Inspection on 12/12/05 for Hillcroft Nursing Home

This inspection was carried out on 12th December 2005.

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

Hillcroft Nursing Home 04/12/08

Hillcroft Nursing Home 20/05/08

Hillcroft Nursing Home 18/02/08

Hillcroft Nursing Home 04/09/07

Hillcroft Nursing Home 21/08/06

Hillcroft Nursing Home 06/06/05

Hillcroft Nursing Home 18/01/05

Hillcroft Nursing Home 20/07/04

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Heathlands

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS Lead Inspector Mrs Cathy Moore Unannounced Inspection 12th December 2005 07:30 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 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 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. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillcroft Nursing Home Address 135 High Street Wordsley Stourbridge West Midlands DY8 5QS 01384 271317 01384 271112 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) Mr. Jayantilal James Bhikhabhai Patel Mrs. Kailash Jayantilal Patel Mrs Christine Dalwood Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (28) of places Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users to include up to 28 OP and up to 10 DE(E) One service user accommodated at the home may be PD. This will remain until such time that the current service users placement is terminated. One service user identified in the variation report dated 9 March 2005 may be accommodated at the home in the category of PD. This will remain until such time that the service users placement is terminated. 06/06/05 Date of last inspection Brief Description of the Service: Hillcroft Nursing Home is situated in a residential area of Wordsley close to a main bus route, shops and other local facilities. The home has been converted from a traditional domestic dwelling and extended for its present purpose a care home providing nursing care to a maximum of 28 residents in the category of old age, many of whom have complex needs and require a high level of care. Ten of these 28 places can be allocated at any one time to older people who have a diagnosis of dementia. Hillcroft, as stated, is registered to provide nursing care and therefore has a registered nurse on duty at all times. The home is on two floors. The ground floor housing the lounge, dining area, conservatory, kitchen, laundry rooms, office, a number of bedrooms, toilets and an assisted bathroom. The home has an attractive garden to the rear and car parking space to the side. The home offers ramped access, has a passenger lift, hoisting equipment and other aids and adaptations to enhance, safety, accessibility and independence. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis and was the second of the homes’ two routine inspections for this year. The inspection involved one inspector and was carried out between 07.30 and 15.50 hours. During the course of the inspection, three residents’ files, to include assessment of need and care plan documents were assessed. Three staff files were also assessed to include recruitment documents and training. The premises were part assessed to include the lounge/ dining room and conservatory and two bedrooms. Medication systems were assessed. Mealtimes were briefly observed. The inspection was conducted mostly in the lounge area where staff/ resident interactions and daily routines were observed. Three relatives and five residents’ were spoken to. The manager and one nurse were involved in the inspection. Not all standards were assessed during this inspection for a full overview of the service this report should be read together with the last inspection report dated 6 June 2005. What the service does well: The home is maintained to a good standard both internally and externally. The home’s atmosphere during the inspection was warm, welcoming and friendly. The manager has been in post for a number of years and is keen to improve practices within the home. A number of staff have been in post for a number of years providing consistency of care to the residents’. Positive interaction was observed between staff and residents’, staff speaking to residents’ with respect and giving them choices. As with past inspections positive feedback was given by residents’ and relatives about the home, staff and management. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 6 One relative said; “ The staff are nice. The home is clean and bright with no odour”. A resident commented; ”The staff look after us”. A letter from a relative sent to the home stated;” Mom always spoke very kindly of you all, for your help and yet at the same time letting her maintain her dignity… in fact you were her ‘ family’ too. A wonderful nursing home, run so efficiently with such caring staff”. What has improved since the last inspection? What they could do better: Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 7 The major shortfalls with this home continue to be the lack of monitoring and checking systems to ensure that operations and practices are being carried out/ attended to as they should be. Record keeping requires further improvement to ensure that documentation is maintained and effective. Staff recruitment processes require greater diligence and scrutiny. 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 Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 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 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9. Further development is needed to ensure that residents’ health care needs are fully met. Medication systems require improvements to ensure that they comply with current legislation and are safe. EVIDENCE: There was ample evidence available to demonstrate that a wide range of health care services are accessed for residents’ on an as needed or regular basis. The dentist, optician and chiropodist visit the home regularly. The home has a good working relationship with local doctors who provide a service to the residents’. Specialist input has been secured for a number of residents who require this examples being; the dietician, speech therapist, Occupational Therapist, Tissue viability nurse and psychiatrist. The home has a low to non existence incidence of residents’ acquiring pressure sores in the home which is positive. There was no evidence however, of pressure sore/ wound treatments for the 2 residents’ who had been admitted to the home with wounds. One of these residents’ relatives commented;” The Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 11 home has worked hard to heel the pressure sore”. The resident agreed with this. There was evidence to demonstrate that falls risk, nutrition and tissue viability assessments are being undertaken on admission and regularly thereafter. Although there was evidence that residents’ weights are being monitored there were no readings available after October 2005. The new resident had not been weighed on admission. There was no moving and handling assessments in place for BA or FMG. Documentation pertaining to daily personal care delivery is not being fully completed on a regular basis. There were no records for BA. Records that were seen were completed on one sheet for all residents’. The format requires revision to ensure compliance with data protection and Access to Records. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents’ are helped to exercise choice and control over their lives. EVIDENCE: It is positive that the home has information displayed pertaining to external advocacy services which residents’ or relatives’ can access if they wish. Information relating to other advice services is also on display for example; ‘ Care Aware Helpline’. Residents’ are all able to vote if they wish using postal services or attending the polling station. Bedrooms viewed held a number of residents’ personal belongings. One resident said;” I have brought my own television into the home, it is in my bedroom”. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents’ and their relatives should be assured that their complaints will be listened to and acted upon. Further development is needed to ensure that residents’ are protected from abuse. EVIDENCE: The home has a written complaints procedure which is on display in the main entrance hall. The complaints procedure contains all of the required information. Two relatives asked confirmed that they were aware of the complaints procedure. No complaints have been received by the home for some considerable time. One concern was received by the CSCI in August 2005. The individual withdrew the complaint and nothing further has been heard since. The substance of the concern was discussed with the manager during the inspection to make her aware but the person was not identified. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 14 The management of one resident is questionable and requires further exploration. Records of management and precise care plans must be in place. It is pleasing that the home has a copy of ‘ Safeguard and Protect’, Dudley Council’s Adult Protection procedures. The home has its own internal procedures which have been confirmed as satisfactory by Contracting. There was no evidence available however, to demonstrate that all staff are aware of these policies and procedures. Staff have received abuse awareness training. The home has a Whistle Blowing policy dated 2002. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24. Residents’ live in a safe, well maintained environment. Generally residents’ live in safe comfortable bedrooms with their own possessions around them. EVIDENCE: The homes environment is maintained, furnished, carpeted and decorated to a good standard. This was confirmed by two relatives during the inspection who said; “ The home appealed to us as it is bright and clean. There are no odours. Communal areas are bright, clean, attractive and warm. The home has an on-going refurbishment/ replacement programme. The home has adequate indoor and outdoor space which is monitored on a weekly basis in respect of safety. Two bedrooms were viewed. These were seen to be maintained to a good standard. Furnishings and carpets were also of a good standard. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 16 The home was able to provide a written audit of each bedroom which is positive. However, where it was highlighted that items had not been provided examples being bedside lighting, easy chairs there were no reasons documented. There was no evidence to suggest that residents’ or relatives had been involved in the audit of their bedroom. Not all residents’ who have nursing needs are provided with adjustable height beds. This requires further work, development, justification and where needed expenditure. One resident commented;” I like my bedroom I have got my own television in there”. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30. More staff need to attain N.V.Q to ensure that residents’ are in safe hands at all times. Further development and diligence is needed to ensure that residents’ are protected by the homes’ recruitment procedures. Generally staff are trained and competent to do their jobs. EVIDENCE: The home has not yet reached the required care staff N.V.Q attainment ratio of 50 . A number of staff are however, working towards this qualification. Although processes have improved an example being the organisation of staff files for established staff shortfalls remain in respect of staff recruitment processes. Two staff have been appointed from Eastern European countries. Documents in respect of these staff were lacking for one there was only one source of identity, for the other none. One staff member only had one written reference, there was no health declaration for the other. Criminal record checks had been undertaken in these staff members’ own countries these of course do not include POVA list checks. This situation must be confirmed by the home. It is positive that an overall training matrix was available. It appears that staff are up to date with mandatory training, with the exception of risk assessment and health and safety training which has been organised for January/ February Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 18 2006. Training plans were seen on staff files perused. The home has internal induction processes which new staff go through within their first days of employment. Formal, prescribed induction materials/ courses are secured for new staff. The recent new staff have not yet commenced on this. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,36 Generally, residents’ financial interests are safeguarded. Further developments are needed to ensure that all staff are adequately supervised. EVIDENCE: It is positive that records were available to confirm that personal items brought into the home by residents’ are recorded on a personal inventory and their files. No resident at the present time manages their own finances. A number of residents’ have small amounts of money held in safe keeping by the home. This is held in individual containers and is recorded. Three of these monies were checked against balances and were found to be correct. It was noted that the homes’ chiropodist gives residents’ a receipt for money paid for his service, the hairdresser however, does not. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 20 It is positive to ascertain that the majority of staff are receiving one to one supervision sessions. It appears that night staff super vision sessions are lacking. Not all staff have yet received the required 6 supervision sessions in the last 12 months. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 21 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 4 x x x x 2 x x STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 2 x x Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 22 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 provider and manager must expand the homes care plans to include the full spectrum of needs examples being: Any areas of risk in relation to nutrition. (Timescales of 18.02.05 and 25/06/05 not fully met). The registered provider must ensure that each residents care plan reflect ALL of each residents needs. And includes the following; wound dressing regimes, nutritional care to include special dietary regimes. Management of any risks. Hobbies, recreation and stimulation. Personal goals , wishes and choices, daily routines. (Timescale of 01/07/05 not fully met). Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 23 Timescale for action 05/01/06 2 OP7 15(1) 05/01/06 3 OP8 12(1) The registered provider must be 05/01/06 able to evidence at all times that full care is being provided. (Daily notes, care charts or other methods). These records must be completed with diligence and consistency. Nail care records lacking. No records in place for B.A. (Timescale of 25/06/05 not fully met). The registered provider and manager must ensure that all care records are documented on individual sheets relating to one resident only. The registered provider must ensure that all residents are weighed on admission and monthly thereafter. That these weights are recorded and monitored. ( Timescale of 31/01/05 and 25/06/05 not fully met). There was no documentary evidence to demonstrate that B.A had been weighed on admission or that other residents’ have been weighed after October 2005. 4 OP8 12(4) 05/01/06 5 OP8 12(1)13 (4) 05/01/06 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 24 6 OP8 13(4) 13(5) 7 OP8 17(1)(a) Sched 3 (n) 13(2) 8 OP9 The registered provider and 20/12/05 manager must ensure that a moving and handling assessment is in place for each resident. No moving and handling assessments were available for BA or FMG. The registered provider and 20/12/05 manager must ensure that a wound/ pressure sore plan is in place for each resident who has a wound or pressure sore. The registered provider and 20/12/05 manager must ensure that where medication administration records are handwritten that two qualified staff are involved/ witness the transfer of information from the medication container to the medication record. ( Timescale of 15/06/05 not met). The registered provider and manager must ensure that the home’s medication policy is available at all times. The medication policy must be reviewed on an annual basis after which it must be signed and dated by the trained nurses. The registered provider must ensure that all incoming medication is counted and recorded. The registered provider and manager must ensure that the nurses only give/ administer medications to the residents’. All trained nurses must be officially reminded of their responsibility to ensure that this is adhered to. 9 OP9 13(2) 24/12/05 10 OP9 13(2) 24/12/05 11 OP9 13(2) 20/12/05 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 25 12 OP9 13(2) 13 OP9 13(2) The registered provider and manager must ensure that blood glucose monitoring machines are available for each resident who needs this procedure to be carried out. The same machine must not be used en-masse. The registered provider and manager must ensure that oxygen cylinders no longer required are returned to the pharmacist. 20/12/05 20/12/05 14 15 OP9 OP9 13(2) 13(2) 16 OP11 12(3) Where oxygen is needed and stored the nationally recognised oxygen signage must be displayed. For advice on this contact the homes providing pharmacist. The registered provider and 20/12/05 manager must obtain an official controlled drugs register. The registered provider and 20/12/05 manager must ensure that all ‘short life’ preparations examples being eye drops/ creams and topical preparations are dated labelled when opened. 20/01/06 The registered provider and manager must ensure that wherever possible the last wishes in respect of death and dying are explored for each resident and recorded on their personal file. Where they do not wish to discuss this subject then this must be documented on their file. Information with the residents consent could be gained from residents chosen representative. ( Timescale of 20/07/05 not fully met). Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 26 17 OP12 16(2)(m) (n) The registered provider and manager must explore and determine the activity preferences of the residents to encourage greater activity participation. (Timescale of 01/08/05 not fully met). 01/08/05 18 OP12 12(1)(2) (3)(4) The registered provider and manager must explore and record using a suitable format the choices and preferences of each resident covering the whole activities of daily living spectrum. This must be carried out on admission for all new residents. (Timescales of 10.02.05 and 01/07/05 not fully met). The registered provider must ensure that all staff are aware of the homes abuse policies and Dudley Council’s Adult Protection procedures. Staff must be asked to read , sign and date these documents. The homes Whistle Blowing policy must be revised . This must include reference to NCSC being changed to CSCI. 01/07/05 19 OP18 13(6) 10/01/06 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 27 20 OP18 13(6) 13(7) 13(8) The registered provider must where residents’ movement is restricted inform all significant others of this management examples being; family, social services, GP, consultant to gain their view and written consent. Management must be clearly written into the care plan with records/ risk assessments of any incidents made. 20/12/05 21 OP24 16(2)( c) The registered provider and 01/02/06 manager must document on the individual bedroom audits why certain items for example easy chairs etc have not been provided – in the case of risk factors. Where residents’ refuse any items they must be asked to sign their room audit to verify this. The registered provider and manager must ensure that adjustable height beds are provided in all bedrooms used for residents who require nursing care. Where it is felt that these beds are not needed then the justification for this must be documented along with a risk assessment. The registered provider and manager must ensure that a documented, collective analysis of resident dependency levels are carried out to determine precise staffing levels required. ( Timescale of 01/07/05 not fully met). 01/02/06 22 OP24 13(4) 16(2)( c) 23 OP27 18(1)(a) 14 01/07/05 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 28 24 OP29 19(1)19 (6)17(2) The registered provider and manager must obtain for each staff member all of the required documents detailed in Schedules 2 and 4 . A copy of each of these documents must be held on each staff members personal files. (Timescales of 18.01.05 and 01/07/05 not fully met). Not in place for new staff members from Eastern European countries. Missing documents include 2 written references, identity and a health declaration. The registered provider and manager must communicate with the CRB to determine if prospective staff members from Eastern European countries require a POVA list check before they commence employment. The response must be requested in writing and a copy forwarded to the CSCI Halesowen office. 12/12/05 25 OP29 19(1)(2) 10/01/06 26 OP29 13(6) 19(1)(2) The registered provider and 20/12/05 manager must until they receive confirmation from the CRB as per previous requirement ensure that risk assessments are in place for each staff member employed from Eastern European countries. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 29 27 OP33 24(1) The registered provider and manager must ensure that effective quality checking systems are in place, preferably a professionally recognised quality assurance system , to meet all of the requirements detailed in standard 33. (Timescale of 18.02.05 not fully met). 01/03/06 28 OP33 26 29 OP35 16(2)(l) The registered provider must ensure that he or a nominated other undertake monthly unannounced visits to the home and produce a report of their findings. A copy of which must be forwarded to the CSCI. The registered provider and manager must ensure that a hairdresser provides receipts for money taken for her service. The registered provider and manager must ensure that the frequency of staff supervision is increased to make sure that all staff receive 6 sessions per year. The registered provider and manager must ensure that staff and resident files are better organised. Staff files should be divided to include the following headings: Application form. Interview questions and answers. Two written references. (one from last employer). Health Declaration. 10/01/06 10/01/06 30 OP36 18(2) 10/01/06 31 OP37 17(2) 01/02/06 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 30 Two sources of identity. (one with current address) Immigration approval. Contract. Job description. Evidence of in-house induction Evidence of TOPSS induction and foundation training. Evidence that staff have been given a copy of the General Social Care Council (codes of conduct and practice). Training certificates. Letters and correspondence, for example offer of job, acceptance of job. Risk assessments. A recent clear photograph must be included on or in the file. A checklist at the front of the file is advisable as a structure for the mentioned documents. Residents files must also be divided into the following: Social worker assessment documents care plans and reviews. Basic information , examples, doctor, social worker, next of kin, date of birth, date of admission etc. Completed contract or terms and conditions ( or copy of ). Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 31 Risk assessments , nutritional, tissue viability, falls risk assessment documentation. Continence assessments. (Copy of continence assessment from assessment team). Weights and weight monitoring. Confirmation from doctor on medication, consent for homely remedies or other. Acceptance from resident e.g their bedroom/ acceptance to take a shared bedroom/ any limitations. Care plans/ Care plan reviews. Daily records. Doctors general visits (must also specifically indicate when medical reviews / medication reviews have taken place.) Services from other care providers, optician, dentist, specialist consultants etc. General correspondence. Evidence to demonstrate that residents have been made aware of the following or how to access the following: Last inspection report. Complaints procedure. Statement of purpose and service user guide. Inventories Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 32 Confidential section. A photo must be included on or within the file. Evidence must also be available to demonstrate: Daily personal care delivery, fluid balance (on risk assessment basis) and food intake. (Timescale of 01.08.05 not fully met). 32 OP38 13(4) The registered provider and manager must ensure that a suitably qualified person is secured to undertake an asbestos assessment of the home. Arrangements are being made for this to be addressed in January 2005. 01/02/06 33 OP38 13(4) The registered provider and manager must propose to the CSCI to address the lack of storage areas in the home, for example the wheelchairs by the front entrance area. (Timescales of 10.02.05 and 01.08.05 not fully met). 01/02/06 Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 33 34 OP38 13(4) The registered provider and manager must ensure that a proportion of the staff receive approved risk assessment training. Health and safety training has been arranged for staff for January 2006. 01/02/06 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 OP15 Good Practice Recommendations The registered provider and manager should consider producing the menu in a pictorial format to aid the understanding of residents who have dementia. Hillcroft Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Nursing Home DS0000004878.V270987.R01.S.doc Version 5.0 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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