Inspection on 20/05/08 for Hillside Lodge

This inspection was carried out on 20th May 2008.

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

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

Other inspections for this house

Hillside Lodge 26/01/10

Hillside Lodge 07/04/09

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Hillside Lodge Spiro Close London Road Pullborough West Sussex RH20 1FG Lead Inspector Beth Tye Unannounced Inspection 20th May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillside Lodge DS0000071323.V363321.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. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Lodge Address Spiro Close London Road Pullborough West Sussex RH20 1FG 01798 877700 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) Shaw Healthcare Ltd Mr Mark Beech Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) Dementia (DE) The maximum number of service users to be accommodated is 60. 2. Date of last inspection New Service Brief Description of the Service: Hillside Lodge is a modern three-storey home registered to accommodate up to sixty people for personal care, dementia and nursing need. Each floor accommodates up to 20 residents who are allocated rooms dependant on their assessed need. The premises are owned by Shaw Healthcare Ltd and are built for specific purpose. The home is situated very close to shops and is on the outskirts of Pulborough village. The registered manager is Mark Beech who has been in post since the home opened. Fees range from approximately £360 (residential) to £829 (nursing) per week. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The unannounced inspection visit was carried out by Ms Beth Tye and was arranged to assist the Commission in assessing the home’s compliance with the key standards of the national minimum standards for care homes for older people. Planning for the visit took into account information received on the service since it opened. The Annual Quality Assurance Assessment was returned to The Commission for Social Care Inspection (CSCI) and informed us areas of improvement, which have been carried out and also identified areas for further improvement. Survey forms received from people living in the home, relatives and members of staff also contributed to our planning. On the day of the visit the inspector spoke at length with the manager and the area manager, who was also at the home on the day, and they provided information. Residents living at the home, staff working at the home and visitors were spoken with to gain their views of the service, the majority of comments were positive and all residents spoken to said they like living at the home. Six sets of admission assessments and the individual plans of care for people living in the home were looked at. A case tracking exercise for these residents was undertaken to examine how their assessed needs were being met. Other records sampled included recruitment and training records for four members of staff, the record of complaints, quality assurance records and records relating to health and safety issues in the home. The premises were viewed including communal areas, kitchens, bathrooms and bedrooms. A number of interactions between people living in the home and staff, arrangements for lunch and medication dispensing were observed. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Due to the high use of agency staff since the home opened it is vital that staff vacancies should be filled to minimise the use of agency staff. This will provide residents with consistent care and enable staff within the home to confidently undertake their roles. Further admissions to the home should be considered in respect of staff ratio to resident care until vacancies have been filled appropriately. The home has a registered manager in place who is a qualified nurse. The deputy manager (also an RGN) is seconded in post on a temporary basis. A team leader oversees each floor of the home, at present some of these posts are filled by agency staff. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 7 Due to the current management structure in relation to the occupancy size it was concluded that the management in place at the home is not robust and could be improved upon. 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. Hillside Lodge DS0000071323.V363321.R01.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 Hillside Lodge DS0000071323.V363321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good To ensure residents needs can be met appropriately by the home, senior staff undertake a full assessment prior to admission. Each resident is provided with a written contract of terms and conditions, which is signed by all involved parties, so residents are clear about their rights within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Senior staff including the manager assesses individuals prior to admission. When nursing care is required, a qualified nurse, most often the manager or his deputy, completes the pre admission assessment. During the visit, pre-admission assessments were examined for six residents. These identified relevant areas of need including, nursing, mobility, communication, health and social needs. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 10 Files seen contained correspondence from external health professionals such as social services and health. Records demonstrated the information collated prior to admission is then translated into care plans and reviewed on a monthly basis by the manager. Risk assessments are in place for each of the residents and these contain information relating to their specific needs and assessed areas of risk. This promotes independence for residents in all aspects of daily living. Admissions are not made to the home until a full assessment has been completed and where relevant the necessary equipment has been purchased to meet specialist needs. All records are kept in a locked cabinet only accessible by care staff to ensure confidentiality. Residents spoken to confirmed they are given up to date information about the home prior to admission, including a Service Users guide and complaints procedure. This information helps them (and their families) to make an informed decision about moving to the home and what to expect. All residents have received a copy of their Terms and Conditions for the home, which they or their families had signed following admission. This informs residents of their rights and what to expect of the home. Hillside Lodge DS0000071323.V363321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Care records set out residents needs in full. Health needs are met with the support of health professionals. Residents self-administer when assessed as safe to do so. Medication is managed safely by the home. Residents’ privacy and dignity is respected This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six residents care plans were examined as part of the case tracking process. Each care plan contains relevant details relating to the residents health needs and social well being. The manager has recently begun work to improve on existing care plans to ensure information is comprehensive and more ‘person centred’. Each floor at the home now has a ‘care plan champion’ who ensures daily monitoring/recording is cross-referenced with individual information. This person also audits care plans regularly to ensure information is relevant and up to date. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 12 Information seen on care files was up to date and easily accessible. There was evidence to demonstrate the manager/senior staff undertake monthly reviews and up dates the care plans as changes occur. Individual risk assessments, behaviour management plans and action points for staff are held on care files. This gives staff a better understanding of need and responses in addition to supporting residents to maintain independence safely where possible. Specialist health needs are referred to community-based professionals via the GP. This includes psychiatrists, occupational therapists, community psychiatric nurses and district nurses. Correspondence held in individual files supported this process and reflected that the home is pro-active in securing appropriate health care for individual need. Information on care plans demonstrated that specialist equipment had been purchased for individuals following their pre-admission assessment and before individuals moved to the home. Pressure-relieving equipment was seen in use when needed and the residents who needed nursing care had adjustable beds and air flow mattresses. Turn charts and air pressure monitoring charts were seen in resident’s bedrooms. Case tracking, feedback and discussion with the residents and their relatives confirmed good practice is maintained in the home and residents are treated with dignity and respect. Residents and relatives commented ‘the staff are very caring and kind’ and ‘the staff are really good and very helpful’ Staff complete a full induction and mandatory training programme. Training is also provided in respect of specialist health needs such as dementia, mental capacity act, continence and catheter training. This training provides staff with the skills and knowledge base to respond appropriately to resident’s specialist health care needs. A Chiropodist visits the home on a six weekly basis and a hairdresser visits on a weekly basis. The residents seen during the visit were very tidy in appearance wearing appropriate clothing with their nails and hair well groomed. Most residents were alert and cheerful. Staff were observed communicating with them in a caring and respectful manner. Staff receive medication training in house. The deputy manager, who is a trained nurse, audits the homes medicines and records on a daily basis. The home has an up to date policy, procedure and code of practice relating to dispensing medication. Medication charts and storage of medicines within the Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 13 home was examined. Records seen were in good order demonstrating staff follow appropriate procedures. The home has a disclaimer form in place for self-administration of medication. Capacity and all aspects of care planning are agreed prior to admission and again during regular reviews, demonstrating that residents and their families are encouraged to participate in decision-making. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are able to make decisions and choices in their lives. A range of activities is offered to residents. Residents are encouraged to maintain contact with family and friends and links with the local community are maintained. Residents are offered a varied diet of good home cooked food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities are organised at the home on a daily basis, offering stimulation to those residents who are less able to explore interests outside the home. These include art and crafts, pampering sessions, music, quizzes, bingo and entertainment. Activities are displayed on community notice boards and in rooms. The home also publishes a monthly newsletter, which outlines forthcoming events within the home. The home employs a part time activity co-ordinator who has assessed each resident within the home to build a picture of their preferences for activities and interests. Social interests are recorded as part of the care planning process. An activities/interest sheets are now kept in resident’s bedrooms to encourage family members to contribute to building a picture of individual and their lives. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 15 Residents who suffer from dementia are provided with more specialist activities relevant to their needs and capacity. These include reminiscence work, gardening and crafts. The manager confirmed that Shaw Health Care have agreed to supply another part time post for an activities co-ordinator so that residents can benefit from more one to one time. Residents confirmed that they could choose what they want to do as far as social events and also what times they go to bed and get up in the morning. Flexibility enables individuals to have choice and express a preference in their daily routines. Residents and relatives confirmed that the visiting arrangements for the home are open and visitors can come and go as they please and are made welcome by the staff. Resident’s meetings are held once a month and relatives meetings every three months. These meetings give the residents and their families the opportunity to comment on how they view the home and contribute to decision-making. Staff escort residents to community events and appointments as required. The menu offered at Hillside Lodge offers a wide range of balanced, home cooked food. The cook takes in to account the preferences of residents and specialist dietary needs. This promotes choice for the residents and provides an opportunity for them to eat what they prefer. An alternative meal is on offer at lunchtime and teatimes. Residents spoken with said they enjoyed the food ‘very much’ and there was plenty to eat. Food is served in separate dining rooms on each floor of the home so staff can monitor and assist as required. Food intake and nutritional requirements are monitored and recorded for each resident. Residents confirmed they can choose where they want to eat, either in the dining area, lounge or bedrooms. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good Residents who use this service or their representatives are able to express concerns, and have an access to an effective complaints procedure. Residents are protected from abuse and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint procedure, which is outlined in the statement of purpose and displayed in the home. Complaints are recorded and investigated with feedback to complainant within 28 days with the actions taken. All residents and visitors spoken to said they knew who to complain to and that they would do so if they thought it appropriate. CSCI has not received any complaints or concerns regarding Hillside Lodge. During the visit the complaint book was seen and four complaints had been recorded since the home opened. All related to minor incidents and had been dealt with appropriately. Staff induction and training records indicated that all staff receive training in safeguarding vulnerable adults. Staff spoken to, did know what to do if they suspected abuse. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 17 Information on advocacy services is displayed and is accessed if needed. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent The home offers a high standard of comfort and facilities for the people who live there. Bedrooms are all individually personalised and the home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from the visit that Hillside Lodge is decorated and maintained to a high standard. The home is modern and built for purpose. The premises are laid out over three floors with a staff team designated to each floor. Communal areas are furnished with flowers, ornaments and pictures, which give the environment a homely feel. The standard of cleanliness and furnishing throughout the home is high. Residents and relatives commented on the cleanliness and ‘lovely décor’ of the home. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 19 Private accommodation is decorated and furnished to a high standard to suit the needs of individual residents. Residents are encouraged to personalise their own bedrooms to give them a sense of ownership. The dining rooms on each floor are attractively presented. There are also separate modern kitchen areas on each floor so staff can prepare snacks and drinks as needed, away from the main kitchen area. In addition to en-suite facilities the home has shared toilets, which provide ample facilities to the residents. There are hoists, bath aids and specialist nursing equipment to promote the independence of those who require assistance with personal care and nursing needs. Anti bacterial soap was evidenced at shared sinks. Laundry and sluice facilities are provided. Policies and procedures are in place for infection control, and all of the staff have attended relevant training for infection control and health and safety procedures. This promotes good practice in the area of safety and welfare for the residents and reduces the risk of infection spreading within the home. There is a passenger lift for residents with limited mobility to access all floors of the house. All radiators throughout the home have been covered. A call bell system is provided in every room so staff can attend an emergency situation swiftly, should it arise. The maintenance log showed all maintenance was completed as required on a regular basis. This means the resident’s environment is kept safe and well maintained at all times. Hillside Lodge DS0000071323.V363321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate Residents in the home are supported by a committed, caring and well-trained staff team and recruitment records are in good order. Staff work hard to maintain a safe environment for the residents. On occasions this has been compromised by insufficient staffing numbers and a reliance on agency staff to cover a high number of shifts. A requirement has been made in respect of this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Recruitment policies and procedures are in place, to ensure staff employed by the home have the necessary skills and experience to fulfil their roles. CRB checks, terms and conditions and reference checks were seen on file for staff members. This ensures that residents are protected in the home. It was concluded from examining the duty rotas, speaking to staff, residents and relatives that current staffing levels are insufficient to fully meet the needs of residents. The home uses high levels of agency staff to cover shifts. However, the inspector spoke to three staff members who stated that the staffing has recently improved as agency workers are becoming known to residents, more confident in their roles and care practice. The manager also confirmed he has recently had a large recruitment drive and has appointed six new full time staff members. He is currently awaiting CRB Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 21 checks before agreeing start dates. This will significantly improve staffing levels and consistency of care practice within the home in the future. People using the service and their relatives feedback that the staff in the home ‘meet needs very well’ and ‘are very committed’ another acknowledged that ’staffing levels have improved since the home had opened but there were still a lot of agency staff being used’ A staff member commented that use of agency meant established staff had to work harder to compensate as agency workers ‘only did the basic jobs and did not know the residents preferences’ Records show that staff complete a four day induction at the start of their employment, then go on to undertake a mandatory training programme appropriate to the needs of residents. Agency workers complete a basic induction at the start of each shift. Permanent staff also, undertake more specialist training in respect of health care needs such as dementia and mental health issues. Staff members spoken to, demonstrated commitment and a clear understanding of the resident’s needs. The recruitment records examined during the visit is in line with the homes policies and procedures. All staff including agency, have up to date CRB and reference checks to ensure the residents are protected from harm. Hillside Lodge DS0000071323.V363321.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The management structure is not robust and is currently under review. At present the home is insufficiently staffed and therefore the manager does not meet all the standards. Service users’ financial interests are safeguarded. The health, safety and welfare of residents are not promoted well enough although there are good administration and record keeping systems in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager in place. He is a qualified nurse who is currently undertaking the Registered Managers Award. The deputy manager (also an RGN) is seconded in post on a temporary basis. A team leader oversees each floor of the home, at present some of these posts are filled by agency staff. Due to the current management structure and the temporary post of the deputy manager as well as staff vacancies it could not be Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 23 evidenced that the management in place at the home is robust. A requirement has been made in respect of this. The manager advised the inspector during the visit that the management structure is under review at present and the senior management of Shaw Health care is considering employing a manager (rather than a team leader) for each floor of the home. Due to the size of the home, this would assist in the management of the complex needs of the residents and reviewing and improving the quality of care. Six new staff have recently been recruited and are currently awaiting checks. At the time of the visit these staff were not in post. Once this occurs it will considerably improve the permanent staffing levels within the home and reduce the use of agency. However many agency staff have filled the current vacancies, which does not always provide consistent care to residents. This was evidenced by feedback gained from relatives, residents and staff on shift during the visit. A requirement has been made in respect of this. The policy of the home is not to manage the financial affairs or handle large sums of money for the residents and any expenditure on the residents’ behalf is billed to their representative to manage for them The inspector examined health and safety records including fire checks, accident book, maintenance checks, water temperatures and environmental risk assessments. Records required to be kept by legislation were in good order and up to date. All care records are kept in a locked cupboard to maintain confidentiality. There are administrative systems at the home to promote all aspects of health and safety. Residents were observed expressing their views confidently and staff responded with consideration and respect, reflecting a positive ethos within the home. The home seeks the views of involved parties through regular staff, residents and relative meetings. Minutes of these meetings are kept on file within the home. Shaw Healthcare has quality assurance procedures in place, which are used to inform the business plan. Questionnaires will be sent out once the home has been open for a year and the results once published, will be available to any involved parties. Questionnaires have been sent out to gain feedback from residents and their relatives about the transition from Croft Meadow to the new premises at Hillside Lodge. Overall feedback was positive and comments reflected that the move was managed well. It should be noted that the premises of Hillside Lodge is temporary (approx 18 months) and residents will be required to move back to Croft Meadow once it has been rebuilt. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 24 Feedback received by the Commission and verbal comments from relatives and residents spoken to at the time of inspection indicated an overall level of satisfaction with the service provided. Most stated that since the home has opened the service has improved considerably in the past few months. The main issue of concern raised related to poor staffing levels and ‘too much reliance’ on agency staff. Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 4 X 4 3 STAFFING Standard No Score 27 1 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X X 2 Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18 (b) Requirement The registered person must ensure employment of any persons on a temporary basis will not prevent continuity of care that is reasonable to meet service users needs The registered person must ensure that at all times there are suitable, qualified staff working in sufficient numbers to ensure the health and welfare of service users Timescale for action 30/09/08 2 OP27 18 (a) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Hillside Lodge DS0000071323.V363321.R01.S.doc Version 5.2 Page 28 - 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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