Inspection on 22/04/09 for Hillfield Nursing Home

This inspection was carried out on 22nd April 2009.

CQC found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hillfield Nursing Home 24/04/08

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hillfield Nursing Home Grainger Park Road Elswick Newcastle Upon Tyne Tyne & Wear NE4 8RR Lead Inspector Mary Blake Key Unannounced Inspection 09:00 22 and 23rd April 2009 nd DS0000070986.V375257.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillfield Nursing Home Address Grainger Park Road Elswick Newcastle Upon Tyne Tyne & Wear NE4 8RR 0191 2261891 0191 2722821 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) www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Lisa Jane Bamling Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 50 The maximum number of service users who can be accommodated is: 50 24th April 2008 2. Date of last inspection Brief Description of the Service: Hillfield Home is registered to provide care for 50 older people. 47 places are for nursing care and three places are available for service users requiring social and personal care only. The home is situated in a residential area to the west of Newcastle upon Tyne. It is close to all local amenities, the town centre and main bus routes. The NHS contracts for 24 continuing care beds at the home and the home manager and the hospital staff carry out the assessments for these places. Hospital staff carry out weekly monitoring and review of the medical care for the service users they have referred to the home. Accommodation is provided over three floors and there are six double bedrooms. None of the rooms have en-suite facilities. There are suitable lounge and dining facilities on each floor and a large conservatory leading on to the garden. Assisted bathing and toilets facilities are available around the home and there is one central passenger lift. The fees for the home are £366 to £539 per week. Further information about the home is available in the service user guide, which contains the statement of purpose and previous inspection reports. This is kept in the reception area of the home. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star – adequate service. This means that the people who use this service experience adequate quality outcomes. An unannounced visit was made on the 22nd April 2009 with a further announced visit on 23rd April 2009. The Pharmacy inspector will visit during May 2009. The Manager was present throughout the inspection. Before the visit: We looked at: • Information we have received since the last inspection in April 2008. • How the service dealt with any complaints and concerns. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff and other professionals, including surveys. • The Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, was sent to the home for their completion, but was not returned to CQC. “Have your say” questionnaires were sent out to people who have used or had interest in the home, twenty one of which were returned to us. During the visits we: • Talked with people who use the service, relatives, staff and the manager. • Looked at information about the people who use the service and how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit A CQC Pharmacist will be making an inspection of the service in May. We told the manager what we found. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 6 What the service does well: People who use the service and relatives explained the admission process; this usually includes a visit from the manager. This helps new residents identify their own needs and enables staff to meet their needs during their stay. The service gives good support to enable individuals to identify and access health care and has strong links with supporting health professionals, who give excellent health support to people who use the service. The service gives good support to enable individuals to maintain and develop personal and family relationships The home and organisation has good systems to enable people who use the service to share their views and they continue to look at ways of involving people and improving individualised services There is a complaints procedure and in addition the views of people who use the service are actively sought. People who use the service felt their views were listened to and acted upon. People who use the service said, and it was seen, that staff were kind, considerate and supportive. More than fifty percent of staff have undertaken National Vocational Training in Care at level Two or above and exceed the minimum standard, ensuring people who use the service receive care from a skilled and knowledgeable staff team. People who use the service and their relatives commented “Hillfield is very caring- always concerned that as a resident I am taken care of”. Supporting health and social care professionals commented “The management has established a good working relationship with a variety of professionals” “Generally a good home, well managed”. The provider and management have developed quality assurance and consultation with people who use the service, relatives, staff and supporting agencies ensuring they provide a service that meets the needs of individuals. What has improved since the last inspection? Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 7 The Manager has addressed all of the previous requirements and recommendations. The care plan format has identified individual personal and health needs clearly enabling staff to more easily follow the plan and meet the needs of people who use the service. A range of social activities is being further developed and takes place both within and outside of the home and this gives people who use the service the opportunity to meet, mix and socialise with others. The gardens and sitting area have given people who use the service more opportunity to enjoy being outdoors. The food provided is of a good standard, with good choice and variety. The dining rooms (although the décor is poor) are well laid out with good staff attendance enabling people to have a pleasant and social mealtime. The provider is developing the quality assurance systems and ways of improving the service they provide to people and the manager has implemented monthly meetings for people who use the service and their relatives enabling them to express their views on the service. What they could do better: The home is not furnished and decorated to an adequate standard and does not provide comfortable and pleasant surroundings for people who use the service. Individual bedrooms do not have sufficient furnishings and are in need of redecoration. Bathrooms and showers are of a poor standard with a limited number of assisted facilities this does not enable people who use the service to feel more comfortable and supported to enjoy this time. The communal areas are poorly decorated and furnished. Throughout the building it was evident that the home is in need of redecorating and refurbishment. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hillfield Nursing Home DS0000070986.V375257.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 Hillfield Nursing Home DS0000070986.V375257.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions to the home are appropriately managed and people who use the service know how their needs will be met. EVIDENCE: Pre-admission assessments are undertaken and reflect the needs of the people who use the service. Care plans had good information to ensure that the home can meet the needs of the prospective service user. The manager is involved in the decisions and in the majority of instances visits the people herself prior to Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 11 their admission. The service is efficient in obtaining a summary of any assessment undertaken through care management and working closely with the care management team. The assessment focuses on achieving positive outcomes for people and ensuring that the facilities, staffing and specialist service provided by the home meet the diverse needs of individuals. People who use the service and their relatives spoke of visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier. The people who use the service also have a care management assessment, which is provided to the home on admission. An individual care plan is produced from these documents. Continuing Care admissions are organised directly with the hospital and are well managed. People who use the service commented, “I am sure I made the right choice coming here” Hillfield Nursing Home DS0000070986.V375257.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and support that is well planned and takes into account their diverse needs whilst promoting their privacy and dignity. EVIDENCE: All people who use the service have a care plan which includes an assessment of their needs and a plan of how these should be met. Southern Cross documentation includes risk assessments for prevention of falls, wound care, and moving and assisting as well as assessment tools for clinical areas such as continence promotion. These had been completed to a good standard, which reflected the health needs of the people who use the service. The care plans were up to date and contained the information to assist the staff to care for the people who use the service. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 13 The Manager had ensured that all recorded information is reviewed and summarised on a monthly basis. The people who use the service receive personal support the way they prefer and their physical and emotional health needs are met. Staff were confident when giving care and are supported by effective training in areas such as moving and handling with health professionals providing individual training for staff. The individual health needs of people who use the service are identified and people are supported to access community health services such as doctor, district nurse, dentist, and optician. The end of life wishes of people who use the service were recorded within their care plans, links had been established with supporting health workers and staff were undertaking training in palliative care. People receiving continuing care have the support of a Consultant Physician, specialist health professionals and specialist palliative care team. People who use the service and their relatives commented, “I have put on weight and feeling a lot better since I came here” “you can get all the help and support you need” “nice atmosphere in the home” “staff are willing to help” “they provide good care”. Staff training has been undertaken to provide awareness and additional support for health related needs. People who use the service feel their privacy and dignity is respected and that they are listened to and what they say is acted upon. Staff receive training that helps them to make sure that everyone is treated with respect, and as an individual. Staff help people make their own decisions and provided information and assistance when it is needed. Staff were friendly toward the people who use the service and were attempting to engage them in conversation. They have a good knowledge of the needs of the people living in the home and the nursing staff are giving good direction and leadership to help them in the day-to-day delivery of care. Health and social care professionals commented, “staff meet individual needs and wishes well” “update and review care plans well” “try to ensure that people get a good variety of food”. Hillfield Nursing Home DS0000070986.V375257.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life and experience of activities meets people’s expectations of the service. People are supported to live full and active lives, and keep links with family and the local community. EVIDENCE: People who use the service were generally happy and enjoyed being able to move freely around the home. Relatives and people who use the service felt that there was a developing social activities programme both within and outside of the home and this was thoroughly enjoyed by all. Each individual has a ‘pen picture’, which outlines their interests and activities they have taken part in on a daily basis. Individuals have the choice to follow their spiritual beliefs and attend church services if they wish. The spiritual beliefs for people who use the service/families nearing the end of their life were particularly well Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 15 supported. Staff had taken time to discuss with all involved their individual wishes and provided a detailed plan of care to meet their cultural needs. The home has sought the views of the people who use the service by questionnaires, meetings, individual social assessment and family reviews. The daily activities that had been provided were varied and thoroughly enjoyed. The social activities coordinator helps develop and support the social interests of people who use the service. A programme of activities was available and being referred to by people who use the service. People are encouraged to go to places in the local area and families are encouraged and supported to take them out and about. The local community participates in home events, which people said they really enjoyed. People who use the service take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. They said they are able to make choices about how they spend their day. The individuals’ bedrooms were personalised but the decoration and furnishings in many rooms were poor. People who use the service have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. The meals served were good and people said they enjoyed the food, which was well cooked. Staff support was on hand. The tables were nicely set and lunch was seen as social occasion. Hot and cold drinks were readily available. The chef is part of the staff team and made themselves available to people who use the service for comments and requests. The menu has been reviewed and the Nutmeg system for nutritional balance implemented. People who use the service were positive about the choice and range of food available. People who use the service commented, “provides us with lovely meals” “food is usually good” “would like more meals out” “more trips out on the mini bus” Staff assist and encourage people who use the service to maintain family links and previous friendships, respecting the individual’s wishes. Relatives commented, “could do with more trips out” “there are more things going on now”. Staff seek permission prior to entering individual rooms and were communicating well with people. People who use the service were observed to move freely around their part of the home. Hillfield Nursing Home DS0000070986.V375257.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns have access to an effective complaints procedure and have their safety and rights protected. EVIDENCE: The home ensures that people who use the service and their relatives are aware of the complaints policy by making it available in a variety of places. Complaints are managed satisfactorily and the necessary action taken and recorded. The complaints procedure is displayed in the home and available to individuals and their families. The complaints record was examined and was satisfactory. People who use the service and their relatives spoken to know how and who to complain to and were confident that their concerns would be dealt with commenting, “any concerns or worries are dealt with straight away” “staff listen to your queries and try to sort things out”. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 17 Staff have undertaken training on the Protection of Vulnerable Adults and there is further training planned. Staff were aware of the whistle blowing policy and felt able to raise concerns if necessary. The manager was aware of the need to protect all people who use the service. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25 and 26 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The facilities are designed to meet the needs of people who use the service. It is homely but is not well decorated or maintained. EVIDENCE: Throughout the home there was evidence of poor decoration, furnishings are repairs and a full inspection of the building was undertaken with the manager. The findings are summarised Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 19 Individual bedrooms Many were poorly decorated, vanity units, bedside cabinets, tables and wardrobes were worn and/or damaged, armchairs were damaged or stained, many did not have armchairs, and carpets were worn and/or stained. Showers and bathrooms Decoration poor, walls damaged, ceiling tiles missing or stained, flooring and tiling stained or damaged. Extractor fans dirty and/or broken. Locks broken. Bath/shower chair rusty. Toilets Decoration poor, walls and sinks surrounds damaged, flooring and ceiling stained. Corridors Decoration poor, paintwork to walls and woodwork damaged. Ceiling tiles missing or stained. Fluorescent lights not covered and/or not working Lounge/dining areas Decoration poor, carpets stained and/or worn. Insufficient lounge chairs Smoking room Damaged ceiling and walls. Carpet burned. Sluice rooms Ceiling tiles damaged or missing. Walls damaged. Not lockable General Heating pipes exposed in corridors, bathrooms, bedrooms, communal areas where heating system had been updated. Water temperatures were satisfactory but radiators (on top floor) although self guarded type were hot to touch. Extractor fans not working and/or dirty Insufficient flip top bins Three food serving trolleys (baine marie) used for serving food were worn and damaged Residents and relatives commented, “place is looking a bit shabby” “would look better if it got a makeover” “doesn’t reflect how nice the home is” Staff commented, “need refurbishment like new furniture, carpets etc.” “home needs new furniture and carpets” “relocation of the smoking room” “home needs to be repaired, new furniture, new carpets and needs a modern buzzer” “we are concerned around the smoking room of residents inside of the home” “need better equipment” “problems with boiler breakdown, effecting the heating and hot water in certain areas of the home which has impacted on client care, but generally not their well being or contentment significantly” “ Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 20 the building could do with refurbishment as it is now outdated” “be redecorated to give the best impression possible” Health professionals commented “the home is looking drab and in need of updating” “the state of the décor doesn’t reflect on the good care being provided” “need a wider range of equipment” The cleanliness within the home was good with no offensive odours. The laundry was well organised but does not appear to have separate areas/access for dirty and clean laundry. The Providers regulation monthly reports from November 2008 comments upon the home needing refurbishment but no programme or action plan was in place. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are adequate numbers of appropriately skilled and experienced staff to care for the people who use the service. The recruitment processes in place protect people who use the service. EVIDENCE: Staffing rotas showed that there are enough staff on duty to meet the necessary staffing levels. People who use the service and their relatives were positive about the staff support and attitude. People who use the service commented, “pleasant” “very helpful” “the staff are good” Relatives commented, “have time to keep you informed”. Recruitment procedures within the home are safe. Records confirm that appropriate checks are carried out for all staff. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 22 The home has an induction programme and the manager is currently developing the training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of people who use the service. Some staff had undertaken refreshers in mandatory training but this wasn’t evident for all staff. Staff said that they are undertaking or had completed National Vocational Qualification in Care level 2 (NVQ) or over, with over 50 staff having NVQ 2 or above. Staff share training with the local health service and on the day of inspection were receiving individualised training on transferring and use of aids by an occupational therapist. Regular staff meetings are held for management, carers (day and night) and ancillary staff and these were documented. Policies and procedures are available. Health professionals commented, “staff willing to help” “carers are involved in residents’ goals”. Staff commented “nurses and carers do their job well” “we try to meet the needs of residents by providing them excellent services which they require” “the home cares for their residents well being with empathy toward them and their families/friends” “the home also care for the well being of their staff” “all staff are supportive and happy about the job” “good team work” “we have a good support framework amongst ourselves” Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is consistent and effective and offers leadership to the staff; this improves the life of the people living in the home and protects them from harm. EVIDENCE: The manager of the home has satisfactorily completed her registration as a manager and is only responsible for Hillfield. The manager has introduced Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 24 systems to enable residents, relatives, staff and supporting health professionals to voice their views and has an open door policy. Regular meetings had been held for people who use the service, relatives and staff to discuss and review practices and the running of the home. The people who use the service and staff made positive comment about the manager and staff team; they gave examples of improved practices and of the staff team taking time to listen and respond to any concerns they may have. The providers’ quality assurance and audit systems are comprehensive covering areas such as medication, home manager audit, catering. Monthly provider visits are undertaken with good written reports and but all issues are not addressed. The manager has an open and inclusive style that was commented upon by staff, residents and relatives. She undertakes daily walkabout to talk to people who use the service, staff and visitors, has an open door policy and holds weekly evening surgeries for any queries. Staff commented, “our home manager ‘Lisa’ is very helpful and nice” “ she always tries to satisfy the relatives, staff and residents” “Lisa always keeps the staff right” “the home would function better with more help and input (financially) from Southern Cross” “the manager is well supported” Health and social care professionals commented, “The home manager is very flexible and open to new ideas” “Eager to be part of the team” “have seen a difference for the better since this manager came to Hillfield” “communication has improved” “home has improved since the new manager is in place” Accident and risks assessment are appropriately documented with good links established with the local health falls prevention programme. Staff supervision records showed a comprehensive process and that the timescales of six per year would be met. Records, policies and procedures were established, clear, concise and appropriately recorded and stored. Fire and other system testing had been undertaken at the recommended timescales and systems established for maintenance to be undertaken when necessary. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 4 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 1 2 x x x 1 1 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X x 3 X 3 Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP19 Standard Regulation 13 (4) (a) 16 (2) (c) 23 (2 ) (b)(d)(p) Requirement The provider must address the following premises issues 1) damaged and worn bedrooms to be redecorated 2) damaged vanity units to be replaced 3) damaged bedroom furniture to be replaced 4) sufficient armchairs to be provided 5) damaged bedside tables to be replaced 6) communal lounges and dining areas to be repaired and redecorated 7) sufficient lounge/dining chairs to be provided in communal areas 8) damaged wood paintwork to be repaired 9) damaged ceilings to be repaired and painted 10) damaged walls to be repaired and painted 11) damaged and stained carpets to be replaced 12) extractor fans to be cleaned and repaired 13) heated food trolley DS0000070986.V375257.R01.S.doc Timescale for action 01/09/09 Hillfield Nursing Home Version 5.2 Page 27 2 OP30 18 (1)(c) 13 (6) (3) to be replaced 14) shower/bath chair to be replaced 15) exposed pipework to be covered and made safe 16) radiators surfaces do not exceed safe temperatures 17) provide adequate lighting in corridors 18) repair/provide locks to all toilets/bathrooms and sluice rooms. The provider must provide all staff with mandatory training in the following areas 1) First Aid 2) Infection Control 3) Health and safety 4) Safeguarding 01/09/09 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 OP26 Good Practice Recommendations To review the laundry system to ensure that safe hygiene practices are met. Hillfield Nursing Home DS0000070986.V375257.R01.S.doc Version 5.2 Page 28 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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