Inspection on 03/08/07 for Hillport House

This inspection was carried out on 3rd August 2007.

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 12/09/06

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 Mr Berwyn Babb Unannounced Inspection 3rd August 2007 02:00 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.V348057.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillport House DS0000033345.V348057.R01.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 30 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (30), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (10) Hillport House DS0000033345.V348057.R01.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 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, and 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 [This work was completed in June 2006] been refurbished with greatly improved facilities at a cost of £250,000. The environmental standards and overall presentation of the home has been vastly improved. Fees were quoted to be £134-35p per week for Respite Care, and £439 per week for Permanent Care. The only things not covered by this being such personal choice items as hairdressing, magazines, or sweets. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by a single inspector through the afternoon of Friday the third of August 2007. He spent time observing the dynamics between the staff and people who use the service, but was not able to engage in meaningful two-way conversation with any of the latter. He undertook a formal interview with a member of staff, and had protracted discussion with the Registered Care Manager. He examined care plans, staff rota’s, menus, Fire records, and other documents pertaining to health and safety. He toured the interior of the home observing all the communal areas, and a sample selection of the private bedrooms. He found everything to be in good order, with staff engaging both professionally and kindly with the people who use the service, and being attentive to their assessed needs, and their known preferred choices. What the service does well: What has improved since the last inspection? All three requirements of the last inspection had been promptly and positively responded to, and there is now a clear protocol in the appropriate care plan, for what staff must do in the event of that person suffering a seizure. Further, the storage area for Containment of Substances Hazardous to Health products has now been fitted with a Yale style lock operated by coded keypad, and the Commission for Social Care Inspection has been informed of all deaths and accidents that have taken place in the home. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 6 The recommended protocol for recording any history of falls has been included in the details to be obtained during pre-admission assessments, and even the smallest concerns are now recorded in a grumbles book. 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. The summary of this inspection report can be made available in other formats on request. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 7 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.V348057.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgment was made using all the available evidence including a visit to the service. Discussion with the care manager and viewing a sample of care plans satisfy the inspector fallen sufficient assessment taken place prior to people who use the service being admitted. The home has proper procedures for the admission of people in emergencies, but does not provide intermediate care as defined by National Minimum Standard, 6 EVIDENCE: The only omission that was found to the preadmission assessment procedure carried out by staff of this home remarked upon in the last report, was that a history of falls wasnt included. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 9 The Registered Care Manager was able to demonstrate, through reference to the documents of several people who have started to use this service since the last inspection, that this is now routinely established. She also confirmed that anybody considering moving into the home was seen in their current environment prior to admission, and that in many cases this was in hospital where they had been admitted following a breakdown of community living. In such circumstances, inevitably, there were times when it would not have been helpful to them to make an introductory visit, but that in these and all other cases, relatives or advocates would visit the home to see for themselves the suitability of the accommodation and care, in relation to their assessed needs, and the likes and choices that they had made in the past, when they were capable of greater expression of their own needs. (Further confirmation of the above statements was made through reading a sample of the personal care plans of the people living in the home, one of which also gave details of the steps taken, in the absence of any known family, to match her with an advocate). Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgment was made using all the evidence available, including a visit to the service. People who use this service had comprehensive care plans that details their assessed needs and personal choices, and how they were assisted to achieve these. The plans demonstrated especially, how attention to the individuals health was being monitored and met, what medications they were receiving, and how best to preserve their dignity, even when they were no longer capable of managing this themselves. EVIDENCE: A sample of care plans were examined including some of people recently admitted to the service. These had been based on a comprehensive assessment of both the known needs, and known and reported choices, likes, and dislikes, of the individual, and details steps taken to assist in both the health and social components of each persons well-being. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 11 There was copious evidence of the input of community health professionals and these included such examples as: Diabetic nurses advising on how best to meet the progressing needs of somebody with that condition; A dietitian giving training to staff on how to ensure that one person had a low potassium input; Community Psychiatric Nurses to advise on a range of needs, both emergent and continuing, and to act as a referral point for the Consultant PsychoGeriatriton. District nurses and Community Matrons to advise on, and attend to, physical problems, including the administration of insulin injections. There was also record of the attendance of a specialist foot care nurse, and of a domiciliary dentist. The home is registered for the accommodation of people who have Dementia, and it is encouraging to record that The Registered Care Manager is a qualified Dementia Trainer, whose experience is available for training both in this home, in other homes managed by the County Council, and in their Day Centres. The care plans reviewed all had an index, which was followed by a review that identified areas of improvement, and in one case it was noted that the care plan had been sent to the social worker so that she could amend her records to reflect the new situation. There was also a section recording the social history of the person, and giving details of family and other links, and this was followed by modules of medical reviews, in which such things were noted as routine blood tests having shown that an individual was anaemic, and the prescription of iron tablets to counteract this deficiency. A full medical history was included, as were a record of visits made by the GP, and health visitor, and any other health professional. Elimination charts were provided, as were regularly reviewed dependency charts. Individual aspects noted included the management of one persons finances by her daughter-in-law, who was paying any unused personal allowance into a savings account for her, and in another care plan though was the request to ASSIST to provide an advocate for the person who had no other known family. There was a programme in the appropriate care plan for the management of events following the regular occurrence of seizures experienced by that person, and in another, instruction for the provision of “Finger foods” for someone with Dementia. Each care plan included an individual risk assessment for evacuating the building in case of fire. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. This judgment was made using all the available evidence including a visit to the service. People who use this service was seen to be offered an appealing and balanced diet, to be enabled to maintain family and friendship links (or have links made on their behalf) to experience activities designed to fulfil them, and to be receiving care from a group of staff who were committed to meeting their needs. EVIDENCE: As detailed in the last report the majority of the people who use this service have Dementia. Very few are able to express directly a view about their care, and although during this inspection observation of the dynamics between them and the staff of the home indicated that their dignity was being preserved, and that they were not dissatisfied with the way they were being cared for. The Registered Care Manager was open enough to point out that this was an unusually quiet afternoon, and that it was not uncommon for some of the people who have Dementia to become more agitated as the day wore on, especially towards teatime. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 13 Discussion about how people were assisted in occupying their time determined that the home employees an activities coordinator for three sessions each week, and that this person spends most of her time in engaging on a one-toone level. Evidence observed in a care plan corroborated the assertion of the Registered Care Manager that where no family contact was maintained or discoverable, steps were taken to appoint an advocate to both be-friend, and speaks on behalf of that individual. The best example to come from this inspection of how people are assisted to retain some control and choice over the events in their lives, came from discussion and observation around meeting their dietary requirements. The rotation of menus was seen to contain both local delicacies, and to allow for the inclusion of seasonal fruit and vegetable, and to allow for two separate cooked alternatives at the main meal. It was said that four or five people who currently have Dementia, have lost the memory of the sequences required to eat, and staff sit with them and talk them through each mouthful, reminding them to chew, and then to swallow, and tell them when they are going to replenish them with another mouthful. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The outcome for the group of people using this service was good. This judgment was made using all available evidence including a visit to the service. People who use this service were being protected by both policies and procedures designed to enhance their personal dignity, and by staff who were committed to ensuring that any concerns they may have would be heard in the appropriate place, and to doing everything they could to ensure they lived in a safe and dignified manner. EVIDENCE: A formal interview was conducted with a member of the care staff, during which protracted discussion took place over the subject of protecting vulnerable adults, together with ensuring that their voices could be heard. This person recognised the primacy of observation of the non-verbal, and allied this with a thorough knowledge of how the individuals for whom she was key worker normally behaved, so that she could determine if they were in pain, if they were distressed about anything, or if they were afraid. She talked about the use of the locally established and highly regarded advocacy service in cases where it was inappropriate for family to speak for someone, or where they had no family. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 15 In a more particular discussion about abuse, she stated that she and all her colleagues had been on the training course, and that the subject was regularly discussed in supervision and at team meetings. She was correctly aware that anybody who had any contact whatever, could turn out to be an abuser of somebody in the home, and that if she suspected any abuse had taken place, then under the policy agreed locally between all relevant agencies, she must immediately inform the person in charge of the home at that time. As well as being aware of those forms of abuse which make headline news, she was emphatic that anything compromising the dignity of someone in the home, or contravening their expressed or reasonably determined wishes, was an abuse, and should lead to formal investigation. Several times during this discussion she was at pains to state that it was her belief that what she did and felt, equally applied to: Everyone else who works here . No complaints have been received about this service during this last inspection period. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were seen to live in a home that was safe and well maintained, had comfortable indoor and outdoor communal facilities, sufficient and suitable lavatories and washing facilities, the specialist equipment they needed to maximise their independence, their own possessions around them in bedrooms that were comfortable and safe, appropriate lighting and heating and means of calling for assistance when necessary, and an environment that was clean, pleasant, and hygienic, and surrounded by gardens and grounds that were maintained to a high standard. EVIDENCE: Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 17 A cursory visual examination of the exterior of the premises was made without detecting anything to cause concern. Brickwork and paintwork appeared to be in good order, and the majority of Windows double glazed UPVC units, that offer the advantages of better installation, and low maintenance. The grounds were particularly well maintained, with a curtain of shrubs at the boundary of the property giving remarkable insulation from the noise of the two busy roads that adjoin the site. Several small areas were available for car parking, and the tarmac had a very fresh appearance, without weeds or broken areas. In the quadrangle formed by the accommodation and there was a further secure garden, that had been laid out with sensory plants, and which gave people with Dementia and outside space that was not only safe for them, but one where they could experience different sensations of touch, sight, and of smell. Internally a selection of bedrooms revealed a good standard of provision with such things as vanity units radiator guards, appropriate privacy locks, emergency call bells, good-quality furniture and fittings, TV points, and thoughtful details such as bedside lamps activated by just touching the shade. The size of the rooms are varied as some of these had originally been for shared or multiple occupancy, though at this time all were being used as a single, which did not preclude, as the Registered Care Manager pointed out, being able to offer a couple, or say, two sisters, a room together. The current priority for the larger rooms was for those with the greatest mobility needs, to accommodate such things as being able to give assistance from either side of the bed, and to navigate a hoist or a wheelchair. It was stated that the policy of the home was to store the wheelchairs of individuals in their own bedroom, when they were not being used. It was felt that having a dedicated wheelchair enhanced the dignity of the user. In addition to that which the home provided in peoples rooms, there were a wide variety of ornaments, pictures, and other memorabilia, which helped to confirm the identity of the occupants, something that is particularly important for people with Dementia, who increasingly find that they have lost those anchor points that help to remind us of who we are. On the ground floor there was one assisted bathroom with a Parker Bath, and a separate shower room. On the first floor there were two assisted bathrooms. All of these were comfortably decorated and furnished, and fitted with appropriate aids such as hand rails and mobility bars, thermometers, and methods of accessing the emergency call system that had been designed to be safe if immersed in water. Regulators were fitted to all hot water taps accessible to people who use this service. Their effectiveness is tested regularly, and the record of this was later examined in the office. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 18 There was a small but well-equipped sensory room, and the Registered Care Manager stated that a body of knowledge was being built up about whom this was most beneficial to, in times of heightened anxiety. She said that it was not beneficial for everybody, and was therefore used selectively as part of a whole range of inputs designed to improve the life experiences of the people in the home. In line with recently introduced legislation the home has designated a smoking room, and in the absence of any current smokers, this was being used by and Lady who like to spend some time on her own, without having to return to her room. When asked, she indicated that she found this arrangement very satisfactory, but would not use it to the point of being isolated, and in fact, she was later seen with other ladies (currently there is only one gentleman using the service) in one of the lounges. The lounges themselves are situated conveniently throughout the home, and people sit where ever they want to as and when the mood takes them, and staff confirmed that they had no rigid seating plans for people, and would respond to their need wherever they might be, as they found this to be both more dignified and more productive, especially at meal times. The home was clean, warm, well decorated, and tidy throughout, and a special mention has to be made of the staff room, the high quality of which was said by the Registered Care Manager to reflect the esteem in which the staff were held by the management. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service benefit from a staff group of sufficient number and skills mix to meet their assessed and emerging needs, and their personal choices. They are protected by a sound recruitment policy and an ongoing commitment to mandatory and specialist areas of training. A recommendation has been made to review the arrangements for staff undertaking a mixture of duties. EVIDENCE: There were 27 people currently using the service, and their needs were being met by the Registered Care Manager, a Care Shift Leader, and three Care Assistants. The staff rota showed that on the early shift this is strengthened to four Care Assistants, to provide appropriate assistance for people getting up at the beginning of the day. Arrangements for cover at night comprised of two Care Assistants in the home awake and watchful, with access to one member of the management team sleeping in. The cleanliness of the home is promoted by having someone on domestic duty until 8 p.m. at night. The kitchen is serviced both by a cook and a kitchen assistant, until 3 p.m., after which, a member of the domestic staff acts as kitchen assistant to cover the provision of tea. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 20 Discussion took place with the Registered Care Manager about following recommended current best practice in ensuring that anybody undertaking a split shift would complete their tasks in the kitchen, before undertaking work elsewhere in the home. There will be a recommendation to this end. A formal interview was undertaken with a member of the care staff and she confirmed that during the process of her recruitment she had been required to provide written references and a clear CRB check, and that the manner in which it had been done would meet equal opportunities legislation, and be in the best interests of the protection of those people using the service. She went on to confirm that a proper induction process had been followed, including training in all mandatory subjects, and stated that she had received regular updates on the training, as and when the certificates had become due for renewal. She had six years experience of working in the home, and whilst talking about how she would undertake a personal care task, she highlighted the importance of awareness of people’s known preferences and usual presentation, in a home where many people were losing the ability to express themselves verbally in a clear and coherent manner. In recounting how she would give somebody a bath, she displayed regard for their dignity, and also a commitment to preserving whatever independence they possessed, as well as ensuring their health and safety, and offering reassurance and support at all times. She confirmed the input of an activities coordinator three times a week, and the appropriateness of concentrating on one-to-one sessions that did not challenge either the ability or the attention span of the people who use this service. The home and currently has no staff vacancies, and the one long-term sickness absence is being covered by existing members of staff with out recourse to the use of agencies. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35,36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were benefiting from a home run by a person fit to be in charge, and of good character and experience to discharge her responsibilities fully, and to have every effort made to establish what their views about the running of the home would be, and to ensure that these were incorporated into a program of promoting and protecting their health, safety, and welfare Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Care Manager has considerable experience gained over a period of years whilst in post in this home, she holds the Registered Managers award, and has extensive experience of working with people who have Dementia. In discussion with members of staff she was praised for the open and inclusive manner of the way she ran the home, and her support to them both in the care they were offering to people in the home, and in furthering their own career. A review of the fire record showed that alarms were tested weekly, emergency lighting tested monthly, and that training and fire drills were undertaken at the recommended intervals or more frequently, and that equipment was regularly serviced by an accredited company. This home is administered by Staffordshire City Council who are undertaking a consultation process regarding the future of their homes, and the manager has produced a newsletter for relatives and friends of the people who use the service assuring them that: As far as our residents are concerned, it is still business as usual, and we will not allow care standards to slip. We will continue to provide the best possible care for your relative during this time of uncertainty, and wont allow it to undermine our spirits! In deference to the comments made in the last report, all deaths that have taken place in the home since then have been notified to CSCI, as have any accidents that involved head injuries or ones requiring medical attention. A member of staff engaged in a formal interview confirmed that ongoing supervision took place adding: If we have anything to say, we say it, and get it sorted out there and then. Quality assurance was being managed through the regular production of newsletters, and by holding regular meetings for relatives so they could express any concerns they might have about the service, and any compliments that they may wish to have recorded. The home is also visited on a monthly basis by a senior member of the local authority management, and that person produces a formal written report which looks at the various areas covered by the National Minimum Standards, and a copy of this is communicated to CSCI. The uncertainty about the future of the home has not had any detrimental effect on the commitment to maintenance of the property, or the level and quality of care being provided within the home. Recent additions of this have referred to the work being done to protect the financial interests of the people who use the service, where necessary, appointing advocates to act on their Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 23 behalf, whether was no member of family or other suitable arrangement in place. Hillport House DS0000033345.V348057.R01.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP27 Good Practice Recommendations The registered person is recommended to review their procedures in relation to the use of a split shift for domestic and kitchen duties, to ensure that all kitchen duties are undertaken at the outset of the shift, and not following any domestic duties. Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillport House DS0000033345.V348057.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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