Inspection on 12/09/06 for Hillport House

This inspection was carried out on 12th September 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 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

Hillport House 18/11/09

Hillport House 03/08/07

Hillport House 17/01/06

Hillport House 11/08/05

Hillport House 22/02/05

Hillport House 27/06/04

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

CARE HOMES FOR OLDER PEOPLE Hillport House Porthill Bank Newcastle under Lyme Staffordshire ST5 0AE Lead Inspector Peter Dawson Key Unannounced Inspection 12 September 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillport House Address Porthill Bank Newcastle under Lyme Staffordshire ST5 0AE 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) 01782 635073 Staffordshire County Council, Social Care and Health Directorate Ms Pegi Wilde Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10) Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 Dementia (DE) - Minimum age 50 years on admission Date of last inspection 17th January 2006 Brief Description of the Service: Hillport House is a local authority care home, run by Staffordshire County Council. The home specialises in the care of older people who are mentally frail or who have mental health needs. The home is registered for 30 older people. The home is located in Porthill, providing good access to a wide range of local community resources. There are pleasant gardens, particularly an enclosed safe garden courtyard in the centre of the building that can easily be accessed by residents from each of the lounge areas, and which is much used during the summer months. Accommodation is provided on two floors, with access to the upper floor being facilitated by a shaft lift and stairs. There are three separate lounge-dining rooms, along with a small smoke room and quiet room/visitors room. There are three assisted bathrooms and a disabled access shower room, plus ample toilets throughout the building. The home has recently been refurbished with greatly improved facilities at a cost of £250,000. This was completed in June 2006. The environmental standards and overall presentation of the home has been vastly improved. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out mainly with the Care Team Leader (Deputy) of this Local Authority home, who was very knowledgeable about the needs of residents and provided a helpful and open discussion about the care provided. The inspection lasted 6 hours and was carried out by one inspector. 17 people were in residence including 4 for short-stay care. All were seen and several spoken to. The majority of residents have a diagnosed dementia and some mental health needs. The communal areas were inspected and also a sample of bedrooms. Staff on duty provided helpful information and records relating to the inspection process were examined. The recent improvements made to the environment are significant following a major refurbishment of the home over a period of twelve months being completed in June 2006. To accommodate this resident numbers were reduced and very positive steps successfully taken to minimise the effect upon the remaining residents. The result is a vastly improved environment, tastefully refurbished presenting a pleasant, comfortable attractive home. Four relatives provided written feedback direct to the Commission and gave very positive comments about the care provided. All expressed high levels of satisfaction which is summarised by the relative of a very dependent resident who is bedfast and requires total care – the relatives comments were: “Mum has received such high care, the fact that she has survived 6 years, is testament to the high care delivered on a daily basis. We could not have bought better care if we had won the lottery. Mum at present is in bed, we as a family, never fail to find her looking so comfortable, propped on pillows, last week I called at 9.40 a.m. and she was bathed, all her skin (which is very fragile at 87) creamed and was just eating her breakfast. The care provided over the last 6 years has been second to none. I am a retired Registered Nurse and have seen better standards of basic nursing care at Hillport House than in local NHS hospital wards”. These comments were endorsed by a man spoken to during the inspection who visits his wife regularly. She has also been resident for 6 years. He was very happy with the care provided and had no concerns or complaints. He was aware of the complaints procedure but felt able to approach staff direct if he had “any concerns whatsoever”. His exchanges with staff were relaxed and friendly. A visiting District Nurse provided written feedback to the Commission indicating close and positive working with staff at Hillport House and expressing the view that care was to a high standard. This view endorsed the Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 6 discussions with staff concerning nursing interventions relating to pressure area management and other general nursing interventions. Staff felt very positive about working jointly with the nursing service. The results confirmed this positive view. Health care issues were a focus of the inspection and the records and care reviewed positively indicated that there was a pro-active approach to health care matters which were well documented and followed through consistently with health care professionals. What the service does well: What has improved since the last inspection? The major refurbishment has transformed the home. Furniture, fittings, and décor are to a very high standard and provided a very comfortable, welcoming and homely feel to the home. Records in the Controlled Drugs Register are now always accurately recorded. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 7 The NVQ training position has been clarified and the home exceeds the required 50 of trained NVQ staff. Information in staff files is now more comprehensive as required in Schedule 2. Relatives confirm good communication with home concerning all aspects of care and any changes which occur. A staff training matrix is now provided and easily identifies training completed or any shortfalls in training. Staff attendance at fire drills is clearer, easily identifying which staff have received training. 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. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 The quality of this outcome is good This judgement is made using the available evidence and a visit to the service. Pre-admission procedures are in place to ensure visits and assessments are comprehensively completed prior to admission. Reviews of placement follow after 6 weeks. EVIDENCE: There is a Statement of Purpose & Service Users Guide available in the home for current and prospective residents and their families providing the necessary information to enable them to make an informed choice about the homes suitability for their needs. All residents are funded by the Local Authority as required and have copies of contracts made between resident and the Local Authority. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 10 Pre-admission visits to the home are the preferred option, but this is not always possible due to the special needs of this resident group (dementia care). However, relatives are always involved in visiting the home prior to admission and involved in the admission procedures including compilation of care plans. All prospective residents are seen in their current environment prior to admission and the homes own assessment is carried out. There is a document which gives a checklist of required information containing the information recommended in Standard 3. The information is comprehensive but does not include a history of falls. It is recommended that this information is included in the assessment as it is an important and crucial aspect of providing care and completing risk assessments. CCA assessments by Care Management personnel are always obtained prior to admission (no the Single Assessment document). The home have insisted upon this provision including situations of emergency admissions. It is important to have an assessment to ensure that needs can be met prior to admission. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 10 The quality of this outcome is good. This judgement is made using the available evidence and a visit to the service. Health care needs are known to staff and well documented in care planning information. There was evidence that Health care needs are fully met. There is a safe system of medication operating in the home. EVIDENCE: The Care plans of 4 residents were examined including two recently admitted residents and 2 long-term. Care plans were seen to be based upon assessed need prior to admission in the former instance including the homes own assessment and the Care Management Assessment. In relation to the latter changing areas of need over a period of years had been reviewed and revised on a regular basis as required. The care planning format is provided by the Local Authority and provides very comprehensive information concerning all aspects of daily living. All areas of the plan had been completed with the required detail. There was evidence of regular monthly reviews by the Care Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 12 Team Leader. Good risk assessments were in place in relation to resident activity from Moving & Handling to Smoking. The standard of plans were high. Health care aspects of residents were reviewed in some detail both generally and for those care plans specifically reviewed. There was good recording of health care information and the interventions (with outcomes) of health care professionals. Two residents currently have pressure area management care from the District Nursing Service (Records seen) and are low grade and intermittent. Another resident has had pressure area sores also which have now healed. All three residents have good nutritional status – all take fluid and food readily with nutritional supplements given as required. Two residents are bedfast at this time, requiring total care. They were seen and their records clearly define their needs and the actions taken to sustain their current level of health. One has been bedfast for 12 months and has been re-assessed as requiring nursing home care. The relatives of this person have provided written feedback to the Commission (referred to in the summary of this report) – commenting about the exceptionally high standards of care, including health care provided in this home. District Nurses are visiting currently in relation to the 2 instances of pressure area management and the usual monitoring of blood sugar levels etc. There is clearly a very positive joint-working ethos between staff at the home and the District Nursing Service. Written feedback received by the Commission directly from the Nursing Service confirmed this view. A resident with high dependency needs, unable to use the usual range of chairs for sitting purposes, has been provided with a specialist chair by the home (cost £400) to allow her to sit in the lounge area for longer periods, with greater socialisation and close monitoring of her safety. This has improved her quality of life. Evidence of regular weighing of residents was seen. One record showed an impossible loss in a specified period and the presumption was that the entries were not correct. These need to be clearly recorded and investigated where there is significant change. Continence assessments are carried out by the homes staff (non-nursing) and continence aids purchased by the Local Authority home. Access to the Continence Advisor was reported to be available for advice if required. Toileting was reported to be individually assessed and provided at the usual times, although several residents are able to indicate clearly that they wish to go to the toilet when asked. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 13 A resident with tablet control for epilepsy was reported to have small seizures, which are recorded and staff aware of this, although there was not detailed information about action to be taken. A protocol is required in conjunction with the GP to give clear instructions to all staff defining the action to be taken (with timescales) when seizures occur. Seizures have not been nocturnal to date. The majority of residents have dementia, but the home does have category to admit a limited number of people with mental health needs. One resident suffers from a Bi-polar condition, on medication and monitored by Consultant. She spends considerable time in bed, arriving mainly for meals from her room. Staff area aware of the need to closely monitor the mental health status of this person. The medication system is provided by Lloyds Chemists, Wolstanton in the Nomad (MDS) format. The system was inspected and accurate recording was evident. A requirement was made in the last report to ensure any variation in administration of pain relief was authorised by the GP. In one instance seen on this inspection the home felt that the analgesic medication was PRN although this was not stated either on the MAR sheet or the medication which was boxed. This must be further clarified with clear instructions from the prescriber. All medication is reviewed with the local GP practice (all residents registered there). Block bookings of 4 are made with the surgery and staff attend (with residents if feasible) and medication reviews carried out at the surgery. Only senior staff administer medication and the Local Authority procedures have been both comprehensive and regularly reviewed with training. Recently the Authority have arranged distance learning courses which are college based to add an independent aspect to the training and practice. Senior staff are all involved in these courses and find the new perspectives very positive and helpful in their practice. Throughout the inspection observations of interactions between residents and staff were very positive and sensitive. People were seen to be treated with respect. Repetitive behaviour and demands for re-assurance were given with great sensitivity and professionalism. Hillport House DS0000033345.V307703.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The quality of this outcome is excellent. This judgement is made using the available information and a visit to the service. There was evidence of staff routines geared to resident need. Activities take account of the limited concentration spans of residents. Visitors are welcomed and warm relationships observed with staff. Menus prove a varied and wholesome diet. Food provision is good with choice at all mealtimes. EVIDENCE: The majority of residents have diagnosed dementia. Some have a single or dual diagnosis of mental health needs. Most are unable to express a view directly about their care at Hillport House, although some indicated in verbal and other responses that they were happy and settled. Two visitors were seen and expressed high levels of satisfaction with the care provided, one was a man regularly visiting his wife who had been resident for 6 years, he was kept informed of any changes in the health and welfare of his wife. He felt able to approach staff if he felt dissatisfied with any aspect of care. Another friend of short-stay resident said that the needs of his friend were quite demanding at home but that he had settled well and was allowed to wander and investigate many areas of the home as he wished seizing items of interest as he Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 15 wandered. He was surprised at the flexibility of staff in allowing him free access. There is an Activities Organiser who works 8 hours per week providing a range of activities which were listed and available in the home. These included the usual craft-based activities, gardening, music/movement, dancing, ball/balloon games, carpet bowls, skittles etc. Personal manicure/hand massage as well as foot-soak, make up etc. Reminiscence is provided having regard to personal histories and interests. A social history is completed for all residents including their family, working-life and social activities which are important knowledge for this group. Many activities are 1:1 with the inevitable limited concentration spans. It was suggested that the 2 people who are bedfast could be included in the 1:1 activities. A record is kept of all activities and recorded in the daily contact sheets of individual residents. There was good personalisation in bedrooms indicating the individual interests of residents with many family photographs re-enforcing identities. The 3 lounge areas provide a choice of location and company. One lounge had TV as low-noise background, another had background music and a third simply used as a quiet room. A new sensory room has been created following completion of the refurbishment and provides for some people a haven or soft stimulation for peace alone, as they may choose or benefit. The room is used selectively where there are obvious benefits to the person. There is an excellent secure garden area in a central area of the home with access from the main lounge areas. This is a safe area, has good level access, good seating and provides a pleasant and interesting area where residents can sit or wander safely as they choose. It is much used during the summer months. The new gardener/handyperson has enhanced the appeal of the area. There is a dedicated hairdressing salon with weekly attendance of hairdresser. This was taking place on the day of inspection and two ladies spoken to had clearly enjoyed the individual psychological boost and physical benefits of the service. Hillport House DS0000033345.V307703.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The quality of this outcome is good. This judgement is made using the available information and a visit to the service. Relatives indicate they are aware of the complaints procedure. It is recommended that however insignificant they may seem all types of issues/complaints raised by relatives should be recorded in the complaints log. Procedures are known to staff to ensure the protection of residents. EVIDENCE: The complaints procedure is available in the home for visitors and there is a copy of the procedure available in all bedrooms. Residents would generally not be able to make complaints due to cognitive impairment. Relatives in feed- back stated they were aware of the complaints procedure. A visiting relative seen during the inspection was aware of the procedure but would prefer to raise matters directly with staff if that were ever a necessary. He would feel quite comfortable in doing so. A complaint was investigated by the Commission prior to the last inspection concerning poor care but was not upheld. Nevertheless a recommendation was made to improve some areas of recording in personal records. Discussion revealed that “domestic type” complaints were raised – e.g. missing personal items. Although these had previously been recorded as “grumbles” Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 17 this has not been continued and it is recommended that matters raised by relatives in relation to all aspects of care should be recorded in the complaints log allowing future retrospective reference. There has been staff training relating to abuse of older people and there is a copy of the vulnerable adults procedures in the home. Hillport House DS0000033345.V307703.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The quality of this outcome is good. This judgement is made using the available information and a visit to the service. The environment has been vastly improved with an extensive upgrading programme completed in June 2006 and meets current standards. EVIDENCE: Over the past year the home has been totally refurbished at a cost of £250,000. All bedrooms are for single use and 2 additional single bedrooms have been created with internal re-arrangement of rooms. An application has been approved for the number of beds to be increased from 28 – 30. The result of the refurbishment is excellent. All areas have been redecorated and furniture replaced on a large scale. The décor presents a soft, homely and warm atmosphere. All bedrooms are individually decorated and communal Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 19 areas have been tastefully redecorated and refurbished. The main lounge areas particularly are bright, attractive and inviting with good natural light supplemented by concealed ceiling lights. Residents have been involved where possible in choosing wallpapers etc. The whole presentation of the home has been vastly improved. The communal areas and a sample of bedrooms were inspected. Bedrooms are of varying sizes, some quite large – rooms having been divided and additional space provided in others by re-arrangement. Presently there are only 17 residents (numbers were temporarily reduced whilst work was being carried out) and numbers will increase. In this situation it has been possible to allocate particularly large bedrooms to residents who are bedfast or require assistance with moving & handling. This allows room for moving equipment/manoeuvre. A new sensory room has been established with some equipment which will benefit some residents on a selective basis. The smoking room has been relocated – there is currently 1 smoker who is risk assessed and supervised whilst smoking. The shape, size, type and decoration of bedrooms are all individual. All were seen to be well-personalised reflecting the individuality of residents. All bedrooms are lockable this is useful in relation to some residents who may wander. There are 1 assisted bathroom with Parker Bath and separate shower room on the ground floor and 2 assisted bathrooms on the first floor. There are no ensuite bedrooms but adequate number of toilets located throughout the building including several immediately adjoining the lounge areas. Some bedrooms have commodes. There is a sluice facility on each floor with good facilities. The safe garden area central to the home allows residents to sit/wander as they wish. The area is attractive and has good seating reported to be much used in the warmer weather. The Fire Officer has been involved in the changes made to the environment and approved the completion of the works. There are no outstanding issues. The laundry was not inspected on this visit. All areas of the home seen were clean and hygienic. There were no malodours apart from detection in one bedroom seen which was immediately actioned by domestic staff who had not reached that part of the building in the daily cleaning routines. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 20 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 - 30 The quality of this outcome is good. This judgement is made using the available evidence and a visit to the service. Staffing levels are satisfactory. Staff training meets required standards. Recruitment documentation is improving. EVIDENCE: Staffing consists of 5 care staff 8 – 2 (including Care Shift Leader) plus Care Team Leader or Manager. There are 4 care staff (including CSL) on duty from 2- 10. The staffing levels have remained the same although the numbers of residents has inevitably been reduced to accommodate the refurbishment work. Catering staff consists Cook 8 – 5, Kitchen Assistant 8 – 3 and Evening domestic (food and general) from 3 – 8. This means there is effectively a kitchen presence from 8 – 8. Domestic hours are daily 2 staff 8 – 2 and Laundry assistant 8 – 1 (5 days). There is a full-time Handyperson employed. Ancillary staff are supervised by the Head of Hotel Services working mainly 9 – 5. The numbers of staff on duty are adequate for the needs of the current resident group. There is presently one part-time care vacancy in the process of being filled. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 21 Shortcoming were identified in the last report relating to the recording of staff training. This has been addressed with a training matrix put into place (seen on this visit). The training records show that over 50 of staff are trained to NVQ2 and above. This was the target to be met by 2005 and is in place. There has been staff training since the last report in medication, moving & handling, the management of violence & aggression, fire and first aid. Future training plans include further training in these areas for staff as necessary and the appropriate updates where needed. A requirement to provide all information required in Schedule 2 for all staff was made on the last inspection. In relation to new staff records showed that a written reference from previous place of employment was still outstanding. All POVA/CRB requirements had been met. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 22 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): 31-33 & 36 – 38 The quality of this outcome is adequate This judgement is made using the available information and a visit to the service. The home is well run and managed by an experienced Manager. There is positive leadership. Staff at all levels ensure the service is run in the interests of residents. Notifications under Regulation 37 must be provided to the Commission. COSHH items must be securely stored to ensure protection of residents. EVIDENCE: The Registered Manager has been in post over a period of years and has considerable experience in running the home. She has obtained the Registered Managers Award and her skill and experience in providing a service for people Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 23 with dementia is extensive. Senior staff receive training relating to the service category and there are clear lines of accountability within the home and in the hierarchical structure put into place by the Local Authority. A Service Development Manager oversees and visits the home on a regular basis providing supervision and support. There is an open style of management in the home, residents and relatives have direct access to senior staff on a daily basis. Open and positive relationships were observed between staff of all levels. Fire records showed that regular testing of equipment was in place and the recording of details of staff involved in fire drills has been improved following a recommendation of the last report. Drills had been provided for staff at appropriate intervals. A fire risk assessment was seen. There are no outstanding fire safety issues following the recent extensive works. COSHH records were examined on the last inspection and found to be accurately kept. On this visit the store containing some COSHH items on the ground floor was open and unattended. It is important in the interests of resident safety that this area must be kept locked at all times. Moving & Handling training is provided for senior staff with annual updates. All other staff receive training also on an annual basis. All senior staff have the required first aid training ensuring that there is a trained first aid person on duty at all times. Finances were not inspected on this visit. The home confirmed that the unannounced financial audits by the Local Authority Audit Section were still in place. It was clear from checking records that all deaths had not been reported to the Commission as required. The accident record also showed that accidents to residents involving head injuries or other injuries requiring medical attention had also not been notified to the Commission as required. This must be done. Records inspected showed a good professional standard of recording. Care plans were particularly detailed and were accurately completed. Regular supervision is in place for all staff. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 2 Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 25 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 OP8 OP38 OP38 Regulation 12(1) 13(4) 37(a) (c ) Requirement Establish a protocol with clear instructions to all staff for action in the event of seizures Storage area for COSHH products must be kept locked at all times. All deaths and accidents to residents must be reported to the Commission as required Timescale for action 13/09/06 13/09/06 13/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP3 Good Practice Recommendations All complaints must be recorded regardless of perceived importance. Pre-admission assessments should include a history of falls. Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office 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 Hillport House DS0000033345.V307703.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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