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Inspection on 30/06/05 for Hillesden House

Also see our care home review for Hillesden House for more information

This inspection was carried out on 30th 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

All of the service users who were spoken with, and this was the majority of people, praised the home, the care they received, and the staff. They all considered that full attention was paid to meeting their health needs and that should they require a GP there was no hesitation towards them getting the care that they received. They also considered that staff showed them great respect and respected their wishes. `I get help when I need it and they let me cope when I want to do things myself.` `The staff are all good` were typical of the comments received. Procedures for the receipt, storage and giving of medication followed good practice. Service users said that they enjoyed their food and the menu plan showed a good variety of nutritious meals. All confirmed that they could make alternative choices should they not want something off the day`s menu. Mealtimes are relaxed occasions which service users find enjoyable, chatting both with each other and with the staff in the dining room that overlooks the spacious grounds. Service users confirmed that their family and friends were always made very welcome at the home. There were no complaints from any of the residents at Hillesden House during the visit, and no complaints had been received by the home since the last visit. The manager is very hard working and puts in a considerable number of hours over and above her contractual hours in order to provide the best service that she can to the service users. At the visit she was supposedly on annual leave during the whole of that week, but staff advised that she had been at work for some part of the day every day. She was out taking someone to a hospital appointment at the start of the visit, returned for the inspection although this was not required, and had a meeting planned with senior staff for that afternoon. She is supported by a dedicated staff team.

What has improved since the last inspection?

An action plan, with timescales, was required by the Commission of the new owners to address some environmental shortcomings at the home. These included such requirements as radiators to be guarded or replaced, painting both internally and externally, new carpets to be selectively fitted, locks fitted to bedroom doors etc. It was pleasing to find that the action plan is being followed to the level agreed by the Commission. This should mean that the health, safety and welfare of the service users in relation to environmental issues will gradually improve. There is a requirement for the work required within the action plan to continue to the agreed timescales.

What the care home could do better:

It was disappointing to find that care needs assessment of new service users, and care plan recording overall had slipped somewhat, including shortfalls in individual risk assessment recording and a lack of recorded reviews of care. To balance this statement it must be noted that the Deputy Manager who undertook some of this work has retired, and also that the issue was being addressed by the manager via delegation to senior staff at the home. An improvement in needs assessment recording, care plan recording, undertaking of risk assessments and monthly review of the care of all service users is required. The home has no formal system for gaining service user views relating to the planning and development of the service and this must be addressed.The manager needs to continue to delegate appropriate tasks to senior care staff so that sufficient time is allocated to these tasks, from which service users would benefit, and for the development of staff themselves.

CARE HOMES FOR OLDER PEOPLE Hillesden House Mount Road Leek Staffordshire ST13 6NQ Lead Inspector Irene Wilkes Unannounced 30 June 2005 10:00 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. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hillesden House Address Mount Road Leek Staffordshire ST13 6NQ 01538 373397 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) Mrs Tervinder Kaur Malhotra Miss Jane Mansell CRH 22 Category(ies) of OP 22 registration, with number DE(E) 6 of places Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Brief Description of the Service: Hillesden House is a two storey extended Victorian villa situated on a quiet road on the outskirts of Leek, being approximately 1.5 miles from the town centre. The home provides long term and respite care provision for up to 22 older people over the age of 65. 6 of these may have dementia as their primary diagnosis. Communal accommodation is provided on the ground floor comprising 3 lounges and a dining room. 6 single bedrooms of which 1 is bedsit accommodation are also found on the ground floor. First floor accommodation offers 8 single bedrooms, 1 with en-suite facilities, and 4 shared rooms. From the windows of the first floor extensive views over the countryside of the Staffordshire Moorlands are afforded. More than adequate toilet and bathing facilities are provided offering both domestic and assisted types. The accommodation is comfortably furnished and offers a homely environment. There are spacious grounds with adequate parking facilities to the front of the home. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a part day in June 2005, and was completed by 1 inspector. There are currently 18 service users living at the home out of a possible registration number of 22. A tour of the home and grounds was undertaken. A senior care worker and 2 care staff were on duty at the visit. The manager was on annual leave, but returned to the home when she was made aware that the visit was taking place. Full discussion was held with the manager, and the other 3 staff were spoken to in varying degrees. There were no visitors to the home during this visit. The care plans of 5 service users were examined in detail. The information contained in 3 of them was cross referenced with the 3 service users to further confirm this evidence, and further clarification about life in the home was sought in varying degrees from the other service users. In this way a fuller picture of what it is like living at Hillesden House was built up. Staff practice was observed throughout the inspection. Staff records regarding training were seen, as were records relating to medication, food, staff rotas, complaints and maintenance. The home had a change of ownership some 3 months ago, and an action plan was required by the Commission to show how some environmental shortfalls would be addressed. Progress against the action plan was a particular focus of the inspection. What the service does well: All of the service users who were spoken with, and this was the majority of people, praised the home, the care they received, and the staff. They all considered that full attention was paid to meeting their health needs and that should they require a GP there was no hesitation towards them getting the care that they received. They also considered that staff showed them great respect and respected their wishes. ‘I get help when I need it and they let me cope when I want to do things myself.’ ‘The staff are all good’ were typical of the comments received. Procedures for the receipt, storage and giving of medication followed good practice. Service users said that they enjoyed their food and the menu plan showed a good variety of nutritious meals. All confirmed that they could make Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 6 alternative choices should they not want something off the day’s menu. Mealtimes are relaxed occasions which service users find enjoyable, chatting both with each other and with the staff in the dining room that overlooks the spacious grounds. Service users confirmed that their family and friends were always made very welcome at the home. There were no complaints from any of the residents at Hillesden House during the visit, and no complaints had been received by the home since the last visit. The manager is very hard working and puts in a considerable number of hours over and above her contractual hours in order to provide the best service that she can to the service users. At the visit she was supposedly on annual leave during the whole of that week, but staff advised that she had been at work for some part of the day every day. She was out taking someone to a hospital appointment at the start of the visit, returned for the inspection although this was not required, and had a meeting planned with senior staff for that afternoon. She is supported by a dedicated staff team. What has improved since the last inspection? What they could do better: It was disappointing to find that care needs assessment of new service users, and care plan recording overall had slipped somewhat, including shortfalls in individual risk assessment recording and a lack of recorded reviews of care. To balance this statement it must be noted that the Deputy Manager who undertook some of this work has retired, and also that the issue was being addressed by the manager via delegation to senior staff at the home. An improvement in needs assessment recording, care plan recording, undertaking of risk assessments and monthly review of the care of all service users is required. The home has no formal system for gaining service user views relating to the planning and development of the service and this must be addressed. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 7 The manager needs to continue to delegate appropriate tasks to senior care staff so that sufficient time is allocated to these tasks, from which service users would benefit, and for the development of staff themselves. 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. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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 standard(s) 3 An assessment of each service users’ needs is undertaken before they move into the home. However, more care needs to be taken when the assessments are completed to ensure that all relevant information is collected and recorded so that all of the needs of each person can be addressed. EVIDENCE: The individual files for the newest permanent resident and a gentleman staying at the home for respite care were seen. In both instances there were complete admission details in place, referring to next of kin, GP etc. Needs assessments had been undertaken in both instances, but whilst these documents generally gave an outline of the individual requirements of each service user, they would benefit from greater attention to detail being paid. For example, the gentleman entering the home for respite care required his weight to be monitored, but his weight on entering the home was not recorded at the initial assessment (his weight when leaving hospital, recorded on different scales was available). An attempt was made to discuss with both service users the procedure that had been followed when they were admitted into the home. However, one Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 10 service user was not feeling well that day and did not want to talk, and the other service user was a little confused. The initial assessments and their shortcomings were later discussed with the manager who is in the process of delegating some responsibility for the running of the home to senior staff. A number of tasks were until recently completed by the Deputy Manager who has now left, and new systems need to be introduced to ensure that her duties are redirected to others. The manager was open and agreed that there were some shortfalls due to pressure of work, but outlined that these were being addressed. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The home promotes the meeting of individual need in practice, but the recording of such needs falls short of the standard required, which means that some issues of the care that is required could be missed. The home responds quickly to any health concerns and medication procedures are sound. This means that service users are confident in the care that is being provided and know that their welfare is at the heart of the service. EVIDENCE: The care plans of 5 service users were inspected. At the previous inspection there had been some improvements in recording and so it was a little disappointing to find at this visit that there were again some shortcomings. The care plans in each case would benefit from being more fully completed, there were limited risk assessments in place, including a lack of assessments for moving and handling, and the most recent reviews of the care plans had taken place in February 2005. To balance this statement it must be stated that the care manager had already arranged to hold a meeting that afternoon with the senior staff of the home to gain their involvement in taking responsibility for this area of work. The inspector sat in on this meeting and agreed that the systems proposed should address these shortfalls. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 12 Whilst the care plans overall could be improved, they showed good recording of each individual’s health needs and the action taken when any health problems were experienced, i.e. full involvement of the GP and District Nurse, hospital appointments, dental, ophthalmic etc. On initial arrival at the visit the manager, although supposedly on annual leave was out taking a resident to a hospital appointment in her own time, from which she returned some 2 hours later. All of the service users spoken with said that the home responded promptly should they have any health issues and there was never any hesitation in calling a GP should this be required. The home has appropriate policies and procedures in place related to medication. Medication receipt, handling, storage and return are appropriate. Part of the medication round was observed and good practice was seen relating to dispensing of medication, discreet observation of the medication being taken, and recording. A member of staff was asked about medication procedures and her knowledge was sound. The majority of service users were spoken to, and several also were happy to chat in more depth about their lives in the home. One had lived at the home for 9 years, another for 4 years, and several up to 4 years. Each one was very clear that the staff treated them with the utmost respect, provided them with assistance promptly should they require it, but also allowed them to do things for themselves where they wished. They confirmed that their privacy was respected at all times. Throughout the day the staff were discreetly observed assisting service users and talking to them. In every instance good practice was observed and there was a genuine rapport between the service users and the staff. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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) 13 and 15 Service users receive visitors as they wish. There is a high standard of food provided in congenial surroundings. These factors contribute to the residents feeling positive about their day to day lives. EVIDENCE: Service users said that that they could receive visitors to the home at any time and likewise some of them were taken on visits by their family, or on holiday. No visitors came to the home during this unannounced inspection, but a number of visitors have been spoken with in the past and confirmed that they have always been made most welcome. The Service User Guide also reiterates that visitors are welcome at any time. The lunchtime meal was observed and consisted of chicken drumsticks, potatoes, cauliflower and peas followed by apple pie and custard or rice pudding. A choice of meal was clearly given; a gentleman said that he didn’t want a cooked lunch and he was offered an alternative without hesitation. The menu book was seen and showed that there was a monthly rolling menu. This showed a good variety of food on offer and that alternatives were provided. The dining room is pleasant with a large window that overlooks the front grounds. Lunch was a relaxed affair and service users were seen chatting with each other and with the staff. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 14 Several service users were asked about the food and the large majority were positive. 1 gentleman said that breakfast and lunch were too close together for him. The manager agreed to discuss this issue with him. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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) 16 The home takes its responsibility seriously regarding the addressing of complaints, and all aspects of the policy and recording system are sound. This means that service users are confident that any issues raised will be acted upon appropriately. EVIDENCE: The home has an appropriate Complaints Procedure in place that clearly explains how a complaint will be dealt with, timescales etc. Should a complaint be made it is recorded in the complaints log, together with a summary of the action taken and the outcome. The Complaints Log was examined and there have been no complaints made in the last financial year. The service users spoken with were well aware of their right to complain and who to complain to. The procedures for addressing any abusive practice have been seen before and are appropriate. Service users all stated that staff treated them very well. The standard will be inspected fully at the next inspection. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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) 19, 20, and 26 An action plan agreed with the Commission to address some shortfalls in the environment is being steadily addressed within the approved timescales. This means that the health and safety of service users is less compromised, and that the Commission’s confidence in the providers’ willingness to meet the requirements remains in place. EVIDENCE: At previous inspections a considerable number of environmental improvements have been required. The home has new owners and an action plan was received from them prior to their registration setting out how the improvements would be addressed, with timescales. This was a requirement of the Commission. This was the first visit since the new owners were registered, and progress against the action plan was reviewed in discussion with the manager and during a tour of the home. The requirements and progress against timetable are as follows: Paint the inside and outside of the building E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 17 Hillesden House A Handyman has been employed and is undertaking a progressive painting programme. An external contractor has commenced work on the outside. Fill in the swimming pool. Timescale of 12/18 months An estimate of costs has been received. Fit locks on bedroom doors. Estimate of costs received. Being addressed on an individual planned basis. Fit guards to radiators or change to low surface temperature type. Timescale – summer, 2005 An order for low surface temperature radiators has been placed. Fit thermostatically controlled radiator valves in service user bedrooms. Being addressed within the above. Reposition a call bell in a service user’s bedroom Has been addressed. Make secure the steps leading to an outside balcony. Timescale: immediate Steps made secure. New ramp to replace steps to be fitted longer term. Replace carpets in identified areas. Timescale: rolling programme to start summer 2005. Orders for carpet were about to be placed at the visit. Provide wash hand basins in the 3 remaining bedrooms. Timescale: 18 months Some plumbing issues. To be discussed. - - - - The owners are also replacing the dining chairs on a planned replacement programme. This was not required in the action plan but was pleasing to note. Service users said that their beds and bedrooms were comfortable. 2 service user bedrooms were visited and they were comfortable and homely. Communal facilities were pleasant with a good range of seats to meet individual preferences. At this unannounced visit all areas of the home were found clean. Staff were observed following appropriate procedures to prevent the spread of infection, i.e. wearing of protective clothing, washing hands, dealing with laundry etc. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 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 and 30 The home ensures that sufficient numbers of appropriately trained staff are on duty at all times with someone in a senior position always being available. This ensures that the needs of service users are met in a timely and efficient manner. EVIDENCE: The home has a complement of 20 staff plus the manager, and is registered for 22 service users. The staffing rotas showed that on each day/evening shift there is a senior care worker on duty and 2 carers. From 9pm until 8am there are 2 carers on duty with the manager, who lives on the premises, being available on call. There are currently 2 staff vacancies. The hours normally worked by these 2 staff members are being covered by the remaining staff undertaking overtime hours. The staff on duty at the visit corresponded to the set rota. Those service users who were asked considered that there were sufficient staff on duty at each shift to meet their needs. No staff files were looked at on this occasion to confirm that the home’s recruitment policies and procedures were being followed. Several have been inspected in the past and were found appropriate. The manager confirmed that the same practices are being followed, and that everyone working in the home has a Criminal Records Bureau (CRB) check, and that this is obtained prior to commencement in the home. The standard will be more thoroughly checked at the next inspection. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 19 The training file and matrix was inspected and this showed that mandatory training in respect of moving and handling and emergency aid was up to date. The manager confirmed that dates for training for fire safety and basic food hygiene had been received. The next visit will monitor that this training has been completed by all relevant staff. The owner has undertaken a recent course in dementia awareness and is planning to pass on this knowledge to staff. Evidence was seen that comprehensive training is in place for induction and foundation training. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 20 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) 33 and 38 The home is concentrating on environmental improvements that will best protect the health, safety and welfare of the service users once completed, and this is as required. Nevertheless attention is still required to other aspects of health and safety, including appropriate assessment of individual risk and completion of mandatory training. Unless these are all in place the standard cannot be achieved, which could compromise the care of service users. EVIDENCE: The manager agreed that the home has not as yet introduced any formal system of quality assurance/quality monitoring involving the views of service users. Service users confirmed that they were not asked about their views. However, it is clear that the new providers undertook and are continually revisiting the action plan developed to meet the requirements of the Commission for the home relating to required environmental improvements, and it is accepted that this is a priority. However, the manager did relate that the service users would be involved in choosing colour schemes for the Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 21 communal areas, and it is suggested that this involvement be extended where the tasks permit, to other refurbishment work being undertaken. Meanwhile the development of effective systems to gain the views of the service users about all aspects of life in the home is required. This could be via anonymous user satisfaction questionnaires, individual and group discussion and evidence from other records, brought together to inform the future planning for the service. This has been a requirement of previous inspections and must be addressed. The registered manager ensures that there are safe working practices in place in terms of fire safety, first aid, infection control. COSHH (Control of Substances Hazardous to Health) requirements were met in terms of safe storage and the information available for staff. The home employs an outside contractor to provide all health and safety advice, including the provision of written policies, risk assessments for all safe working practice topics and associated written records of all risk assessments for the environment. As stated previously in this report, and also found at previous inspections, there is a lack of written risk assessments in place related to areas of individual need, including safe moving and handling. This must be addressed as a priority. To balance this statement, there was evidence to show that this is to be addressed by the home from the date of this inspection. Evidence was seen that staff receive induction and foundation training to TOPSS specification. Some mandatory training (basic food hygiene and fire safety) is required, although dates have been received for the completion of this training. Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 22 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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x x 2 Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 23 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. 2. 3. Standard 3 7 7 Regulation 14 and Schedule 3 15 and schedule 3 15 and Schedule 3 23 Requirement Record all relevant information relating to new service users at the initial care needs assessment Record all information relevant to the service user in their care plan Review the care plans with the involvement of the service users on a monthly basis, and record the findings Continue with the action plan to improve the premises to the stated timescales agreed by the Commission (this is a requirement from the registration date of the new owner and is being incrementally addressed by agreement of CSCI) Implement the introduction of a quality assurance system Ensure that individual risk assessments, as applicable, are put in place for each individual service user Ensure that all mandatory training is up to date Timescale for action 31/8/05 31/8/05 31/8/05 4. 19 as per action plan timescale 5. 6. 33 33 24 15 30/9/05 31/8/05 7. 8. 30 18(1)c 30/9/05 Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 24 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 31.6 Good Practice Recommendations The manager, together with senior care staff should consider the delegation of further tasks to them Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Hillesden House E51-E09 s.63416 Hillen House Unannounced v. 236077 30.06.05 Stage 4.doc Version 1.40 Page 26 - 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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