth. The documentation on file evidenced that the care pathway system is working well as it is providing a range of comprehensive information about care needs and how these are to be met by the staff at the home. Discussions with staff on duty at the time of the inspection confirmed that they felt this was an very good system and provided them with clear information over care needs and how these are to be met. Discussions over specific care needs confirmed that these are clearly understood and followed, with good communication in place to ensure any changes are notified and addressed. In addition to the main care pathway separate information is maintained for specific nursing interventions – fluid balance, pressure care, weight monitoring, etc. Twelve residents were spoken with from all areas in the home and all confirmed they felt well looked after. Those residents who were able to do so confirmed they see their GP or other healthcare professional when needed and the staff at the home ask the GP to visit as soon as the resident wants. There are records in place for GP visits, dietician, continence adviser, etc. Advice was given that the professional input/visits sheet could include all professionals (continence, dietician amongst others). At present, input from these two professionals is recorded in the daily records which does not easily give an audit trail or a way of monitoring their input. Two comment cards received from General Practitioners’ all confirmed that the home communicates clearly and works in partnership, they are able to see their patients in private, the staff have a clear understanding of the care needs of residents and any specialist advice is incorporated into the residents care plan. One GP comment card raised an issue that there is not always a senior member of staff to confer with. This was brought to the attention of the manager at the time of the inspection. The home has received comments from relatives which are recorded. These include “carry on with the excellent way you and your staff look after my mum and all the residents. Mum is now more lucid, obviously very content. Everything from tidiness, cleanliness of the home to excellent care of my mum”. “Thank you for the tea and sandwiches - Mrs B looked very well when we visited today.” “Thanks again for the care and attention J received during her stay.” Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 13 Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Activities within the home are an area for development so that residents individual lifestyles, preferences, etc., can be met and they can receive social stimulation within the home. There are no restrictions for families and friends visiting the home which means the residents benefit from seeing familiar faces when they want. Arrangements and planning to provide good nutritional food are excellent which means the residents are provided with high quality food to ensure healthy living. EVIDENCE: At present, staff provide Recreational Therapy (RT) during the afternoon but, due to the needs of the residents, this tends to be on 1 to 1 basis. Social activities are currently being reviewed with a number of staff due to attend a specialist course which will enable them to identify suitable activities and develop this as an area. Staff spoken confirmed that they provide some activities in the afternoon and recognised the difficulties in identifying Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 15 appropriate activities due to the needs of the residents. Staff confirmed a training course to look at activities has been organised with an external trainer and were looking forward to developing this within the home. The unit for people with dementia was recently visited by the inspector and another healthcare professional when a “dementia care mapping” exercise took place. This was carried out with the cooperation of both the manager and the staff on the unit. The purpose of the exercise was to provide an audit of the service provided to the residents. A separate report was produced and the home has a copy of this, along with all the relevant information and evidence obtained at the time. During this inspection, discussions with the nurse in charge, staff on the unit and from observations it was clearly shown that the observations and recommendations made at the time of the mapping exercise have been used to improve the service to the residents. For example, residents now have a change of scenary/environment, the unit is much calmer and quieter, staff have specific roles so that no-one misses having a drink. Observations during lunchtime also evidenced that staff now sit down with individual residents, talking to them, telling them what they are eating and giving encouragement. and information. Discussions with staff and relatives confirmed that they are able to visit at any time. The multi-sensory facility has been moved onto the Unit for people with dementia where it was felt it could be used more effectively. Staff spoken with gave examples of how they enable the residents to have choice over their day to day life – for example, when dressing being offered a choice of clothing. One member of staff has made a start to aid communication and choice by developing a personal history book and photographs for some residents. It is intended that these will be kept in the resident’s own room and used as a means of communication and to demonstrate that the individual resident is a person, someone with their own background, history, hopes, wishes and family. It will be interesting to see this develop for the next inspection. As with the other homes in the Hillcroft group, the home has now had the input of the Head Chef who has revised all the menus to provide an excellent standard of food. The menus are organised over a four week rota. On each day there is the provision for a range of breakfasts – from full English breakfast to porridge, prunes, eggs, etc. At lunchtime, there are a range of main courses on offer – with two main courses and specialist diets (soft, vegetarian, diabetic) being catered for. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 16 A sample of the menu is as follows:- chicken and ham pie, lambs liver and onion with cauliflower, leeks and cream sauce, chips provided. The soft diet being minced beef and the vegetarian option an omelette. For the evening meal again there are a range of choices, including – soup option, grilled pork sausages, chicken supreme, fried mushrooms and potato wedges. Ravioli on toast, assorted sandwiches, ham salad; followed by fruit cocktail, malt loaf. In addition, there is fresh fruit, yoghurt or a cheeseboard on offer. All the food is home made. Observations regarding the afternoon tea provision were passed onto the manager who is to discuss with the Head Chef. One resident spoken with about the food said the “food is very good indeed”. The resident said that if they send anything back the Chef will personally visit to see if there was anything wrong or if the resident would prefer something else. The resident said they appreciated this individual input. The chef on duty was spoken with who also confirmed that communication is very good within the home and he feels very much part of the team – On admission, a nutritional form is completed so that he knows about individual likes and dislikes, etc. and he will be informed if there are changes to any residents which means they may need a more specialist diet. This information was seen on the information board in the kitchen. One resident case tracked has a high protein diet. The chef spoken with was aware of the resident and confirmed the specialist diet is provided. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints system in place with evidence that views and concerns are listened to and acted upon. EVIDENCE: There is a formal complaints procedure and this is included in information provided to prospective residents and/or their family members. Because of the needs of most of the residents in the home, it is unlikely they would be able to use this complaint system and are reliant on their relatives and staff to ensure their care. Since the last inspection one complaint has been made about this service which was substantiated. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards within this section were assessed during this inspection EVIDENCE: Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 There is a clear training programme for all staff which provides staff with information, skills and training to meet the range of both care and support needs within the home. EVIDENCE: Discussions took place with the Clinical Supervisor at the Hillcroft (Caton Green) home when the programme for the training of staff was discussed in great depth. The findings below were recorded at this previous inspection but for Hillcroft (Morecambe) are as follows. Over the last couple of years, the company decided to have a dedicated training organiser to identify, organise, access funding and personally provide training to the number of staff who work at the home. This person has the title of Clinical Supervisor. Discussions with the Clinical Supervisor confirmed that there is a comprehensive training programme in place for the staff who work at this home. All new staff receive a three full-day induction provided at the Carnforth home prior to commencing work. This is the TOPSS Induction as recognised by the Commission for Social Care Inspection. All existing staff, both care and ancillary, access a range of courses, both inhouse and from external providers. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 20 Training for care staff includes – mandatory training, update training, TOPSS foundation training, National Vocational Training and specialist courses – challenging behaviour, death and dying, effective communication, pressure care, care of ageing skin, abuse and needs of service users. At present at Hillcroft Morecambe there are 11 people who are doing National Vocational Qualification (NVQ) Level II, 1 person doing NVQ Level III. Update training is also provided for qualified nursing staff at the home and includes – dressing and bandages update, continence care, dementia care, controlled drugs procedure update and supervision training. Training provided for ancillary staff includes –National Certificate in Further Education, food hygiene, healthy eating, National Vocational Qualification in cleaning and support services, infection control and health and safety. There are full training records for all staff which are maintained by the Clinical Supervisor. It was confirmed that there is a working relationship with the local college who will provide a yearly needs analysis for training. Monitoring of both the training and those who access the training is carried out by the Clinical Supervisor who confirmed some staff are counselled if there is no clear progress evidenced. This high level of training commitment provided to staff is excellent and is something that should be continued. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The residents live in a home that is very well managed and provides a safe and comfortable environment for them to live in. EVIDENCE: As with the other homes in the group, the health and safety of the home is managed by the manager with the support of the Housekeeper. The housekeeper has responsibility over the domestic, laundry and handyman and ensures the cleanliness and maintenance of the home. Regular update meetings with the manager take place. The pre-inspection questionnaire confirmed that a new ambulift has been fitted to one bath and shower heads have been lifted to comply with current standards. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 22 The pre-inspection questionnaire also confirmed that regular safety checks are carried out in the home. There are arrangements in place for the safe disposal of clinical waste. Safe working practices and health and safety training is provided to all staff, both care and ancillary and this has been evidenced via training records. The manager has previously confirmed that she is aware of the relevant legislation which must be complied with. Risk assessments are carried out for working practices. Risk assessments are also carried out as part of the care pathways planning – initially at the point of assessment by the manager and from then on by the qualified staff in the home. The accident and incident book was examined during this inspection and it was confirmed that the manager sees all accident and incident forms and will follow up on issues or questions raised. There are also procedures in place for the manager and General Manager to monitor these on a monthly basis. Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 24 Are there any outstanding requirements from the last inspection? 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 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. Refer to Standard OP12 Good Practice Recommendations The area of activities to continue to develop to ensure the residents accommodated are offered appropriate and tailored activities which provide them with stimulation and meaning. Obtaining personal history information for each resident would be most beneficial to the development of activities within the home Continue with the National Vocational Qualification training 2. OP30 Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillcroft (Morecambe) Nursing Home F57 F09 S6142 Hillcroft (Morecambe) V185611 180805 Stage 4.doc Version 1.40 Page 26 - 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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