Inspection on 21/08/06 for Hillcroft Nursing Home

This inspection was carried out on 21st August 2006.

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 12/12/05

Hillcroft Nursing Home 06/06/05

Hillcroft Nursing Home 18/01/05

Hillcroft Nursing Home 20/07/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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 21st August 2006 07:15 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.V306632.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. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcroft Nursing Home Address 135 High Street Wordsley Stourbridge West Midlands DY8 5QS 01384 271317 01384 271112 christinedalwood@hotmail.com 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.V306632.R01.S.doc Version 5.2 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. 12/12/05 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. The charges for this home range from £ 369-471 per week. Additional costs include hairdressing and private chiropody. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.15 and 15.45 hours. The inspection process assessed all of the key National Minimum Standards for older people. To aid the inspection process a pre-inspection questionnaire was forwarded to the home weeks before the inspection for completion. At least 50 of the inspection was conducted in the living areas where care practices and staff/resident interaction could be observed. During the course of the inspection four residents’ files to include assessment of need and care plan documents were assessed. Three staff files to include recruitment documents and training were also assessed. The premises were part assessed to include the lounge/dining room, conservatory, five bedrooms, the laundry, kitchen, garden, bathrooms and toilets. Medication systems and the safe keeping of resident money were assessed. Breakfast and lunch times were observed. Six residents, four staff and three relatives were spoken to during the inspection. What the service does well: The home is maintained to a very good standard both internally and externally with an on-going redecoration and refurbishment programme in operation. The homes’ atmosphere 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 further. A number of staff have been in post for a number of years providing consistency of care to the residents’. Only one staff member has left employment since the last inspection carried out in December 2005. Positive interaction was observed between staff and residents, staff speaking to residents with respect and giving them choices. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 6 As with past inspections positive feedback was given by residents’ and relatives about the home, staff and management examples are as follows; “ The food is really very good”. “ Home is very, very nice”. “ My wife is well cared for she wouldn’t be here otherwise”. “ The home is tidy all the time, they clean it a lot”. “ The staff make me feel welcome”. “I love it here, the staff are marvellous”. Positive feedback was also received in resident questionnaires that either they or their relatives had completed and included the following; ‘Happy here’. ‘Good home with good staff’. ‘The staff are always available and caring’. ‘We are very satisfied with this home’. Another relative made the following comment;” Good home with very good staff. Run by a good manager”. What has improved since the last inspection? What they could do better: Fine tuning is needed in a few areas examples being; care plans and quality assurance. Staff recruitment needs further improvement in the area of obtaining references. Medication systems have improved an up dated a medication policy however, still needs to be produced. The manager must bring to the relevant social workers attention any resident who is not receiving their personal allowance regularly from their family. Where residents’ are assessed as being at risk nutritionally or have lost weight a record of all food consumed daily must be made. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 7 An additional staff member must be provided each morning if only up until mid day. 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.V306632.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 Hillcroft Nursing Home DS0000004878.V306632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. The overall judgement for this set of standards is good. Each service user has a written contract. No service user moves into the home without having their needs assessed. EVIDENCE: Eleven of the thirteen completed resident questionnaires received stated that they had been given sufficient information prior to admission to enable them to make the decision that the home would be suitable for them. One said that they had not but explained that this may have been because they were admitted straight from hospital. One relative commented;” We were invited by the matron to visit the home at a time convenient to us not pre-arranged. When we visited we were impressed with what we saw”. A contract document was available within the home to peruse. A copy document is not kept as procedure on file. The manager told the inspector that the plan is to have a pack containing various documents, this one included in each bedroom. That residents are issued with contracts was further confirmed Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 10 by completed resident questionnaires received, thirteen of the thirteen respondents stated that they had been issued with a contract. The manager was advised that new amended Care Home Regulations come into operation in September 2006 concerning terms and conditions and fees and it would be in the best interests of the home and the residents to obtain a copy of these. Assessment of need documentation was available on each resident file examined along with assessment notes from the funding authority or hospital where they had been discharged from. Hillcroft Nursing Home DS0000004878.V306632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The overall judgement for this set of standards is good. Further improvements are needed to ensure that all residents’ needs are included in their care plan. Generally the home meets the health care needs of the residents’. Medication systems are of a good standard. Residents feel that they are treated with respect. Work is needed to determine the last wishes of each resident. EVIDENCE: Care planning has improved over the last year however, more improvement is needed to capture all needs for example one resident had been assessed as being at high risk of tissue breakdown but there was no mention of this in his care plan. Similarly, one resident had lost over a stone in weight yet this was not mentioned in her care plan. Work is needed to ensure hobbies, recreational and daily routine preferences are explored and captured in resident care plans. It is positive that care plans produced are being reviewed monthly. Generally, the health care needs of residents are being addressed but not always recorded in respect of access to dental or chiropody services. There was evidence of health care reviews carried out by doctors and input from specialists examples being; diagnostic testing and the psychiatrist. One relative Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 12 said; “ The staff always inform me of doctors visits. I always make sure that I am here”. It is positive that records are being made to demonstrate that residents are being weighed on admission and monthly thereafter. Tissue viability and nutritional assessments are being carried out for all residents. One relative made the following comment;” The nursing care is excellent”. Another commented;” Extremely pleased with the care and support”. It is extremely positive that the manager has secured dementia training for staff from a local college. This training is recognised and accredited. It is positive that recording of daily personal care delivery has improved. Residents seen looked well cared for. Ladies with clean nails and tidy hair, men shaven. One relative said; “ We try to come at different times of the day- she always looks nice and clean”. The Commission pharmacist carried out a full assessment of the homes medication systems in January 2006. All requirements made following this and the previous key inspection have been met with the exception of the updating of the homes’ medication policy. The medication administration process was indirectly observed and good practice was seen. The nurse locked the medication trolley each time he left it. Ensured drinks were available before giving medication. Stayed with each resident to ensure that they had taken their medication before signing the medication record. Used a volumatic machine to administer one residents inhaler and took pulses before giving Digoxin. The preferred name for each resident has been determined and recorded. The preferred name for at least two residents was heard being used during the inspection. Toilet and bathroom doors were seen to be shut when in use. Staff were observed knocking bedroom doors before entering. The optician was on site during the inspection. A vacant room was used for eye tests to maintain resident dignity. Staff observed during the inspection were polite and respectful to residents giving them choices wherever possible. One relative said;” The staff are always polite”. It was noted from records that there was no evidence that the last wishes of each resident has been determined as they should be. Hillcroft Nursing Home DS0000004878.V306632.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The overall judgement for this set of standards is good. More work is needed to ensure that residents preferred daily routines are explored and that activity provision is improved. Residents are very much encouraged to maintain contact with family and friends. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome diet in pleasing surroundings at times convenient to them. EVIDENCE: There are activities provided by the home by the staff such as games and manicures. Every two weeks an external exercise provider visits the home. Seasonal events are celebrated. However, activity provision and the recording of such needs to be improved. To this end the manager is in the process of appointing a part time activities co-ordinator. The manager confirmed that this person will produce a schedule of activities and ensure that recording of participation by residents is maintained. There was little evidence to suggest that the daily routines of each resident have been explored and recorded. The manager did confirm that this is done informally on a daily basis. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 14 The general routine of the home was observed during the inspection. It was noted that breakfast was served from 07.15 – 11.00 hours allowing residents’ flexibility in rising times. One resident who had got up early said;” I am hopeless at staying in bed”. A relative said;” I asked if Mum could stay in bed later in the mornings and the home have arranged this. Sometime when I visit mid morning she is still in bed which is good. I did worry that if she got up late she would not be given breakfast but this is not the case, they just give her breakfast late”. The home has open visiting arrangements with the exception of meals times. Visiting times are displayed at the front door. One visitor said; “ I visit every day, the staff are great make me feel welcome”. Another said; “ There is no problems with visiting”. The home has written materials informing relatives and staff about external advocacy services. Residents are encouraged to bring personal belongings into the home. Belongings seen ranged from pictures and ornaments to televisions in some cases. The home has produced a set of menus which are displayed on each table. The menus are clearly written and detail 4 main meals per day, breakfast, lunch, tea and supper. The home has a good main cook who is very much in favour of home cooking. Attractive home made cream cakes and trifles were seen. The breakfast time was observed residents could choose from hot and cold options cereals, toast or a full cooked breakfast. Two male residents were seen eating bacon, egg and tomatoes. The main meal of the day looked attractive and appetising, with good size portions offered. The home has adapted feeding utensils examples being; plate guards and spouted cups to aid independent feeding. Unfortunatley, staff were not available for most of the breakfast time but were available at lunchtime. They were seen sat feeding residents who needed to be fed. One resident said of the food; “ It is really very good we have what we like”. Another said; “That was really nice”. One relative commented; “ “ Mum has put on weight so is obviously enjoying the food”. The home has a copy of the Commissions guidance on meal provision titled ‘ Highlight of the day’. Hillcroft Nursing Home DS0000004878.V306632.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The overall judgement for this set of standards is good. Service users and their relatives are confident that their complaints will be listened to and acted upon. Generally the home has in place systems to prevent abuse. EVIDENCE: No complaints have been received by the home or the Commission for some considerable time. The home has a written complaints procedure which is on display in the front entrance hall. This assures that complainants will be responded to within 28 days. Twelve of the thirteen completed resident questionnaires confirmed that; ‘ They always know how to make a complaint”, demonstrating that they are aware of the homes complaints processes. There have been no allegations or incidents of abuse at the home for some considerable time. The manager showed the inspector video training materials that are used within the home as an interim until other training can be secured. The manager discusses the video with staff and there is a written exercise that can be done following the viewing. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 16 The home has Dudley MBC multi-agency procedures titled ‘ Safeguard and Protect’. The manager confirmed that this is the process she would use if there was an allegation of abuse. A quick reference flow chart if available within the home for easy access for staff. The manager confirmed that staff have read these procedures there was however, no evidence of this. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26. The overall judgement for this set of standards is good. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor space. Service users live in safe, comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. EVIDENCE: The home is bright, welcoming with a positive atmosphere. There are a number of homely touches examples being; the décor, ornaments and flower decorations and the fish and birds in the lounge. The homes’ environment is maintained, furnished, carpeted and decorated to a high standard. The home has an on-going refurbishment / replacement of fabric programme. Since the last inspection a number of bedrooms have been provided with new carpets, as Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 18 have the first floor landings. A number of new chairs and mattresses have been purchased and new laundry equipment has been provided. The home provides adequate indoor and outdoor space examples being; the large lounge /dining area and conservatory. The home has pleasant gardens and a balcony area off the conservatory. The home was able to provide a written audit of each bedroom which is positive but these lack confirmation of resident/relative involvement. Not all residents’ who have nursing needs are provided with adjustable height beds. This needs on-going monitoring. Five bedrooms were viewed during the inspection these were seen to be comfortable and well maintained and held a number of resident personal belongings. One resident said; “ I like my bedroom”. A relative said; “ I can go into Mums bedroom when I want to”. The laundry consists of two separate rooms one for clean laundry/ ironing the other for dirty washing. A sink is available in each room. The home has two washing machines and two dryers. The décor and flooring in the laundry rooms is good. Bathrooms and toilets were viewed for infection control purposes. All were provided with waste bins, disposable towels, gloves, aprons and liquid soap which is positive. The home has a mechanical sluicing disinfector for the adequate cleaning of commode pots and urinals. The only shortfall identified was the lack of hand wash signs in toilets, bathrooms and other high risk areas. The home was clean with no offensive odours. One resident said; “ They clean it up a lot”. A relative said; “ Mums bedroom is spotless. The home has no smells”. It is positive that twelve of the thirteen completed resident questionnaires confirmed that ‘ The home is always fresh and clean’. It is positive that staff either have or are undertaking accredited infection control training. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall judgement for this set of standards is adequate. Care staffing levels need to be increased from early morning until at least mid day to ensure that service user needs are met at this time. The home is not quite meeting the 50 requirement for care staff attainment for N.V.Q. Fine tuning is needed to ensure that the homes recruitment practices are safe and sound. Generally, staff are trained and competent to do their jobs. EVIDENCE: Only 4 care staff were provided on the morning of the inspection. One of these being a trainee. It was observed that there was no care staff available to feed residents’ who needed assistance at breakfast time. General feedback indicated that an extra carer in the mornings would greatly benefit the residents. It was noted that one care staff members performance has not been as it should. Evidence was available to demonstrate that the manager is trying to deal with this. It was emphasised to the manager that there is a degree of risk concerning this persons attitude which may have the potential to jeopardise the home. Positive comments were received about the staff in general which included the following; “ The staff are always pleasant”. “The staff make us feel welcome”. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 20 “The staff keep me informed”. Further comments received included;” The staff are very helpful and caring”. “ The staff are kind and helpful”. The home as yet is not meeting the 50 attainment level concerning care staff trained to N.V.Q level. However, as a number of staff are shortly to complete their N.V.Q training this shortfall should be rectified. It is positive that the manager has arranged for other staff to enrol for N.V.Q in the autumn of 2006. Generally, recruitment processes were seen to be satisfactory with the exception of one staff member without references from her previous employer. References were on file from other sources yet these were not authenticated as they were addressed to ‘Whom it may concern’ and ‘Dear Sir’. Further the references had been brought to the home by the staff member rather than them being sent for to enhance verification. The home has a copy of the Commissions guidance on recruitment fro reference purposes titled ‘Safe and Sound’. It is positive that there was evidence of in-house induction for new staff as well as bank and agency staff. The manager was able to demonstrate that the ‘Skills for Care’ standards are available for use in the home. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall judgement for this set of standards is good. Service users live in a home which is run and managed by a person who is fit to be in charge. Further developments are needed to finalise the homes quality assurance processes. Service users financial interests are safeguarded. Staff are appropriately supervised. Generally, the health and safety of staff and residents are promoted but fine tuning is needed in some areas. EVIDENCE: The manager is a first level registered nurse who has an appropriate management qualification. She has been approved by the Commission as being a fit person to run the home. Quality assurance processes have progressed in recent months. The manager has been monitoring and using satisfaction questionnaires. The production of Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 22 an annual business plan and a system to audit compliance across all National Minimum Standards is required to complete the process. An audit of 4 resident monies against balances was undertaken. This was found to be correct. A receipt for services is provided by the chiropodist and hairdresser but this is a blanket receipt rather than individual as required. A discussion was held with the manager about relatives being reluctant to give the home money from their relatives’ personal allowances. In some cases the home is paying for services such as hairdressing and is being owed money by these relatives. The manager was advised to raise this issue with residents’ social workers or if concern is felt cases should be referred to vulnerable adult processes. There was written evidence available to demonstrate that staff are receiving regular one to one supervision sessions. Generally health and safety issues are being dealt with. Evidence was available to show that regular servicing of fire fighting and other equipment is being carried out. There were written risk assessments available for perusal. Requirements following the last fire inspection have been met. A few areas need fine tuning examples being; two bedroom doors not fitting correctly into their rebates which could pose as a fire risk. There is no restricted access to the sluice room which houses equipment which could be hazardous. The kitchen was found to be in good working order with records of the required checks to confirm that they are being undertaken. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 x x x 3 x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 3 x 2 Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered 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, tissue viability etc. (Timescales of 18.02.05, 25/06/05 and 05/01/06 not fully met). 2. OP7 15(1) 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. Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 25 Timescale for action 15/09/06 15/09/06 (Timescale of 01/07/05 and 05/01/06 not fully met). 3 OP9 13(2) 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. (Timescale of 24/12/05 not met). 4 OP11 12(3) 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. (Timescales of 20/07/05 and 20/01/06 not fully met). 5 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). 6 OP12 12(1)(2) (3)(4) The registered provider and manager must explore and record using a suitable format the choices and preferences of DS0000004878.V306632.R01.S.doc 01/10/06 20/10/06 01/11/06 01/10/06 Hillcroft Nursing Home Version 5.2 Page 26 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). 7 OP18 13(6) 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 sign and date these documents. (Timescale of 10/01/06 not fully met). 8 OP26 13(3) The registered person and manager must ensure that ‘hand wash’ signs are provided in all toilets, bathrooms and other high risk areas such as the laundry. The registered provider and manager must increase care staff by one every morning up until at least mid day. 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, 01/07/05 and 12/12/05 not fully met). Not in place for one new staff member include 2 written references from last employer and official identity. 21/09/06 01/10/06 9 OP27 18(1)(a) 21/09/06 10 OP29 19(1)19 (6)17(2) 21/09/06 Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 27 11 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. This to include a production of an annual plan and a monitoring system across all of the National Minimum Standards for Older People. (Timescales of 18.02.05 and 10/01/06 partially met). 01/11/06 12 OP35 16(2)(l) The registered provider and manager must ensure that a hairdresser provides receipts for money taken for her service. (Timescale of 10/01/06 not fully met). This also applies to the chiropodist. 01/10/06 13 OP37 17(2) 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: Two written references. (one from last employer). Health Declaration. Two sources of identity. (one with current address Risk assessments. 21/09/06 Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 28 Residents files must also be divided into the following: Completed contract or terms and conditions ( or copy of ). 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. Services from other care providers, optician, dentist. . 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 A photo must be included on or within the file. Evidence must also be available to demonstrate: Food intake. (Timescales of 01.08.05 and 01/02/06 not fully met). Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 29 14 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. In progress. 01/11/06 15 OP38 13(4)( c) 16 OP38 13(4)(a) 17 OP38 23(4)(a) The registered person and manager must ask the trainer to detail on the 1st aid certificates how long they are valid for. The registered person and manager must fit a suitable locking devise to the sluice room door. Advice on the type may need to be sought from West Midlands Fire Service. The registered person and manager must ensure that work is carried out to ensure that bedroom doors 1 and 5 fit correctly into their rebates. 01/11/06 21/09/06 10/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillcroft Nursing Home DS0000004878.V306632.R01.S.doc Version 5.2 Page 30 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. 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