CARE HOMES FOR OLDER PEOPLE
Hillsdon Nursing Home 37 Springfield Road Lower Parkstone Poole Dorset BH14 0LG Lead Inspector
Marjorie Richards Unannounced Inspection 18th January 2006 09:55 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 Hillsdon Nursing Home DS0000049686.V279179.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. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hillsdon Nursing Home Address 37 Springfield Road Lower Parkstone Poole Dorset BH14 0LG 01202 742753 01202 740114 hillsdon1@btconnect.com 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) Baselink Care Limited Mrs Alison Jane Thomas Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Hillsdon Nursing Home is a large detached property, situated in a residential area of Parkstone. The home is not far from local shops and amenities. Although these are not easily accessible on foot, a local bus route serves Parkstone, Poole and Bournemouth. Limited car parking for visitors is available at the front of the home, with additional parking on nearby roads. Hillsdon Nursing Home is registered to provide care to a maximum of 18 persons over the age of 65 years who are in need of 24-hour nursing and personal care. Accommodation is provided on ground and first floor levels with bedrooms, a lounge, staff areas, (office and nurses station) kitchen and laundry on the ground floor and further bedrooms on the first floor. The home has fourteen bedrooms and four of these are for shared use. Three bedrooms have ensuite facilities. There are sufficient communal bathrooms and toilets sited around the home in close proximity to bedrooms and the lounge. Access to the first floor is via a passenger lift and central stairway. The first floor has a divided level accessed by additional steps. A Stair-Matic stair climber is used to enable residents to access this level. The registered persons have undertaken much redecoration and refurbishment of the property since they became registered in August 2003. Building work is currently in progress, which will include the provision of further bedrooms and a new dining room. At present, access to the large rear garden can only be achieved via a steep flight of steps. However, plans are in hand for a substantial improvement of this area, creating an attractive facility, which will be available to all residents. Hillsdon Nursing Home provides 24-hour nursing and personal care, all meals, laundry and domestic services. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours on the 18th January 2006. Mrs Thomas, the registered manager, was not on duty but the nurse in charge assisted with the inspection. Mr Graham Thomas also made himself available briefly on behalf of Baselink Care Ltd, and this was appreciated. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to view progress in meeting the two requirements from the previous inspection. A tour of the premises took place and a variety of records and related documentation was examined, including the care records for four residents. Time was spent talking with seven residents, as well as Mr Thomas, the staff on duty and a visitor to the home. The majority of those Standards assessed and found met during the previous inspection in August 2005 were not reassessed during this inspection; this report should therefore be read in conjunction with the report from the previous inspection. As part of the inspection process, comment cards were distributed to the care home for completion by residents, relatives, G.P.s, health and social care professionals etc. The following comment cards were received; 11 from service users, 4 from relatives and 3 from General Practitioners. All express satisfaction with the care provided. Those comments received were very positive in their views of the home. (E.g., The standard of care is of very good quality. As always, very happy with the care my relative receives and also with the attitude of the staff, friendly and welcoming.) What the service does well:
Written information about Hillsdon Nursing Home is available for prospective residents and their relatives or representatives, to let them know what they can expect from the home and help them decide if Hillsdon Nursing Home is right for them. All residents are issued with a contract describing the terms and conditions of occupancy at the point of admission to the home. A care planning system is in place, which ensures that staff have the information necessary to meet the health and personal care needs of residents. Care plans are regularly reviewed and updated where necessary. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 6 Residents are treated with respect and their privacy and dignity is promoted at all times. Staff were observed throughout the inspection to be treating residents with courtesy. Residents commented, The staff are very good to me. We have a good group of staff here. The one who looks after me is a special sort of person, she is so kind and patient as I am very slow. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. Individual preferences and routines are respected. Residents spoke highly of the food provided, The food here is first class. Our cook is excellent. We have lovely meals. If you dont want what is on the menu, the cook will prepare something else for you. A system is in place for dealing with any complaints and residents expressed confidence that complaints would be listened to and dealt with appropriately. The registered provider has made a considerable investment in the refurbishment of the home, resulting in an attractive, well maintained and comfortable environment for residents. Staff at Hillsdon Nursing Home undertake a number of training courses to ensure they are competent to do their work. Staff commented, I have done a lot of training courses since working here. I have found them really interesting and very helpful in my work. I have done a lot more training here then I did in previous jobs. Measures are in place to promote the health and safety of residents, e.g. servicing of equipment such as the lift and hoists, also maintenance of the fire warning system etc. Fire training and drills are carried out at the required intervals to ensure that staff are fully aware of what to do in the event of fire. What has improved since the last inspection?
The registered provider continues with the redecoration and refurbishment of the care home. Recent building works to create a new dining room, and three new bedrooms and to re-site the laundry, treatment room and lounge have now being completed. Residents appreciate the improved communal areas and the use of a dining room. Work is currently taking place to improve access to the garden at the rear of the home. This is currently inaccessible to residents, but a new walkway leading to a large decking area will make it possible for residents to enjoy the steeply sloping garden. Staff have started work on creating life histories for residents. Information gathered about residents social, religious and recreational needs will help to
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 7 ensure that activities can be tailored to meet individual needs and expectations. Plans are in hand to completely refurbish and update the kitchen. 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. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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 Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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 and 2 Information provided about Hillsdon Nursing Home allows prospective residents to make informed decisions about admission to the home. Residents are issued with a contract describing Terms and Conditions of occupancy at the point of admission to the home. EVIDENCE: The Statement of Purpose and Service User Guide contain all of the information required about the home and its facilities. The Service User Guide gives a good indication of what a resident can expect from the home. These documents are available in every residents bedroom. They can also be viewed in the entrance hall by any visitors to the home, as part of an Information File containing the Statement of Purpose, Service User Guide, feedback from Quality Assurance questionnaires and copies of the last two inspection reports. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 10 All residents at Hillsdon Nursing Home are issued with terms and conditions of residence. These are signed by the resident or their representative and the registered provider. The resident and/or their representative retain a copy and a copy is held on file. A further blank copy of the terms and conditions is in the Service User Guide, which is available in every bedroom and in the Information File in the entrance hall. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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 and 11 Hillsdon Nursing Home has a care planning system in place, which ensures that staff have the information necessary to meet the health and personal care needs of residents. A start has been made in recording more information about residents social care needs, in order to make sure these needs are also being met. Residents are treated with respect and their privacy and dignity is promoted at all times. Residents are treated with sensitivity and respect at the time of their death. EVIDENCE: Three care plans were examined and these detailed the particular health and personal care needs of each resident and the staff assistance necessary to ensure these needs are met. At the last inspection, information about social, cultural, religious and recreational interests and needs was found to be very limited, making it difficult to assess if these were being met. Evidence was seen during this visit to demonstrate that staff are working with residents to prepare life histories which will provide much more detailed information
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 12 about each residents background, interests etc. (See also Standard 12.) It is hoped to see such information completed for all residents at the next inspection. Examination of care plans demonstrated that they are regularly reviewed and updated where necessary. Staff spoken with confirmed there was good information and communication on residents needs. Staff were observed throughout the inspection to be treating residents with courtesy, patience, kindness and respect. Staff spoke politely to residents and always knocked at bedroom doors before entering. Toileting activities were carried out discreetly. Residents commented: The staff are very good to me. The staff are always cheerful. I look forward to seeing them. Most of the staff are very pleasant and always willing to help me when I need it. We have a good group of staff here. The one who looks after me is a special sort of person, she is so kind and patient as I am very slow. Residents are able to go to their rooms at any time, thereby offering an opportunity to be on their own if they wish, or allowing privacy for any visitors or personal care needs. A number of residents say they choose to spend most of their time in their rooms and this decision is respected by staff. However, staff confirm they do encourage residents to socialise and would provide assistance to reach the communal lounge if required. Residents commented: I like to stay in my room. I am very comfortable here. I go down to the lounge sometimes, but it is nice and peaceful in my bedroom. Where rooms are shared, screening is available to help protect each residents privacy and dignity. The care plan of a recently deceased resident was examined. The care provided was well detailed and relatives had been kept informed of the situation. Formulation of the care plan also showed involvement from the resident/relative. Health care professionals provided support to the home’s staff. The home has a comprehensive death and dying policy in place. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Information about each residents social, cultural, religious and recreational needs is currently being collected, so that activities can be tailored to meet individual need and expectation. Residents are encouraged to choose their own lifestyle within the home and their individual preferences and routines are respected. There is a high standard of meal provision at Hillsdon Nursing Home with alternatives offered and individual specialist diets and preferences well catered for. EVIDENCE: Current activities at Hillsdon Nursing Home include a variety of board games, watching videos of old films and listening to music. Mr Thomas says entertainment is arranged on a fortnightly basis. A notice in the entrance hall gave details of a singer booked to entertain residents later in the month. There are still few opportunities for interaction or activities for those residents who remain in their rooms due to general frailty etc. Residents commented, There is nothing much to do here. I try to walk around a bit when I can. We can watch TV, but it would be nice to have more conversation. Sometimes the staff are too busy to just sit and chat. I
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 14 feel quite isolated sometimes. Most people stay in their rooms, so it is difficult to arrange anything. The staff do try. I dont want any activities, I like to be in my room. I dont want to go down to the lounge. The staff arrange things sometimes, but not very often. I wish I had someone to talk to me, or perhaps read to me sometimes. A start has been made in collating information about each residents background, social history, previous hobbies and interests etc. Mr Thomas says staff are preparing life histories, which will help to ensure that the activities on offer at Hillsdon Nursing Home will be meeting the individual needs, preferences and expectations of residents. It is important that urgent consideration be given to ways of engaging those residents who are more frail or less able to make autonomous decisions. This issue was raised at the inspection in August 2005 and it is hoped to see some progress by the time of the next inspection. A minister from the local church visits the home on a monthly basis and provides communion for all that require it. Staff say that residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, what to eat or drink and freedom to come and go as they please. For some residents, such choices may be more limited because of physical frailty, but staff were observed to be offering choice wherever possible, e.g., Shall we change your cardigan? Which one would you like to put on? What would you like to drink? Residents are able to bring their own possessions into the home to personalise their bedrooms. Residents confirmed that their individual preferences and routines are respected. I have a new bed which is more comfortable, so I like to stay in bed sometimes. They help me get up when I am ready. Lunch on the day of inspection was roast lamb, with roast potatoes, cauliflower and cabbage. This was followed by baked rice pudding. The cook demonstrated a good knowledge of individual likes/dislikes. Alternatives were seen to be provided to suit individual taste and preference. These always include jacket potatoes and a variety of omelettes and salads. Specialist diets such as soft, diabetic and puree diet are well catered for. Thought and care is given to the presentation of these meals, e.g. with elements of the puréed meal presented separately on the plate. Staff were observed assisting some residents with feeding. This was carried out with care and sensitivity. Residents were informed about the meal they were being offered and enabled to eat at their own pace. Residents spoke highly of the food provided and the following comments were received: The food here is first class. Our cook is excellent. We have lovely meals. We could not ask for better food. We had a roast meal today which was delicious. I wish I had a better appetite and could eat more. It always looks
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 15 so nice and I cant do it justice. If you dont want what is on the menu, the cook will prepare something else for you. Plans are in hand for a complete refurbishment of the kitchen. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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 and 18 A system is in place for dealing with any complaints. Residents are confident complaints would be listened to and dealt with appropriately. The home has a comprehensive Adult Protection policy in place to ensure residents are protected from possible abuse. However, it was not possible to evidence that all staff had received training in adult protection issues, to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the Service User Guide provided to all residents in their bedrooms. A copy of the complaints policy is also available to visitors in the entrance hall. The home has received many compliments giving thanks for the kindness, care and dedication shown and these are available to read in the Compliments File, which is also kept in the entrance hall. Only one complaint has been received by the home in the last year and this was referred to the Commission for Social Care Inspection prior to the last inspection. The investigation found this complaint to be partially substantiated. The provider has subsequently taken appropriate action. Contact with residents demonstrated they would feel able to voice a complaint and felt that their concerns would be taken seriously, and acted upon. Comments included: I am very happy and would not want to complain about anything, except the fact that Im getting much too old ”. I have raised concerns on occasions,
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 17 but these have always been dealt with promptly and efficiently . I have no complaints about this place. I have never had to make a complaint . The home has a comprehensive Adult Protection policy in place to protect residents from possible abuse. This makes reference to the Department of Health No Secrets document, which is also available to staff. It was not possible to evidence that all members of staff have received training in Adult Protection issues. Mr Thomas said this would be arranged as soon as possible, to ensure a proper response to any suspicion of abuse. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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, 20, 21 and 24 Considerable investment in the upkeep and refurbishment of the home is resulting in an attractive, safe, well-maintained and comfortable environment for residents, where standards are constantly improving. Building work in the communal areas has now been completed, resulting in improved facilities for residents. There are sufficient bathrooms and toilets available to meet the needs of residents. Bedrooms are comfortably furnished and individually personalised to suit the needs of their occupants. EVIDENCE: The registered provider has undertaken much redecoration and refurbishment of the property since being registered in August 2003. Recent building works to create a new dining room, add three new bedrooms and re-site the laundry, treatment room and lounge have now been completed. A new alarm call system has been fitted and all calls are logged so the manager can ensure response times are satisfactory.
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 19 Records demonstrate regular servicing of equipment, such as hoists, passenger lift, sluice, Stair-Matic, the fire warning system, emergency lighting and fire fighting equipment, to ensure the safety of residents and staff. Hillsdon Nursing Home previously had only limited access to communal space. Building work has now been completed to re-site the lounge and create a separate dining room. At present, the large garden at the rear of the home is not accessible to residents due to a steep flight of steps. The garden itself is also steeply sloping. However, plans are now underway to improve access to the garden and create a large decking area, linked by a walkway, where residents may sit out and enjoy the views. A resident commented, “There have been lots of improvements since the new owners took over. The staff say we shall be able to go outside in the garden soon and I am looking forward to that ”. Residents have access to a sufficient number of communal toilets and bathrooms. Two wet-rooms are available offering easily accessible showers. The home also has an assisted whirlpool bath. A resident commented, I go in the special bath, which is lovely. I dont have to do a thing, just enjoy it. Building work on the new extension has now been completed, resulting in the addition of three extra bedrooms. A tour of the building confirms that all bedrooms are comfortably furnished and personalised to varying degrees. Three bedrooms have ensuite facilities. Residents commented, “I am very comfortable here, I have everything I need”. I find my bedroom more than adequate for my needs . Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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): 28 and 30 Hillsdon Nursing Home is working to achieve the minimum ratio of 50 trained members of care staff at NVQ level 2, to ensure residents are in safe hands. The home acknowledges the importance of staff training and is seeks to ensure that staff are well trained and competent to do their jobs. EVIDENCE: Hillsdon Nursing Home has a dedicated team of care and support staff that are working positively with residents to ensure their needs can be met. At present, three members of care staff have NVQ level 2 and three staff have NVQ level 3. In addition, one member of care staff is currently undertaking NVQ level 2 training and three are undertaking NVQ level 3. Mr Thomas says he plans to exceed the minimum ratio of 50 trained members of care staff at NVQ level 2, to ensure residents at Hillsdon Nursing Home are cared for by well trained staff. A resident commented, I feel very safe here, we are so well looked after. Two staff files were checked and they showed that a variety of training had been undertaken such as moving and handling, first aid, basic food hygiene, health and safety, meeting the needs of older people in care homes, infection control and continence. (The requirement to ensure staff receive Adult Protection training is covered at Standard 18.) Copies of all training certificates are retained to provide evidence that staff receive a minimum of three paid days training per year.
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 21 Staff commented, I have done a lot of training courses since working here. I have found them really interesting and very helpful in my work. I enjoy working here. We are a good team and we all work well together. I have done a lot more training here then I did in previous jobs. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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, 36 and 38 Mrs Thomas leads by example to ensure that residents receive a consistently high standard of care. She is well supported by a team of nursing, care and ancillary staff with all staff demonstrating an awareness of their roles and responsibilities. A formal staff supervision system is now in place, but this is not always being implemented at the recommended intervals. The home seeks to provide a safe environment to ensure the protection of residents. EVIDENCE:
Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 23 The manager was not on duty at the time of this inspection, therefore it was not possible to fully evaluate Standard 31. This will be covered in more detail at the next inspection. However, staff and residents spoke highly of the management of the home. Ms Thomas is an experienced Level 1 Registered Nurse and is currently undertaking the National Vocational Qualification (NVQ) Level 4 in management, which she intends to complete by the end of 2006. Mrs Thomas is well supported by Baselink Care Ltd. Staff spoke highly of the manager, She is very fair. She is always seeking high standards. She is very supportive and approachable. Residents commented, Matron is very nice, I enjoy talking with her. She gets things done. She is not afraid to roll her sleeves up where necessary. Care staff should receive formal supervision at least six times a year, as a means of ensuring good practice, emphasising the philosophy of care within the home and looking at individual career development needs etc. Records did not evidence that supervision is always taking place at the necessary intervals. Staff meetings provide additional opportunities for staff to express their views and ideas. Staff appraisals are also carried out annually to ensure they are fulfilling their role satisfactorily and meeting the needs of residents. From touring the premises, looking at records and discussions with staff and residents, it is evident that measures are in place to promote the health and safety of residents, e.g. equipment, such as the lift, portable electrical appliances, hoists etc are regularly serviced and maintained. All substances that could be potentially hazardous to health are handled and stored safely. The majority of radiators and pipework at Hillsdon Nursing Home are now guarded or have guaranteed low temperature surfaces and work is in hand to complete this task. Hot water temperatures at baths/showers were tested and found to be close to 43° C, to prevent any risk of scalding. Examination of the fire records shows that appropriate procedures are in place to ensure the safety of residents and staff. Regular maintenance of the fire warning system, emergency lighting and fire fighting equipment is taking place. Routine checks are carried out at appropriate intervals and staff confirm this. Staff and records confirm that fire training and fire drills are being carried out at the required intervals, to ensure that staff are fully aware of what to do in the event of fire. However, the records of fire drills contain only minimal information. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 X X STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X 3 Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 25 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 OP7 Regulation 15(1) and 15(2) Requirement All aspects of each resident s health and welfare needs, including social care needs, must be recorded and regularly reviewed. Previous timescale of 31/12/05 not fully met The registered persons must consult residents about their interests and provide a suitable programme of activities. Consideration must also be given to ways of engaging those residents less able to make autonomous decisions. Previous timescale of 31/12/05 not fully met. It is required that all staff receive training in adult protection issues to ensure a proper response to any suspicion or allegation of abuse. It is a requirement that Mrs Thomas obtains a National Vocational Qualification level 4 in management. Timescale for action 31/05/06 2 OP12 16(2) (m) and (n) 12 31/05/06 3 OP18 13(6) 31/05/06 4 OP31 9(2)(b)(i) 31/12/06 Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 26 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 Refer to Standard OP28 OP36 OP38 Good Practice Recommendations It is recommended that a minimum of 50 of care staff achieve NVQ level 2 training. It is recommended that formal staff supervision be carried out at two monthly intervals. It is recommended that more detail is recorded with regard to fire drills. Hillsdon Nursing Home DS0000049686.V279179.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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