CARE HOMES FOR OLDER PEOPLE
Hillcroft Residential Care Home 16-18 Long Lane Aughton Ormskirk L39 5AT Lead Inspector
Mr Paul Wright Unannounced Inspection 23rd June 2006 12:10 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 Residential Care Home DS0000063777.V308786.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 Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hillcroft Residential Care Home Address 16-18 Long Lane Aughton Ormskirk L39 5AT 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) 01695 422407 01695 420866 weineger@aol.com Raycare Limited Mrs Susan Cornmell Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 29 service users in the category of OP - (Old age, not falling within any other category). 1st November 2005 Date of last inspection Brief Description of the Service: Hillcroft provides personal care and accommodation for up to 29 older people on 2 levels, with adequate communal space. It is situated in the village of Aughton with easy access to a range of community and leisure facilities within the nearby town of Ormskirk. The secure, well-maintained gardens are easily accessible and there is a small courtyard and patio area at the back of the building. Information about the home can be found in the Hillcroft service user guide. Weekly charges at the home, as at 26th June 2006, vary from £320.50 to £360.50. This does not include individual costs for hairdressing, toiletries, newspapers, continence aids, transport or chiropody. Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key unannounced inspection visit took place over two days and was carried out by one inspector. Twenty-five residents were living in the home on the days of the visits. The information in this report was gathered from various sources, which included residents, visitors, staff, management, records, a tour of the building and observation of care. Wherever possible the views of residents were obtained about their life at the home. However, due to memory and communication difficulties, several residents were unable to engage in conversation or make comment about their experience of living in the home. The manager of the home had sent a written report to the Commission before the visits, and the inspector had been able to get some further information from this. There have been two complaints to the Commission since the last inspection, both of which were upheld. Remedial action was taken to ensure requirements raised in the investigations were met. What the service does well: What has improved since the last inspection?
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 6 New owners took over in May 2005 and the present manager was appointed in January 2006. The changes have had different effects on residents and their relatives as well as staff working within the home. Some have taken the effects of the change in their stride such as one resident who told the inspector, “If you’ve had a long life, like I have, the only change I worry about is the change in my purse”. A relative expressed a similar view and told the inspector “ If you don’t expect change, then you can’t expect things to improve. Our hope is that, once things settle down, they are going to get better. We’ll give it a chance and see”. One resident, however, said that she “is starting to forget who is who now as there have been so many comings and goings and whoever they are, they’re always rushing around and understaffed”. Some relatives have also been affected and unsettled by the changes, particularly as they noticed the effect this had on some residents Notes from a recent staff meeting, residents meeting and other records completed by the home’s owner, all confirmed that the changes had made an impact on life in the home. There were, however some signs that the groundwork was being prepared for services to be improved. Some improvements had been made in the way care plan records were being developed and maintained. More effort was being made to get residents involved in making decisions about day-to-day activities and choices. The manager had tried to develop different ways of keeping relatives and stakeholders in touch with information about the home. This included an introductory letter to relatives telling them about her appointment, informing them of news from the home and inviting them to get further involved in the home. Staff confirmed that training opportunities are improving. A programme of regular staff supervision still has to be established, and this is something that the manager says she is starting to develop. The programme of annual appraisals was said to be almost complete. What they could do better:
The service user guide needs to be reviewed and revised to include more detailed information for potential residents. There is a need to develop quality assurance systems including residents surveys and what existing / previous residents and stakeholders say about the service. An audit of all bedrooms must be undertaken to make sure that the facilities meet the required standard. An audit of furnishings and fittings should also be undertaken so that a programme of maintenance and replacement can be developed.
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 7 The plans of care viewed showed that they did not set out all of the resident’s personal, health and social care needs nor did they all include likes and dislikes. All risks must be identified and action taken to reduce or manage these. The plan must tell staff precisely how they should meet these needs. The plan should be written with the input of the resident if possible and then kept under review. This is so that the information in it is current and accurate. Any new needs that are identified should be added to the plan of care. Current medication procedures should be changed to minimise the risk of maladministration. Thorough checks must be made on all staff, including their work history and explanations for any gaps. Management systems need to be in place to show what training staff have undertaken, how future training needs are identified and what training is planned. The manager should undertake, as a matter of urgency, a health and safety hazard check throughout the home to ensure that residents and staff are safe at all times. The service’s general administration and record keeping systems need to be significantly improved. 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 Residential Care Home DS0000063777.V308786.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 Residential Care Home DS0000063777.V308786.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): 1,2,3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission information was not detailed enough to fully assist prospective residents in deciding whether the home could meet their needs. EVIDENCE: A resident who was trying to decide whether to take up long stay residency or not said that the guide did not give her enough useful information to be able to make an informed choice. Two residents’ files contained no evidence that they had received written confirmation that their care needs could be met before they were admitted. Neither resident was aware of any contract between themselves and the home. The resident’s files did have a copy of the home’s contract in place but other than a name and room number, no other details were recorded and no signatures had been made. The manager makes an assessment of a resident’s needs before they are admitted to the home.
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 10 Hillcroft Residential Care Home DS0000063777.V308786.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The information from pre-admission assessment records was not always transferred to a written care plan. Care plans did not provide enough information to identify residents’ health, personal and social care needs and how these were to be met. Risks to residents’ health were not properly managed. Current medication procedures did not fully minimise the risk of maladministration. EVIDENCE: A new system of care planning is still being developed within the home. As arrangements stand, it would not be possible for a new carer to be able to go to one source and identify what care they were required to give to the resident. Care plans systems should be able to provide this level of information, especially as agency care staff are used within the home on a regular basis. Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 12 Separate daily records were of a poor standard and gave little information about whether a residents care needs had been met as required or not. There was little evidence of review. Medication practices within the home need to be reviewed, as observed practices were noted not to be safe. The observed practices could lead to incidents of maladministration. Staff treated residents with dignity and respect. Privacy was an issue for several residents. The layout of the home, coupled with the way staff are deployed and routines of daily living activities, means that some residents are denied opportunity of privacy. One resident told the inspector that although she was happy with the care staff, they did not have enough time to attend to her. She said, “They do a great job under the circumstances, but I can’t go to my room to get a tissue or potter around, as I need help, and staff are not available to take me.” She then went on to say what this meant in terms of her privacy: “I can’t see people in private – there’s no privacy in this place at all – when (my relative) comes and I want to talk about things – our future and our personal things, I can’t because we both get so upset and don’t want other people to see us worrying about each other so much”. Hillcroft Residential Care Home DS0000063777.V308786.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were restricted in the choices they were able to make by the routines of the home itself. Residents were not always satisfied with the meals provided. EVIDENCE: Resident’s own accounts of their experiences within the home demonstrated how their experience of life in the home did not tally with their expectations. One resident, for example, told the inspector that she preferred to get up and go to bed at particular time, yet limited staff availability and practices within the home meant that this did not happen. The same resident told the inspector that she liked to “have a long soaky bath”, but because of limited bathing facilities and staff availability, she had been denied this choice. Another resident told the inspector that her fees had been significantly increased without notification and that she was not sure what additional services she could expect for this increase. She had received no new contract. The inspector observed several visitors coming and going over the days of the inspection and noted that they were warmly greeted and attended to by staff. Residents spoken too all confirmed that contact with relatives, friends and the wider community were encouraged by staff.
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 14 Observations at meal times on the day of inspection showed that dinner and teatime meals were a largely regimented affair. Many service users needed to be assisted to the toilet before meals. This meant that staffs were pressed to make sure that everybody was ready for meals on time. Many service users were put into wheelchairs in order to move them quickly to the dining room in the time available. This limited their opportunity for mild exercise in order to maintain mobility. Several residents remained seated at the dining table in their wheelchairs throughout the meal. Three relatives commented that the food was good. Comments from residents themselves were less positive. Their comments included, “Food is poor – they do everything on the cheap.” “It’s alright, but I don’t look forward to it” and “Heinz must make a fortune from this place.” Hillcroft Residential Care Home DS0000063777.V308786.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, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures ensure residents and their relatives are fully aware of how to make a complaint about the home. Other policies and procedures, together with ongoing staff training, helps to keep residents safe from harm or abuse. There have been two complaints to the Commission since the last key inspection. EVIDENCE: The complaints procedure in the service users guide included all the required information. Residents and their relatives said they knew how to make a complaint if necessary. A rolling programme to train staff in the Protection of Vulnerable Adults (POVA) has been started. A notice on the staff notice board showed evidence of forthcoming events. POVA checks are made on all staff before they are appointed. There have been two complaints to the Commission since the last inspection in November 2005. Both were received in February 2006. The first complaint was referred to the home manager for investigation. The outcome of this investigation upheld part of the complaint, which was that bedding in a resident’s room was stained. The home manager undertook remedial action.
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 16 An inspector visited the home in response to the second complaint. There was evidence to uphold part of this complaint; that a young carer had been left in charge of the home, and that there was some poor practice with regards to resident’s medication. Hillcroft Residential Care Home DS0000063777.V308786.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): 19,20,21,22,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were a considerable number of hazards around the home, which risked residents’ and staff members’ health and safety. Several residents rooms were sparsely furnished and gave little evidence of the resident’s own personal stamp. EVIDENCE: A considerable number of hazards were identified throughout the home. These included wheelchair footplates being left in a corridor, wheelchairs stacked outside the dining room and the handles protruding into the main doorway, pest control boxes laying loose and uncovered in the laundry and hallway, and hazardous liquids being improperly placed and secured. The manager should assess these risks and take action to minimise them.
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 18 Several bedrooms seen by the inspector had minimal furniture, and in some rooms the furniture was in need of repair and refurbishment. One resident told the inspector that her room was sparsely furnished, but added, “Although I was told that I could bring my own furniture in”. An audit of all bedrooms must be undertaken to make sure that the facilities meet the required standard. An audit of furnishings and fittings should also be undertaken so that a programme of maintenance and replacement can be developed. A shower room on the top floor was in a state of repair and could not be used by residents. A mattress was stored in the bathroom on the middle floor. A member of care staff told the inspector that this particular bathroom was rarely used, as “it is more convenient to use the one downstairs”. A specialist hoist had been provided for one resident who required this, although it was stored in her own bedroom and cut down the amount of useable floor space that was available. One resident told the inspector that she would like to use her own bedroom as somewhere where she could gain privacy. But, because she needed staff to take her to and from her room, and staff were always too busy, this choice was denied. The home was clean throughout, apart form areas identified in the kitchen and laundry. There were no offensive odours. Hillcroft Residential Care Home DS0000063777.V308786.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Services provided by the numbers and skill mixes of staff did not always meet residents’ needs. The recruitment policy and practices did not always fully protect service users. Management systems did not show what training staff have undertaken, how training needs are identified and what training has been planned. A staff appraisal system was in place, and the manager was developing a system of regular supervision. EVIDENCE: One resident told the inspector that staff are “… always so busy and rushing doing things that they don’t have time to talk to you”. Insufficient records were held in the home for the inspector to be able to determine which staff had been on duty and in what capacity at any one time. Rotas did not show whether senior staff, who provide management cover in the manger’s absence, were working shifts to provide care or management cover. There was no system of recording that showed the actual hours worked by any member of staff on any specific day. A common theme of the conversations that the inspector had with residents and staff was that they considered the home to be understaffed. On the evidence available, it was not possible for the inspector to determine whether it was the number of staff
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 20 members, or the way in which they were deployed, which gave rise to these views. An immediate requirement notice was issued. This required the responsible persons to take action to make sure that the home is, at all times, staffed at a level which ensures that residents needs are met. Staff files were poorly maintained, and a sample of those viewed showed that thorough checks had not always been made with regard to their work history. Some staff photographs were also missing from their files. Staff confirmed that a programme of appraisals has now started, but that there is no formal supervision process at present. Hillcroft Residential Care Home DS0000063777.V308786.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): 31,32,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced in the care of older people and is steering change to ensure that the services is based on the best interests of residents. There is no recognised internal quality assurance system. EVIDENCE: The manager of the home has a registered managers award and has been in post since January 2006. She has introduced a considerable number of changes, particularly to the care planning system, changes to the environment to ensure safety, staff working practices, administration and getting residents involved in making decisions about day to day activities and choices. The manager had also tried to develop different ways of keeping relatives and stakeholders in touch with information about the home. This included an introductory letter to relatives telling them about her appointment, informing
Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 22 them of news from the home and inviting them to get further involved in the home. The manager told the inspector that, with so many changes, she has had to prioritise her work. Bu, she is aware of those areas which still require attention, such as administration and record keeping, staff supervision and training, and introducing quality assurance systems. The manager told the inspector that a lot of custom and practice within the home has led to services being based on staff needs rather than resident’s needs. She is slowly changing this, but said that she does not expect change to be made overnight, as there has to be better consultation with staff and residents to achieve this. As part of this programme, she has introduced a programme of staff appraisals, and plans to shortly introduce a formal staff supervision programme. The manager was also aware that the standard of record keeping within the home needed to be improved to ensure that residents rights and best interests are safeguarded, and stated that she is working on this. Plans to build a walkway to the outside of the building will allow the manager to identify more appropriate office facilities and proposed adaptations will ensure that her office provides her with a better administrative space than she has available at present. Hillcroft Residential Care Home DS0000063777.V308786.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 2 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 2 2 3 2 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 3 2 2 2 Hillcroft Residential Care Home DS0000063777.V308786.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. Standard Regulation Requirement Timescale for action 30/08/06 1 OP2 5 (b) (c) & Schedule 4 14 (1) (d) All residents must be provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately) 2 OP4 3 OP7 15 No resident must be offered 30/08/06 placement within the home until they have been provided with written confirmation that their care needs can be met within the home. The care plan for each individual 30/08/06 resident must clearly set out their personal, health and social care needs and how they are to be met. Care plans must be regularly reviewed and where, as a result of review, changes in a resident’s care needs have been identified, the care plan must be revised and amended to reflect this. Residents and/or their representatives must have the
DS0000063777.V308786.R01.S.doc 4 OP7 15(1)(2) 30/08/06 5 OP7 15(1) 30/08/06 Hillcroft Residential Care Home Version 5.2 Page 25 opportunity to be involved with the drawing up and review of care plans. 6 OP7 12(1) The registered person must ensure that planned care is carried out to meet the needs of the resident Risk assessments and risk management strategies must be included within all residents’ care plans. Care plans must contain details of residents’ likes, dislikes and preferences about their daily life and routines. Food storage and food issue systems must be improved so that they can demonstrate that resident’s nutritional needs (or otherwise) are being met. (Previous timescale of 01.12.05 not met) Arrangements must be made to protect residents’ personal belongings. The registered person must develop and maintain a programme of maintenance and replacement of bedroom furniture Activities likely to increase the risk of spread of infection must cease. This would include the use of the kitchen as a thoroughfare to other parts of the home / garden. All areas of the home must be kept clean and reasonably decorated. This includes the kitchen and laundry.
DS0000063777.V308786.R01.S.doc 30/08/06 7 OP8 13(4) 30/08/06 8 OP14 12(2)(3) 30/08/06 9 OP15 16 (g) Schedule 4 (13) 30/08/06 10 OP24 12(4) 30/09/06 11 OP24 13(4)(c) 30/11/06 12 OP26 13(3) 30/08/06 13 OP26 23(2)(d) 30/08/06 Hillcroft Residential Care Home Version 5.2 Page 26 14 OP27 18(1)(a) The registered person must ensure that there is sufficient staff on duty at all times and deployed in such a manner so as to meet the needs of the residents at all times. 30/08/06 15 OP27 18(1) (a) Schedule 4 (7) 30/08/06 A staff rota, completed in ink, which shows: - the names of all staff on duty at any time during the day and night (including agency staff) - in what capacity the member of staff is working (e.g. manager, senior care, carer, domestic, cook etc. - the start and finish time of the staff members shift, must be maintained at all times. A system to confirm that staff have completed each session as shown on the roster must be developed. 16 OP29 19 & Schedule 2 18(1) The registered person must ensure that all information required under this regulation are obtained and retained on file Staff must receive training appropriate to the work they are to perform. This would include: structured induction training and training in safe working practice topics A system for reviewing and improving the quality of care must be established and maintained. Written records of all financial transactions must be properly maintained at all times. (Previous timescale of 01.12.05 not met)
DS0000063777.V308786.R01.S.doc 30/08/06 17 OP30 30/11/06 18 OP33 24 30/11/06 19 OP35 17(2) Schedule 4 (9) (a) (b) 30/08/06 Hillcroft Residential Care Home Version 5.2 Page 27 20 OP37 17(3) (a) (b) All records must be accurately and effectively maintained at all times (Previous timescale of 01.12.05 not met) 30/08/06 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. 2. 3. 4. Refer to Standard OP7 OP7 OP12 OP12 Good Practice Recommendations Care plans should clearly set out the actions to be taken to meet resident’s needs. Residents’ daily progress notes should contain accurate information about the care provided. Staff should receive training in providing suitable activity and occupation for residents with dementia. The activities log should be further developed to include a record of consultation and levels of satisfaction with the activities provided. The registered person should ensure that mealtimes are unhurried and that residents are given sufficient time to eat. Kitchen cleaning schedules should be further developed to indicate cleaning routines, methods and products. 50 of care staff should be trained to NVQ level 2. Environmental risk assessments and strategies should be further developed. This would include the assessing the risks of: - continued use of pest control boxes - inappropriate storage of wheelchairs / other items so as to cause fire hazards 5. 6 7 8 OP15 OP26 OP28 OP38 Hillcroft Residential Care Home DS0000063777.V308786.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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