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Inspection on 06/06/05 for Hillcroft Nursing Home

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

This inspection was carried out on 6th June 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.

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

Overall the home is maintained to a good standard both internally and externally. The home`s atmosphere is warm, welcoming and friendly. The staff and management endeavour to provide a high standard of care to the residents at all times. Staff and management are interested in their work, keen and motivated. Perceived outcomes for residents appear to be positive in all respects. Residents and relatives complimented the home in general and on care delivery, food, staff and the manager. Comments from residents included " The home is really nice, I feel very settled". " It`s home from home here". " I`ve got a lovely room". " I get on well with all the staff, they are all nice to me". " I`ve got no complaints". Comments from relatives included, " I`d come and live here if I had to". " I am happy with the visiting times, staff make me feel welcome". " The manager and staff are marvellous ". Letters have been received by the home and by the Commission for Social Care Inspection. Extracts from these letters included " I am writing to you because I wanted to let you know how fantastic your team at Hillcroft has been especially the matron". " It is impossible to put into words how much it has meant to me not to worry and know that she was in safe hands". " I would like to congratulate you on running such an exceptional nursing home".

What has improved since the last inspection?

Since the last inspection record keeping has improved in areas such as care planning, risk assessment, however further improvement is needed. Record keeping in the kitchen has also improved. A new fridge has been ordered. A number of requirements have been met since the last inspection. Staff recruitment and checking processes have improved, but require further work. New hot water control valves have been fitted throughout the home, only four remain outstanding. The laundry has much improved. Walls in both laundry rooms have been painted, the clean laundry area has had new flooring and cupboards, the floor in the other laundry room is being prepared for new flooring to be fitted. The registered provider has undertaken some monthly visits required by regulation.

What the care home could do better:

The major shortfalls with this home are the lack of monitoring and checking systems to ensure that all operations are being carried out as they should and lack of or poor recording/record keeping. This includes overall quality assurance and monitoring systems. Record keeping in respect of care delivery, planning and reviews, health and safety and risk assessment all require improvements. Measures must be taken to improve records, record keeping and organisation particularly regarding to resident and staff files. Staff training in care planning and record keeping is lacking.

CARE HOMES FOR OLDER PEOPLE Hillcroft Nursing Home 135 High Street Wordsley Stourbridge DY8 5QS Lead Inspector Cathy Moore Unannounced 06.06.05 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 Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hillcroft Nursing Home Address 135 High Street, Wordsley, Stourbridge, West Midlands DY8 5QS 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) 01384 271317 01384 271112 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 E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A condition has been approved for two named residents under the age of 65 years to be accommodated. Date of last inspection 18/01/05 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 facilitiies. 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 assisited 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 E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an unannounced basis. The inspection was the first of the home’s two statutory inspections for this inspection year. The inspection involved one inspector and was carried out between 07.4015.50 hours. During the course of the inspection, three residents files, to include assessment and care plan documents and three staff members files were scrutinised. Health and safety, equipment service, maintenance and risk assessments were assessed. The kitchen, laundry, communal areas, some toilets and bathrooms and two bedrooms were viewed. Five residents, five staff including the manager and two relatives, were spoken with in detail or were involved in the inspection process. What the service does well: Overall the home is maintained to a good standard both internally and externally. The home’s atmosphere is warm, welcoming and friendly. The staff and management endeavour to provide a high standard of care to the residents at all times. Staff and management are interested in their work, keen and motivated. Perceived outcomes for residents appear to be positive in all respects. Residents and relatives complimented the home in general and on care delivery, food, staff and the manager. Comments from residents included “ The home is really nice, I feel very settled”. “ It’s home from home here”. “ I’ve got a lovely room”. “ I get on well with all the staff, they are all nice to me”. “ I’ve got no complaints”. Comments from relatives included, “ I’d come and live here if I had to”. “ I am happy with the visiting times, staff make me feel welcome”. “ The manager and staff are marvellous “. Letters have been received by the home and by the Commission for Social Care Inspection. Extracts from these letters included “ I am writing to you because I wanted to let you know how fantastic your team at Hillcroft has been especially the matron”. “ It is impossible to put into words how much Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 6 it has meant to me not to worry and know that she was in safe hands”. “ I would like to congratulate you on running such an exceptional nursing home”. What has improved since the last inspection? 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 Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 Though the outcomes of standards 1, 3, 4 and 5 are addressed to a degree, all could be further developed and improved. EVIDENCE: The home has a combined statement of purpose and service user guide. One relative confirmed that he had been given a copy of this document when he visited the home prior to his wife’s admission. The document however, does not fully detail how the environmental standards are being met. Assessment of need documentation was available on the residents files viewed. This documentation is assessed as being adequate, however there was no evidence to demonstrate that residents had been involved in the assessment process. The manager confirmed that she is producing a letter to acknowledge to prospective residents how the home will meet their assessed needs. However, to date this letter has not been finalised or been put into operation. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 9 One resident and two relatives confirmed that they had been to visit the home before they or the prospective resident had been admitted. The home has in place a trial period. This trial period gives residents time to ascertain the suitability of the home before their placement is formally confirmed. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11 Though there is anecdotal evidence that health and social care needs are being met and recording documentation is available, recording must be further developed and completed diligently. EVIDENCE: Care plans have improved slightly since January 2005, however, they still are not to standard. The home had not produced a care plan for one new resident (ML). There was no evidence to demonstrate that residents are being involved in their care plan compilation or any subsequent review process. Two residents have been assessed as being at risk or at high risk in respect of nutrition and tissue viability, yet these risks are not captured in their care plans. Other areas for example activity provision, recreational pastimes and catheter care were also lacking in care plans. One resident and two relatives commented that the personal and nursing care provided was of a good standard. One relative said, “ My wife is looked after very well”. There was evidence available to demonstrate that health care services are being accessed for residents on a regular or as needed basis. Written evidence to demonstrate what personal care is provided on a daily/ weekly basis was available although some records were incomplete or not consistently completed. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 11 Evidence showed that one resident had not been weighed between the February 05 and May 05. In May 05 it was identified that she had lost over a stone. There was evidence available however, that the resident had been referred to her doctor and the dietician in respect of her poor appetite and weight loss. The home is using a risk assessment framework for falls and other concerns, however the process is not always being followed through. For example, it was recorded that one resident was prone to wandering at night; the risk assessment stated that she must be monitored every 20 minutes, there was no evidence that these 20-minute checks were carried out. Other risk assessments identified potential risk but there were inadequate written strategies or instructions to staff how these risks are to be managed or minimised. The home has recently changed its pharmacy provider to a well-known large organisation. The manager commented that she is still awaiting medication return books for medications and has not yet received a contract from the pharmacy provider. The home has purchased a new medication trolley. The temperature of the medication fridge was above that recommended which may be due to a build up of ice. One resident self administers one tablet, however a risk assessment in respect of this had not been undertaken. Consent has been obtained from the consultant and doctor in respect of resident (NS) covert medication administration. A care plan in respect of this covert medication administration has yet to be produced. There was evidence available to demonstrate that the manager is actively asking individual doctors to confirm the medications of new residents and to approve homely remedies for residents using these products. Prescribed, unlabelled nutrition / supplement were seen in the kitchen, dry storage cupboard. It was noted that locks are provided on toilet and bathroom doors. Staff observed showed respect in the manner they dealt with and spoke to residents. One staff member spoken to confirmed that they “ treat residents as they would want to be treated themselves and treated them as individuals” to show respect, another said “ When providing personal care I always ensure that the door and where needed, curtains, are closed and keep as much of the body covered as possible to enhance privacy and dignity”. The preferred form of address had been identified and recorded in respect of some residents but not all. Some residents have confirmed verbally that they prefer to have their hair attended to by the hairdresser in the lounge area. There was some evidence available to suggest that residents choices and wishes in respect of dying and death are being explored, but not for all. Care of the dying training has not yet been received by staff. A letter was received by the Commission for Social Care Inspection from a relative whose mother had passed away recently. The letter praised the manager and staff for the care that they had provided. Another similar letter was available in the home Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 12 praising the manager and staff for the care they provided to his mother in her last days and the support during the time of the funeral offered by the manager. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 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 standard(s) 12,13,15 Attention to social, cultural and religious and recreational interests and needs requires significant development, including how this is recorded. Residents are encouraged to maintain contact with family and friends and this is facilitated by the home. Dietary provision is of a good standard. EVIDENCE: It was evident from speaking to the manager and viewing records that activity participation is poor. The activity book mostly detailed activities such as hair and nail care. External activities are purchased in on an intermittent basis. One relative commented however, that ” birthdays are very much celebrated at the home, the week before the cook made a resident a lovely birthday cake”. It was identified by speaking to residents and observations of staff during the inspection that informal resident and relative consultation is on-going, formal meetings not so frequent. Documented preferences in relation to daily living, routines and personal choices was seen to be limited. The home has open, flexible visiting times, which are detailed in the homes statement of purpose. During the inspection day many visitors came to the home. One relative commented” I am happy with the visiting times”. One Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 14 relative commented, “ the staff make me feel welcome, they are friendly”. Another visitor stated, “ I visit my wife everyday, I come before lunch and go home during the evening”. One relative commented, “ when we visit we can use the bedroom or sit in the lounge”. Visitors are offered drinks and some, meals during the time they are at the home. Mealtimes are of a good standard. Staff are on hand to assist where needed. Tables are attractively laid. The meal times observed were relaxed. The menu is in normal print font. Only three meals are detailed on the menu at present. The main meal of the day reflected the set menu, this included two choices. For high risk situations for example where residents have a poor appetite, food consumed is recorded daily. Supper however, is not recorded as a matter of course. Residents can choose a full cooked breakfast every day if they want to. Residents were very complimentary about the food. One said, “ I can’t complain about the food at all. The food is good food, like home cooking”. The home offers residents with a choice of semi-skimmed or full fat fresh milk. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 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 standard(s) No standards were assessed at this visit. EVIDENCE: Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25,26 The comfort and cleanliness of the residents’ environment has and continues to improve. EVIDENCE: Work has been carried out on the homes water system in the last few months, replacing hot water control valves. This work has been nearly completed, only four more valves need to be replaced. Copper piping was seen exposed in the assisted ground floor bathroom. The home employs dedicated laundry and domestic staff. The clean laundry room has much improved since the last inspection. This room was seen to be better organised and less cluttered. Storage boxes with lids have been purchased to store residents clothes individually until they are returned to their rooms. The walls have been repainted, the flooring replaced and cupboards fitted. The other section of the laundry where the washing of laundry is carried out has also improved, the walls have been painted and the floors are being prepared for new flooring to be fitted. The laundry has two commercial Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 17 washing machines, one washing machine capable of providing sluice/ disinfection cycles. The home has three dryers, two are commercial models. Wash hands signs were seen in all toilets and bathrooms viewed. Disposable aprons and gloves (in new wall mounted dispensers), liquid soap, and paper towels were available in all high risk areas. The majority of staff including laundry and domestic staff have received infection control training. Laundry and domestic staff are working towards their housekeeping N.V.Q awards. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,29 Generally numbers and skill mix of staff appear adequate. Recruitment policy and practices require improvement and greater diligence. EVIDENCE: A staff rota was available to peruse. The home has been short of a trained nurse in the last few weeks due to an unpredicted early leave of absence of one nurse and the resignation of another. This situation has been managed and one new full time and one bank nurse are in the process of being employed. It was noted that there are sufficient nurse hours to allow the manager to have at least three supernumerary shifts per week on average. The home was short of .5 of a care staff on the morning of the inspection. There was evidence that a dependency rating assessment tool is in operation within the home, however there was no evidence that the individual dependency ratings for each resident are collated collectively and analysed on a regular basis. Staffing records have improved however work is still required to meet this standard. The full file of the new nurse was not available on site although it was available within the organisation. A health declaration was not available for all staff, one staff member lacked references from her last, previous employer. Copies of disclosures were held on personal files, not a separate secure file. There was a lack of interview questions and answers, not all staff files held a copy of a job description or evidence that staff have been issued with codes of conduct and practice. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 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 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) 31,33,37,38 The manager is clearly pivotal to the quality of this home. However, formal quality assurance processes require further development and technicalities of record keeping require attention so that the operation of the home in the best interests of the residents can be clearly and unambiguously demonstrated. EVIDENCE: The manager is a first level nurse with numerous years experience caring for older people with complex nursing needs. The manager has attained an approved management qualification and is able to demonstrate on-going learning. The manager provides leadership and direction to the staff group. Relatives complimented the manager on her skill and attitude towards her work. One relative whose wife had been in hospital where the experience had not been positive said about the manager” that’s what managers should be like, kind, helpful with the proper knowledge”. Another relative said, “ the manager is exceptional”. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 20 There was evidence available within the home to demonstrate that questionnaires are in use. The home is looking to work towards attaining Investors In People accreditation. However, gaps remain that must be addressed to ensure that the requirements in respect of quality monitoring and assurance are met. The registered provider had undertaken a number of monthly visits to the home and has produced reports reflecting his findings. Record keeping is not the homes strongest point, areas such as care planning risk assessment and other documentation require expansion or improvement. There was little evidence to demonstrate that nurses and carers have received recent training in respect of care planning and record keeping. There was little organisation or structure in respect of staff and resident record keeping/ file storage. Overall documentation pertaining to health and safety has improved somewhat in the last months. Records were assessed in respect of appliance and equipment maintenance which all appeared to be in order. Checking mechanisms were seen to be in place in respect of wheelchairs, the proper closing of doors (the only one identified as having a fault was the kitchen door) fire alarm and emergency lighting tests. The homes fire risk assessment was not available, there was no evidence that the building had been assessed in respect of asbestos, bath water temperature checks are not being recorded and there is no formal analysis of accidents undertaken and there was no evidence that staff have received risk assessment training. Kitchen procedures have improved in the last few months. Documentation was available to demonstrate cleaning undertaken, probe collaboration and the dating of short life products. The kitchen has been totally refurbished in the last twelve months all cupboards are made of stainless steel. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 1 x x x 1 2 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 22 Yes 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 OP1 Regulation 4,5) Requirement The registered provider and manager must ensure references to the following standards are made in the statement of purpose and summarised in the service user guide : 20.1, 20.4, 21.3, 21.4, 22.2, 22.5 and 23.3. Timescale of 18.02.05 not met. The registered provider and manager must ensure wherever possible and that this be evidenced that residents are involved in their assessment of need process. The registered provider and manager must be able to evidence that each new resident has been given a written acknowlegement in respect of Regulation 14(1)(d) Timescale of 18.02.05 not met. The registered provider and manager must expand the homes care plans to include the full spectrum of needs examples being: Physical care/ personal hygiene/ oral care. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 23 Timescale for action 01.08.06 2. OP3 12(3) 07.06.05 3. OP4 14(1)(d) 01.07.05 4. OP7 15(1) 25.06.05 The management of / verbal aggression/ challenging behaviour. Any areas of risk in relation to falls, tissue viability, nutrition and accidents. Timescale of 18.02.05 not fully met. The registered provider and manager must ensure that a care plan is produced for each resident on admission to the home. Timescale of 31.01.05 not met. The registered provider and manager must unless it is impracticable ( then the reasons for this must be documented) must consult with each resident about their care plan. at the time of its production or subsequent reviews. The registered provider must 01.07.05 ensure that each residents care plan : Reflects ALL of each residents needs. And includes the following (where appropriate) in suffcient detail: Physical care, catheter care, incontinence care and continence promotion, diabetic care, pressure area care to include pressure relieving appliances, wound dressing regimes, nutritional care to include special dietary regimes, nutritional/ supplement drinks) encouragement to eat processes, Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 24 5. OP7 15(1) 20.06.05 6. OP7 15(1) prevention of dehydration . Personal care, washing, bathing, dressing, feet, oral, eye care. Management of behaviour and agression. Management of any risks. Dementia care. Medication. Hobbies, recreation and stimulation. Personal goals , wishes and choices, daily routines. Care of the dying. Care plans must be specific to each need for example: what is the need. How is the need to be met. How often, when. 7. OP8 13(4) By whom. The registered provider and manager must ensure that risk assessments are carried out in respect of any area of concern , examples being aggressive behaviour, nutrition, tissue viability , and that these assessments give clear, precise instructions to staff to ensure that these risks are eliminated or minimised as far as possible. That where specific instructions are given to minimise or manage risk for example, observe every 20 minutes throughout the night Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 25 01.07.05 then records must be maintained to evidence that this has been done. Where risks are identified examples being, poor appetite, weight loss or other areas, then these must be referred to a relevant practitioner for advice and guidance. The registered provider must be 25.06.05 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 dilegence and consistency. The registered provider must 6.06.05 ensure that all residents are weighed on admission and monthly thereafter. That these weights are recorded and monitored. Timescale of 31.01.05 not fully met. The registered provider and manager must ensure that a documented risk assessment is carried out with regard to any resident who self medicates. The registered provider and manager must ensure that approved medication fridge temperatures are maintained at all times. Advice to be sought from the pharmacist. 8. OP8 12(1) 9. OP8 12(1) 13(4) 10. OP9 13(2) 15.06.05 11. OP9 13(2) 06.06.05 12. OP9 13(2) The registered provider and manager must ensure that the medication fridge is attended to on a regular basis to prevent frost/ice accumulating. The registered provider and 06.06.05 manager must ensure that all prescribed drink supplements are stored securely and appropriately. Version 1.30 Page 26 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc 13. OP9 13(2) The registered provider must ensure that a contract is obtained from the homes pharmacy provider. Timescale of 18.02.05 not met. The registered provider and manager must continue to ensure that confirmation is obtained from new residents doctors that medication being prescribed/ brought into the home on admission is correct. To gain approval from residents doctors for any homely remedies being used. Records of medications confirmed and prescribed must be included in the residents care plans and must be maintained at all times, for example when new medications are prescribed or medications are discontinued. The registered provider and 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. The registered provider and manager must ensure that full guidance on covert medication practice must be included in individual residents care plans together with instructions from the consenting doctor/ consultant. 01.07.05 14. OP9 13(2) 06.07.05 15. OP9 13(2) 15.06.05 16. OP9 13(2) 15.06.05 17. OP10 12(3) Timescale of 31.01.05 not met. The registered provider and 25.06.05 manager must ensure that residents consent is obtained (in writing) regarding them choosing Version 1.30 Page 27 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc 18. OP10 12(3) 19. OP11 12(3) 20. OP11 12(3) 18(1) to have their hair attended to in the lounge area. The registered provider and manager must ensure that the preferred form of address is determined for each resident on admission and that this information is detailed on their personal file and relayed to staff. 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. The registered provider and manager must arrange training for staff on the subject of death and dying. Timescale of 18.02.05 not fully met. The registered provider and manager must explore and dertermine the activity preferences of the residents to encourage greater activity participation. The registered provider and manager must explore and record using a suitable format the choices and preferences of each resident covering the whole actvities of daily living spectrum. This must be carried out on admission for all new residents. Timescale of 10.02.05 not fully met). The registered provider and manager must ensure that the 25.06.05 20.07.05 01.08.05 21. OP12 16(2)(m) (n) 01.08.05 22. OP12 12(1)(2) (3)(4) 01.07.05 23. OP15 16(2) SCH 4( 01.07.05 Page 28 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 13) homes menu is expanded to include all meals breakfast, lunch, tea and supper. where residents are assessed as being at risk nutritionally for whatever reason all food consumed must be recorded, including supper. The menu should also include other alternatives available that are not presented on the existing menu examples being, salad or jacket potatoes. The registered provider and manager must ensure that the remaining four hot water control valves are fitted. And That all copper pipe work in toilets and bathrooms is guarded. In the interim period risk assessment/minimisation strategies must be implemented to prevent or eliminate risk of burning/ scalding And Ensure that bath water outlets are included in the monthly hot water temperature testing processes. The registered provider and manager must be able to demonstrate that the hot water system is capable of maintaining the required storage, distribution and return temperatures. The registered provider and manager must ensure that sufficent staff are provided at all times. The registered provider and manager must ensure that a documented, collective analysis 24. OP25 13(4) 15.07.05 25. OP25 13(4) 15.07.05 26. OP27 18(1)(a) 06.06.05 27. OP27 18(1)(a) 14 01.07.05 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 29 28. OP29 19(1)19(6) 17(2) of resident dependancy levels is carried out to determine precise staffing levels required. 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. Timescale of 18.01.05 not fully met. The registered provider and manager must ensure that staff disclosures / POVA list checks: Are not held on their personal files. A secure file must be used for this purpose. Are not held for longer than 6 months. (A list must be generated to evidence that these disclosures/ POVA list checks have been obtained). For further information download: Code of Conduct and Explanatary Guide for Registered Persons and other recipients of Disclosure Information and Policy statement on the Secure Storage, Handling , Use and Disposal of Disclosures and Disclosure information. From the CRB / disclosure website. 01.07.05 This must be before the commence ment of employment for new staff. 01.07.05 29. OP29 17(2) 30. OP33 24(1) The registered provider and manager must ensure that effective quality checking systems are in place, preferably a professionally recognised 01.08.05 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 30 quality assurance system , to meet all of the requirements detailed in standard 33. Timescale of 18.02.05 not fully met. The registered provider and manager must ensure that all staff receive the following: Record keeping training. Care planning training and that all staff are competent in record keeping and care planning systems. 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. Two sources of identity. (one with current address) Immigration approval. Contract. Job description. Individual training plan. Evidence to demonstrate that all staff have at least 3 days paid training per year. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 31 31. OP37 17(2) 01.08.05 32. OP37 17(2) 01.08.05 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 correspondance, for example offer of job, acceptance of job. Risk assessments. Confidential information, for example discplinary action. Supervision records. A recent clear photograpgh 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: Assessment of need. Regulation 14 letter acknowleging how the home will meet their needs. Social worker assessment documents care plans and reviews. Basic information , examples, doctor, social worker, next of kin, date of birth, date of admission etc. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 32 Completed contract or terms and conditions ( or copy of ). 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 correspondance. Evidence to demonstate 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. Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 33 Inventories 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. 33. OP38 13(4) 34. OP38 13(4) 35. OP38 13(4) 36. OP38 13(4) The registered provider and manager must ensure that a adequate formal documented system is established to analyse accidents to enable identifcation and minimisation/ erradication of accidents. The registered provider and manager must ensure that a suitably qualified person is secured to undertake an asbestos assessment of the home. The registered provider and manager must ensure that the baths are included and recorded in the checking of the homes hot water temperatures. 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. Timescale of 10.02.05 not fully met. The registered provider and manager must ensure that all 01.07.05 01.08.04 01.07.05 01.08.05 37. OP38 13(4) 01.07.05 Page 34 Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 bedrails are risk assessed on a regular basis and that records are maintained. Timescale of 18.02.05 not fully met. The registered provider and manager must ensure that a copy of the homes most recent fire risk assessment is forwarded to the CSCI. The registered provider and manager must ensure that the kitchen door receives the required attention to ensure that it closes properly into its rebate. The registered provider and manager must ensure that a proportion of the staff receive approved risk assessment training. The registered provider and manager must ensure that : Regular documented audits are carried out in respect of the kitchen. That food delivery temperatures are taken and recorded. That records are made of the standard of food delivered, i.e food fresh, packaging intact etc. That all food stored in the kitchen is date labelled. That risk assessments are expanded upon in respect of kitchen equipment( to include manufacturers guidance). That adequate ventilation of the kitchen is provided as per Environmental Health report dated 20th July 2004. (Twice daily recordings of the kitchen Hillcroft Nursing Home E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 35 38. OP38 23(4) 01.07.05 39. OP38 23(4) 20.06.05 40. OP38 13(4) 01.08.05 41. OP38 16(2) 20.07.05 temperatures must be taken and recorded, a documented risk assessment must be carried out. Timescale of 10.02.05 not fully met. 42. OP38 16(2) The registered provider and manager must purchase a suitable thermometer for the dry food store. Daily temperature readings for this room must be taken and recorded. 01.07.05 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 15 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 E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 36 Commission for Social Care Inspection West Point Mucklow Office park 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 E55 S4878 Unannounced Hillcroft V231404 060605 Stage 4.doc Version 1.30 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!