Inspection on 06/01/06 for Hillgrove

This inspection was carried out on 6th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Hillgrove 28/06/06

Hillgrove 13/03/06

Hillgrove 09/02/05

Hillgrove 27/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hillgrove 79 Eleanor Road Bidston Wirral CH43 7QW Lead Inspector Les Smith Unannounced Inspection 6th January 2006 09:30 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 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 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. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillgrove Address 79 Eleanor Road Bidston Wirral CH43 7QW 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) 0151 652 1708 Mayflower Care Homes Ltd Mrs Jacqueline Anne McCabe Care Home 23 Category(ies) of Dementia - over 65 years of age (23) registration, with number of places Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: Hillgrove is a large detached property adapted for use as a care home, situated in a quiet residential area of Bidston, Wirral. The home is registered with the Commission for Social Care Inspection for the personal care and support of twenty-three older people who suffer from dementia and other organic psychoses. Accommodation is provided in both single and double rooms on three floors. Access to the upper floors is via a passenger lift. The home is equipped with appropriate aids such as grab rails, ramp, assisted bathrooms and a call alarm system. There is a car park at the front of the home and garden at the rear. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a total of eight hours, one hour of which was a night visit by two inspectors. The inspector spoke to several staff members, residents and visitors. Both staff and care records were examined, as also were corporate documents and certificates. A tour of the premises was undertaken with the manager. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 6 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 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Prospective residents and their relatives can be confident that their needs will be assessed prior to admission and be assured that the home is able to meet those needs. EVIDENCE: The home has a Statement of Purpose and Service Users Guide that detail most of the required information. References to the National Care Standards Commission (NCSC) need to be changed to Commission for Social Care Inspection (CSCI). Detail in the documents falls short of that required in schedule 1 of the Care Homes Regulations 2001. An example of this is the reference to internal documents as the complaints procedure. The complaints procedure should be detailed to include details of who to complain to, timescales for response and what to do if not satisfied including the address and telephone number of the CSCI. All residents or their representative have signed a Statement of Terms and Conditions that includes all required information but this document also requires updating to change the references to NCSC to CSCI. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 8 The manager or deputy manager carry out pre-admission assessments with prospective residents and were possible their relatives or representatives. The pre-admission documentation is adequate but lacking in detail and needs to be developed particularly in respect of cognitive ability and behavioural patterns. Hillgrove provides care for older people with dementia and other organic psychoses. Examination of files and discussion with staff could not evidence that any training in dementia or that any other specialist training has been carried out. This was a requirement of the last report when it was required to have been carried out by 30th April 2005. Prospective residents and their relatives are welcome to visit the home and have trial visits should they wish in order to assess the suitability of the home. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Care plans have been developed to meet residents’ assessed needs but still fall short of the standard required in order to meet the residents’ personal, health and social needs. Medication management is not compliant with current regulatory requirements and places the residents’ at risk of harm or injury. EVIDENCE: The manager has made significant improvements to the care planning process since the last inspection but there remains a lack of risk assessments and inadequate evaluations and reviews. Examination of a random sample of resident files showed identification of needs based on the activities of daily living and included a life profile. There was evidence that care plans are reviewed at monthly intervals, however these reviews were inadequate consisting of a statement such as ‘no change required’ without appropriate justification. Although key workers are allocated to carry out the reviews it was evident that some monthly reviews had not been carried out. The key worker carries out reviews and any changes then discussed with the manager. Evidence was seen that in some cases care plans had been discussed with the residents’ representative but this is not always the case. The inspector was Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 10 informed that collaborative care planning was not always possible due to some residents having no relatives or representative or that family only visited rarely. Daily diary sheet entries were generally inadequate for both day and night shifts. Daily diary sheets must give details of the actual care delivered and how the resident spent their day. There were no risk assessments in place for skin integrity (Waterlow), falls or Nutrition and these must be developed and incorporated into all residents’ care plans. The inspector was informed that at least one resident spent most nights in a chair in the lounge however there was no risk assessment in place or evidence that this had been communicated to or discussed with the residents representative. The chairs in the lounge are not suitable for this purpose and recliner chairs would be more appropriate to meet this need. The inspector found Statements of Terms and Conditions and Social Service agreements in the care files. These documents contained confidential information other than care and it is not in accordance with the Data protection Act 1998 for such documents to be available for all staff to see. Evidence was seen of care input from Professions Allied to Medicine and all residents are registered with a General Practitioner. On the day of inspection one resident was being referred to hospital and the inspector observed numerous efforts made to contact the resident’s family, which was achieved. The Medication Administration Records (MAR) were examined and found to have numerous gaps in the signatures. It is essential that when a medication is not given a reason be given. Eye drops in use were not annotated with the date of opening to ensure that they were discarded after 28 days as per manufacturers instructions. There is no drug refrigerator available and medications requiring this type of storage are kept in a kitchen fridge and a liquid antibiotic preparation was found that belonged to a resident that no longer resided at the home. As noted in the last report handwritten transcriptions on the MAR sheets are still not being countersigned by a second person. There is no storage facility available for controlled drugs and there was one (a night sedation) in current use. This had been dispensed in a blister pack and was kept amongst the other blisters. The controlled drug book record was inadequate being an ordinary hardback notebook ruled into columns by staff. Controlled drug registers are required to have sequentially numbered pages and the book in use does not meet these requirements. Two people must always sign the controlled drug register for the administration of controlled drugs. The record book in use evidenced that this frequently does not happen. It is a serious concern that although this was highlighted during the inspection on 5th January the practice had not changed on the 12th January when a night visit was made to the home to complete the inspection. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 11 Residents and visitors spoken to all confirmed that staff always respects residents’ privacy and dignity. Privacy screens were observed in all shared rooms and the inspector was informed that the fabric in the screens was going to be renewed in the near future. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 As far as possible residents have choice and flexibility in how they spend their day in the home, and are supported and encouraged to make choices thereby promoting maximum independence and individuality for each resident. Meals at Hillgrove are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences EVIDENCE: The activities co-ordinator left the home in December 2005 and the home is currently trying to recruit a replacement for 20 hours per week. There is a programme of activities in place with activities scheduled for both morning and afternoon. The activities provided should be reviewed to reflect the needs and capabilities of the current residents and also provide for one to one activities and interactions were appropriate. Records are kept of the activities and participants. It is recommended that participation in activities be recorded in individual care files. This would allow for profiles of likes and dislikes to be established thereby allowing activities to be tailored to meet needs and preferences of individual residents. Residents are positively encouraged to maintain relationships and contact with friends and family. On the day of inspection the inspector observed numerous visitors to the home throughout the day and residents have the choice of Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 13 seeing the resident in a communal area or in the privacy of their own room was given. A varied and nutritious diet is provided with residents special dietary needs or cultural preferences being catered for. The inspector was shown a two-week cycle of menus which included alternative choices. A record of the meals prepared is kept in a diary. On the day of inspection the inspector observed the mid-day meal being served. Meals were well presented and appeared to be wholesome and nutritious. Staff members were observed helping residents in a discrete, unhurried and sensitive way during the mealtime. The kitchen was well organised and fridge and freezer temperatures are now recorded as required. The storage facilities in the kitchen are in poor condition e.g. a kitchen cupboard was hanging off, and require repair and/or replacement. The food stores were examined and found to be clean, well stocked and well maintained. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has a complaints and adult protection policy and procedure in place to help ensure the safety and welfare of residents. EVIDENCE: Hillgrove has a complaints procedure. It is recommended that the detailed complaint procedure including the address and telephone number of the CSCI be displayed in a prominent position in the home available to all visitors and staff. Complaints are recorded in a comments book along with general and complimentary comments about the home. It is recommended that a separate complaints register be maintained that gives full details of complaint, actions taken, outcome and relevant time scales. All residents are registered on the electoral roll and have their legal rights protected. The inspector spoke to several members of staff who demonstrated an awareness of abuse and adult protection and appropriate policies are in place. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 The standard of decor and furnishings within this home require attention. There is some evidence of maintenance and future planning. EVIDENCE: The inspector toured the home with the manager and observations are as follows: The majority of bedside cabinets in the rooms had trim damaged or missing, a number had handles missing or loose or mismatched replacement handles. In several areas ceiling tiles were damaged or stained. A large number of carpets in both rooms and communal areas are very worn and stained. Furniture in the dining room is in poor condition Décor in the small lounge upstairs and room 11A is particularly poor due to water damage from a leak some months ago. Communal toiletries and razors were present in both the shower room and ladies toilet both of which present risk to the residents. The automatic closure on fire door by room 9 was broken. Rooms 13 and 18 were malodorous Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 16 Window frames in rooms 4,16 and kitchen appear to be rotten. Two of the available toilets had no towels available The bed in room 13 had been made with no cover on the duvet Bed in room 15 had been made with a dirty sheet A sliding door and a toilet grab rail across the aperture secure the stairs to the basement. The door itself does not function properly and the grab rail is coming away from the wall. The grab rail is not adequate protection if the door is left open and a properly fitted safety gate needs to be fitted to ensure that residents’ are well protected. A Fire Safety officer conducted a inspection at Hillgrove on 5th August 2005. Requirements from that inspection have not been met. The inspector was informed that a quote has been obtained for the pruning of the tree overhanging the fire escape but the work has not been carried out. Fire exit signage was seen to have fallen down and the requirement in respect of fire signage is also outstanding. Communal toilets are situated close to rooms and communal areas and are sufficient in number. Hillgrove has various adaptations and aids in place to help ensure that residents’ are supported to maximise their independence. This includes grab rails, handrails, a call system, lift and assisted baths. Residents’ are encouraged to personalise their rooms and evidence of this was seen with personalisation to varying degrees evident in individual rooms. On the day of inspection many of the rooms were found to be cold and radiators had been turned off. The inspector was informed later that it is the responsibility of the day staff to close windows and turn radiators on. The rooms seen on the second visit were found to be significantly warmer and acceptable. Whilst reducing the level of heat during the day via the thermostatic controls is acceptable the practice of turning the radiators off is not as residents’ may wish to spend time in their room during the day and a comfortable temperature should always be maintained. Radiators should be guarded or have guaranteed low temperature surfaces and this is not always the case. The laundry is situated in the basement and has two washing machines and two dryers. Neither of the washing machines have a sluice facility which compromises infection control. A member of staff told the inspector that if any clothing was very badly soiled then it would be disposed of. On the day of inspection the carer doing the laundry had no knowledge of the procedures for defluffing the dryers and a substantial amount of fluff was removed. Build up of fluff in the dryers is a significant fire risk and all staff must be instructed in the relevant procedures to maintain safety. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There are sufficient competent staff employed to meet the assessed needs of the residents but recruitment policies are not robust enough to ensure the protection and safety of residents. EVIDENCE: Care staff are rostered in sufficient numbers to meet the assessed needs of the residents. A visitor to the home when spoken to by the inspector complained that their relative had been sent to hospital on her own without an escort. The provision of two carers on duty from 2200 to 0800 is considered adequate providing there is an on-call system in place should for example a carer be taken ill or have to escort a resident to hospital. The inspector was assured that this is the case but later found a written ‘verbal policy’ dated 30th December 2005 in the staff communication book. This specifically stated that the on-call was for advice only and if an incident should occur one member of staff was to go to the hospital as escort whilst the other remained at the home. Should another incident occur to ring the on-call again and she will come in. The instruction went on to say that the remaining member of staff should not attempt to leave the ground floor e.g. early morning cups of tea. This clearly compromises the care of residents and is not acceptable. There is a high proportion of staff with NVQ qualifications at Hillgrove: 2 have NVQ 4, 1has NVQ 3, 11 have NVQ 2 and 4 are currently working toward NVQ 2. It is strongly recommended that copies of specific training certificates obtained during NVQ qualification be obtained to place in files thereby providing appropriate evidence of relevant training. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 18 A random selection of recently started personnel files were examined and the findings are as follows: Employee A: Commenced 21/11/05 but there was only one reference, no Pova First, No Criminal Records Check and no record of induction. Employee B: Commenced 05/12/05, there was no Criminal Records Check but a PovaFirst was present dated 20/12/05,No references All other documents required were found to be present. The lack of written references was an identified problem at the time of the last inspection and a requirement made then has not been met. The practice of starting employees without appropriate references or checks places residents at risk and must stop. There is no TOPPS compliant induction process in place Staff members spoken to demonstrated a good understanding of their roles and responsibilities. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,37,38 Residents benefit from a manager who is qualified and competent to ensure that the health, safety and welfare of residents is promoted and safeguarded. EVIDENCE: The manager at Hillgrove has only been in post since September 2005 and is currently having her application for registration processed by the CSCI. The manager has previous experience of managing a care home. The manager has made significant improvements as previously mentioned in relation to care planning and has a clear vision and objectives for the future. From discussions with staff and observation it is clear that good relationships are evident with the residents and their families. Staff meetings are held and a notice of the next meeting to be held was seen in the staff room. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 20 No monies are held at the home for residents and any additional charges e.g. hairdressing are invoiced to the residents’ families or representatives. Residents’ and their representatives have access to their records and any information held. Records are kept securely in accordance with the Data protection Act. The fire logbook was seen and regular tests of both the fire alarm system and emergency lighting are carried out. Tests on the water system for Legionnaires are carried out and were last done in June 2005. Hot water outlets are not checked on a regular basis and it is strongly recommended that that checks be carried out and recorded. A valid periodic electrical safety certificate was seen but the inspector was unable to see a gas safety certificate. The required six monthly Loler test certificates for the lift and bathroom hoists were not available. A valid public liability insurance certificate was seen which expired on 8th January 2006. The inspector was unable to evidence that staff had received appropriate training in fire prevention or manual handling. Approximately two-thirds of staff have received first aid training. The inspector was informed that over 50 of residents use continence aids. Disposal of these items is currently via the general waste disposal and suitable arrangements for disposal of this waste must be made. Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 18 3 2 2 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X 3 2 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 4 Requirement The registered person must provide a Statement of Purpose that includes all the information as detailed in schedule 1 The registered person must ensure that staff receives the training appropriate to the work they are to perform. The registered person must ensure that risk assessments (refer to standard 7) are completed and incorporated into all residents’ care plans The registered person must ensure that the receipt, storage, administration and disposal of medications meet the requirements of the Medicines Act 1968 and The Royal Pharmaceutical Society guidelines for administration and control of medicines in Care homes. Timescale for action 28/02/06 2 OP4 12(1) 18(1) 31/03/06 3 OP7 13(4)(b,c) 28/02/06 4 OP9 13(2) 31/01/06 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 23 4 OP9 13(2) The registered person must 28/02/06 ensure that all controlled drugs are kept in accordance with the requirements of the Medicines Act 1969 and the Misuse of Drugs (Safe Custody) regulations 1973 The registered person must ensure that the receipt, administration and disposal of controlled drugs are recorded in a register that meets the requirements of the Medicines Act 1968 and The Royal Pharmaceutical Society guidelines for administration and control of medicines in Care homes. The registered person must ensure that a programme of maintenance and refurbishment is produced and implemented. The registered person must ensure items of risk in bathrooms and shower rooms are securely stored and that communal toiletries are not used The registered person must ensure that the requirements of the 2005 fire inspection are met The registered person must ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated (Refer to inadequate protection of basement stair entrance) The registered person must ensure that furnishings in communal rooms are of good quality and suitable for needs of residents. (Refer to need for recliner chairs) DS0000040990.V276987.R01.S.doc 5 OP9 13(2) 28/02/06 6 OP19 23(2)(d) 28/02/06 7 OP19 13(4)(a) 31/01/06 8 OP19 23(4) 28/02/06 9 OP19 13(4)(c) 28/02/06 10 OP20 16(1, 2) 28/02/06 Hillgrove Version 5.1 Page 24 11 OP25 13(4)(a)(c) 12 OP26 16(2)(j) 13 OP27 18(1)(a) 14 OP29 19 15 OP38 16(2) 16 OP38 23(4) 17 OP38 16(k) The registered person must ensure that all parts of the home to which residents’ have access are free from hazards and unnecessary risks are as far as possible eliminated. (Refer to unguarded radiator surfaces) The registered person must ensure that satisfactory arrangements for maintenance of hygiene are in place. (Refer to lack of a sluice washing machine) The registered person must ensure that there are sufficient numbers of staff on duty at all times to meet the assessed needs of residents’. The registered person must ensure that a robust recruitment procedure is put in place and that all documents as per schedule 2 are obtained and kept in personnel files The registered person must obtain all the relevant safety certificates – Loler tests for lift and hoists and gas safety certificate and forward copies to the CSCI The registered person must ensure that all staff receive training in fire prevention and manual handling The registered person must ensure that suitable arrangements are in place for the disposal of clinical waste 28/02/06 28/02/06 31/01/06 31/01/06 28/02/06 28/02/06 28/02/06 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 25 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 5 6 Refer to Standard OP1 OP2 OP12 OP16 OP16 OP30 Good Practice Recommendations It is strongly recommended that a copy of the complaints procedure be displayed in a prominent place. It is recommended that references to the NCSC in the Statement of Terms and Conditions be changed to CSCI. It is recommended that participation in social and recreational activities is recorded in individual care files. It is recommended that the complaints procedure be displayed in a prominent position in the home. It is recommended that a separate complaints register be maintained. It is strongly recommended that copies of relevant certificates for specific training be obtained from those staff who have completed or working towards NVQ qualifications. It is strongly recommended that regular checks are carried out on the hot water outlets and documented. 7 OP38 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Hillgrove DS0000040990.V276987.R01.S.doc Version 5.1 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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