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Inspection on 07/02/07 for Hillcroft Residential Care Home

Also see our care home review for Hillcroft Residential Care Home for more information

This inspection was carried out on 7th February 2007.

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

What has improved since the last inspection?

There was a statement of purpose and service user guide to inform residents and relevant others of the services and facilities the home offered. There was a contract/terms and conditions document, which explained the rights resident`s could expect if they wished to reside at the home. Residents were given written consent the home could meet their needs. Wheelchairs were stored in a manner, which did not pose a threat to the health and welfare of residents. Environmental and fire risk assessment had been undertaken to protect the health and welfare of residents and staff. The refurbishment of the kitchen provided a safer environment to cook food. A new cleaning system helped protect the health and welfare of staff and residents. Resident`s doors were lockable and each resident who wanted had a lockable box to safeguard their valuables. The routine maintenance program had highlighted areas of concern within the environment and suitable action had been undertaken to improve the home. The new walkway bypassed the kitchen as a thoroughfare and minimised the risk of contamination of food. All areas of the home were clean and improvements to the kitchen and laundry ensured these areas could be easily maintained. Recruitment procedures protected residents from possible abuse. The staff rota clearly showed the names, roles and times staff worked. The staff rota demonstrated sufficient members of staff were employed to help meet resident`s needs.

What the care home could do better:

The registered manager should ensure every resident is now issued with the terms and conditions of residency. Where a resident is unable to give their written consent a family member should be contacted. Each resident should be aware of their rights when accommodated in residential care. The registered manager must ensure the plans of care be developed to clearly demonstrate the needs of a resident and the required action to produce a good outcome for each individual. The registered manager must the ensure plans of care are reviewed in a detailed manner on a monthly basis to ensure staff are up to date with the changing needs of residents. The registered manager must ensure the daily records of residents reflect the care they receive for good information to be available to any person who has the right to view them. The registered manager must ensure the nutritional, pressure area and mobility needs are regularly assessed and include a falls risk assessment to fully meet the needs of residents. Two members of staff said, "We have been short staffed but we are getting there. We have had to employ agency staff" and "We have enough staff but it would be better if we had our own team". The responsible person should look at alternative ways to employ regular staff and provide better continuity of care for residents.Quality assurance questionnaires must be undertaken to gain the views of and react to the changing needs of people and professionals connected to the home.

CARE HOMES FOR OLDER PEOPLE Hillcroft Residential Care Home 16-18 Long Lane Aughton Ormskirk L39 5AT Lead Inspector Mr Graham Oldham Unannounced Inspection 7th February 2007 10:00 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.V328093.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.V328093.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 sv22susan@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.V328093.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). 23rd June 2006 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. A statement of purpose and service users guide is available for residents or their families to be informed of the facilities and services the home provides. The fees for Hillcroft range from £320 to £375.50 per week. This does not include individual costs for hairdressing, toiletries, newspapers, continence aids, transport or chiropody. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection, which included a visit to the service, took place on the 7th February 2007. Much of the information gained was obtained from talking to the registered manager, two members of staff and two visitors. Three residents were case tracked. One resident case tracked was unable to verbally contribute to the inspection. Case tracking gave the inspector an overall view of the specific care for the individual resident by checking the plans of care, other documentation and talking staff. Two staff were questioned about the residents case tracked to ensure they were familiar with the care required for each individual. The inspector took detailed notes during the inspection, which have been retained as evidence. Paperwork examined included plans of care, assessment documentation, policies and procedures or documents relevant to each standard. Staff were directly and indirectly observed interacting with residents. A tour of the building was conducted. What the service does well: There was a statement of purpose and service user guide to inform interested parties about the services and facilities the home had to offer. Residents were assessed prior to admission and received written confirmation their needs could be met. Assessment allowed staff to be aware of each residents needs before they entered the home. Resident’s case tracked said, “Staff help me when I need it. They have got me going again” and “I do most things for myself but on the whole staff are lovely”. Another resident said, “The girls help me a lot – they are all nice”. One visitor said, “I am very satisfied with the care my mother gets. She is well looked after. It’s brilliant”. Residents were satisfied they were well looked after. Residents case tracked said, “You get a good choice of food and they make sure I follow my diet” and “The food is marvellous. I am eating well here. You always get a choice”. Another resident said, “The food is smashing, we get enough and you have a choice but I am not fussy”. Residents appreciated the food served at the home. Residents case tracked said, “I have to be careful which activities I join in because of my arthritis – but I do play bingo and dominoes. I do some gentle exercises” and “I have been out at Bingo – to church with my friends. I like to join in the activities”. Another resident said, “I like to watch television and prefer my own company. I don’t like to join in the activities”. Leisure activities were suitable to resident’s tastes. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 6 Resident’s case tracked said, “There are no problems with visiting – they bend over backwards to help them” and “They are good with everybody”. Another resident said, “My daughter and her husband visit me nearly every day – there are no problems with visiting”. A visitor said, “Staff make me welcome and make a cup of tea”. There were no problems with visiting. Visiting at the home was encouraged for the benefit of residents. The complaints procedure was accessible and allowed residents to voice their concerns. Policies, procedures and training protected residents from possible abuse. Residents case tracked said, “My room is lovely and I have some of my belongings” and “My room is very nice and comfy. The room is warm and I have my own toilet”. Another resident said, “I have a grand room”. A visitor commented, “It’s clean and tidy. The home is lovely and always smells nice. It’s a nice place and he is happy here”. The improved environment at the home met resident’s expectations. Safeguards were in place to protect the health and safety of residents and staff. Resident’s case tracked said, “They treat everybody the same. We are one big happy family. The staff are kind and helpful. It’s an excellent home” and “I am happy. The girls are lovely. I thank God for what I have got. Its got a lovely atmosphere and I can recommend it”. Residents were happy with their choice of home. What has improved since the last inspection? There was a statement of purpose and service user guide to inform residents and relevant others of the services and facilities the home offered. There was a contract/terms and conditions document, which explained the rights resident’s could expect if they wished to reside at the home. Residents were given written consent the home could meet their needs. Wheelchairs were stored in a manner, which did not pose a threat to the health and welfare of residents. Environmental and fire risk assessment had been undertaken to protect the health and welfare of residents and staff. The refurbishment of the kitchen provided a safer environment to cook food. A new cleaning system helped protect the health and welfare of staff and residents. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 7 Resident’s doors were lockable and each resident who wanted had a lockable box to safeguard their valuables. The routine maintenance program had highlighted areas of concern within the environment and suitable action had been undertaken to improve the home. The new walkway bypassed the kitchen as a thoroughfare and minimised the risk of contamination of food. All areas of the home were clean and improvements to the kitchen and laundry ensured these areas could be easily maintained. Recruitment procedures protected residents from possible abuse. The staff rota clearly showed the names, roles and times staff worked. The staff rota demonstrated sufficient members of staff were employed to help meet resident’s needs. What they could do better: The registered manager should ensure every resident is now issued with the terms and conditions of residency. Where a resident is unable to give their written consent a family member should be contacted. Each resident should be aware of their rights when accommodated in residential care. The registered manager must ensure the plans of care be developed to clearly demonstrate the needs of a resident and the required action to produce a good outcome for each individual. The registered manager must the ensure plans of care are reviewed in a detailed manner on a monthly basis to ensure staff are up to date with the changing needs of residents. The registered manager must ensure the daily records of residents reflect the care they receive for good information to be available to any person who has the right to view them. The registered manager must ensure the nutritional, pressure area and mobility needs are regularly assessed and include a falls risk assessment to fully meet the needs of residents. Two members of staff said, “We have been short staffed but we are getting there. We have had to employ agency staff” and “We have enough staff but it would be better if we had our own team”. The responsible person should look at alternative ways to employ regular staff and provide better continuity of care for residents. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 8 Quality assurance questionnaires must be undertaken to gain the views of and react to the changing needs of people and professionals connected to the home. 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. The summary of this inspection report can be made available in other formats on request. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 9 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.V328093.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP1, OP2, OP3 and OP4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a service user guide and statement of purpose to inform residents of the facilities and services the home provided. There was a contract/terms and conditions document, which provided residents with their rights while accommodated at the home. The assessment and written confirmation residents received ensure their needs could be met at the home. EVIDENCE: The registered manager produced a copy of the statement of purpose and service user guide, which had been amended since the last inspection. The documents gave residents or interested professionals a good insight into what they could expect if accommodated at the home. A contract document, which met the current guidelines of the Commission for Social Care Inspection (CSCI) had been developed since the last inspection. Of three residents case tracked one resident had a signed copy of the document retained within her files. The registered manager was aware that each resident Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 11 must be aware of the terms and conditions for residing at Hillcroft. Every resident (or a family member) should be issued with a copy of the terms and conditions for residing at the home to understand their rights. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 and OP10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care did not fully identify the health care needs needs of residents. Medication policies and procedures protected the health and welfare of residents. Residents were satisfied their privacy and dignity was maintained and were satisfied with their care. EVIDENCE: Three residents were case tracked during the inspection. Plans of care had not been sufficiently developed to enable staff to be able to read them and be fully aware of the up to date needs of residents. The review of plans of care was not sufficient. There was a poor dating system and no evidence to say which member of staff had undertaken the review. Daily notes did not reflect the care staff gave. Advice was given on what constitutes good practice for developing plans of care. This included input from residents or their families. Residents case tracked were satisfied with the care they received and said, “Staff help me when I need it. They have got me going again” and “I do most things for myself but on the whole staff are lovely”. Another resident said, “The girls help me a lot – they are all nice”. One visitor said, “I am very satisfied with the care Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 13 my mother gets. She is well looked after. It’s brilliant”. Staff were aware of the care needs of the residents case tracked. Plans of care should be developed using a recognised format and contain sufficient detail for staff to be aware of the changing needs of residents. Three residents were case tracked during the inspection. Plans of care showed residents had attended health care specialists. There was a record of the food preferences for each resident but this did not constitute a nutritional assessment. The weight of residents was recorded on a monthly basis. The home employed an occupational therapist to assist resident to exercise. There was no evidence to demonstrate the pressure areas of residents had been assessed. A falls risk assessment of had been completed for one resident. One resident case tracked said, “I am going to see the specialist soon and they will arrange it – we only have to say what we want and they will do it”. The deputy manager was advised to get advice from a dietician and tissue viability nurse. All aspects of each individual’s health care must be assessed to fully meet the needs of residents. The registered manager said, “All staff who administer medication have undergone training”. The medication administration charts had been correctly used. There was a controlled drugs cupboard and register. Policies and procedures had been amended using Royal Pharmaceutical Society guidelines. The safe administration of medication protected the health and welfare of residents. All residents, including two residents case tracked were satisfied that they were treated privately by staff and their dignity was maintained. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 and OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The leisure activities offered at the home were suitable to resident’s tastes. Visiting was unrestricted for the benefit of residents. Residents were offered choices to maximise their satisfaction. Food was satisfactory to residents and met their nutritional needs. EVIDENCE: Resident’s case tracked said they were satisfied with the activities on offer. The registered manager had improved the system for recording which activities were popular and had bought new equipment to stimulate residents. An occupational therapist provided gentle exercise. Leisure activities were suitable to resident’s tastes and helped occupy resident’s time. Residents and visitors said visiting was unrestricted and allowed positive social contact. Residents said they were offered choice within the daily routine and for many aspects of their lives. The choices residents made helped maintain their independence. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 15 The cook said, “I talk to residents on a regular basis and amend the menu accordingly”. All comments made by residents case tracked were positive. Other residents were also positive about the food served at the home. Food served at the home met residents expectations. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 and OP18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was an accessible complaints procedure for residents to voice their concerns. Adult abuse policies, procedures and staff training protected residents from abuse. EVIDENCE: Two complaints had been made to the CSCI since the last inspection. Both complaints had investigated within the timescales required. The complaints procedure was written in the service user guide and each resident had a copy. Residents were able to complain to improve the services and facilities the home provided. Protection of vulnerable adults training (POVA) had been undertaken by some members of staff and a further six staff were taking POVA training on the day of the inspection. There were adult abuse policies and procedures for staff including Lancashire County Councils to follow a local initiative. There was a copy of the ‘No Secrets document. There was a whistle blowing policy. There have not been any allegations of abuse made since the last key inspection. Adult protection systems guarded residents from possible harm. Hillcroft Residential Care Home DS0000063777.V328093.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 – OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was satisfactory for residents and provided a warm and comfortable home. EVIDENCE: A tour of the building was conducted on the day of the inspection. All communal areas and some bedrooms were inspected. Many improvements had been made to the home and included a refurbishment of the kitchen, new bedroom furniture, new carpets and a new walkway for staff to bypass walking through the kitchen. New furniture such as easy chairs had also been provided for some residents. Wheelchairs were stored in corridors were residents did not have to pass and were not a threat to their health and safety. The cook carried out environmental checks and used a recognised cleaning system to protect residents from possible harm. The home was clean, tidy and no offensive odours were present. Residents and a visitor commented on the homes cleanliness. Environmental controls such as restricted window openings, radiator covers and hot water temperature controls protected residents from Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 18 possible injury. Maintenance was carried out in a controlled manner although a handyman was available to carry out urgent tasks to keep the home in a suitable manner. Both the fire services and environmental health departments had undertaken visits. New fire doors and improved kitchen cleaning systems helped improve the safety of residents. There were suitable infection control systems in place to protect the health and welfare of staff and residents. All residents spoken to on the day of the inspection were very satisfied with their rooms. Rooms had been customised to resident’s tastes and many residents had personalised their rooms with their own belongings. The warm and homely atmosphere provided suitable accommodation for residents. Hillcroft Residential Care Home DS0000063777.V328093.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 and OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were employed on each shift to be able to meet resident’s needs. There was a recognised induction and foundation training system to enable staff to gain competency. Recruitment systems protected residents from possible abuse. EVIDENCE: There was a staff rota, which demonstrated the numbers and skill mix of staff on duty. Recruitment was proving difficult and on the day of the inspection two of the four members of staff on pm duty came from an agency. The manager said recruitment was very difficult the Responsible Individual was looking at different strategies such as employing staff from overseas. Both staff members spoken to said there were enough staff on duty but they would prefer permanent staff. It is advised that the responsible person talk to the permanent staff before deciding upon any action. Sufficient staff was employed on each shift to meet the needs of residents. Two staff members confirmed they had received a good training background and had completed NVQ training. Two staff files contained certification the training was undertaken. There was a recognised format for induction and foundation training. One file contained a document, which when complete would demonstrate induction and foundation training meets current standards. Training of staff was ongoing and helped staff to attain the confidence to care for residents in a competent manner. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 20 One staff file for a new employee demonstrated recruitment procedures had been tightened and helped protect residents from possible harm. Hillcroft Residential Care Home DS0000063777.V328093.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 and OP38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was managed by a suitably qualified and experienced person who was registered with the CSCI. Residents were protected from possible financial abuse. Health and safety policies, procedures and staff training protected the health and welfare of residents. EVIDENCE: The registered manager said, “I have completed the Registered Managers Award but I am still waiting for the certificate”. The registered manager had attained relevant qualifications to meet the requirements of the CSCI. Staff and residents meetings were held and recorded by the registered manager. There was an annual development plan. The service had attained the Investors in People benchmark. No quality assurance questionnaires had been Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 22 undertaken to gain the views of and react to the changing needs of people and professionals connected to the home. The registered manager said, “We do not handle residents monies”. When asked how residents paid for things the example given was “the hairdresser leaves a receipt and families pay”. Residents were safeguarded from possible financial abuse. Electrical and gas installation and appliances had been maintained. Up to date maintenance records were observed for the hoists, the lift, Legionella protection, fire systems and extinguishers and a current removal of waste certificate. There was a health and safety policy and procedure. There was a copy of a letter from United Utilities saying home meets current water standards. The registered manager was aware of current legislation. Accident records were suitably maintained. Fire protection systems were up to date and tests undertaken on a regular basis Staff have been trained in many aspects of health and safety issues as described within the staffing section. Safeguards were in place to protect the health and safety of residents and staff. Hillcroft Residential Care Home DS0000063777.V328093.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 3 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hillcroft Residential Care Home DS0000063777.V328093.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 Requirement Timescale for action 30/04/07 2. OP7 15(1)(2) 3. OP7 15(1) 4. OP7 12(3) The registered manager must ensure the care plan for each individual resident must clearly set out their personal, health and social care needs and how they are to be met. (Brought forward from 30/08/06) The registered manager must 30/04/07 ensure care plans are 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. (Brought forward from 30/08/06) The registered manager must 30/04/07 ensure residents and/or their representatives must have the opportunity to be involved with the drawing up and review of care plans. (Brought forward from 30/08/06) The registered manager must 30/04/07 ensure plans of care contain details of residents’ likes, dislikes and preferences about their daily life and routines. (Brought forward from 30/08/06) DS0000063777.V328093.R01.S.doc Version 5.2 Hillcroft Residential Care Home Page 25 5. OP8 12(1)(a) 6. OP33 24 The registered manager must ensure the health care needs of residents are met. A falls risk assessment; pressure area assessment and nutritional assessment are undertaken. A system for reviewing and improving the quality of care must be established and maintained. 30/04/07 30/04/07 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 OP2 OP7 OP7 OP8 Good Practice Recommendations The registered manager should ensure all residents are issued with a copy of the terms and conditions document. The registered manager should clearly set out the actions to be taken to meet resident’s needs within the plans of care. The registered manager should ensure the daily progress notes should contain accurate information about the care provided. The registered manager should contact professionals to take advice on nutritional and tissue viability assessment. Hillcroft Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Care Home DS0000063777.V328093.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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