Inspection on 12/09/06 for Hillside Nursing Home

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hillside Nursing Home 31/01/06

Hillside Nursing Home 06/08/05

Hillside Nursing Home 02/02/05

Hillside Nursing Home 25/10/04

Hillside Nursing Home 14/07/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Hillside Nursing Home Bicester Road Aylesbury Buckinghamshire HP19 8AB Lead Inspector Chris Sidwell Unannounced Inspection 12th September 2006 10:00 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 Hillside Nursing Home DS0000019229.V305794.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 Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Nursing Home Address Bicester Road Aylesbury Buckinghamshire HP19 8AB 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) 01296 710011 01296 710013 None Southern Cross Care Homes No 2 Limited Elizabeth Patricia Nicholas Care Home 67 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (36), of places Physical disability (11) Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Hillside Nursing Home provides care for sixty-six adults, eleven of whom are younger adults with physical disabilities. The building is divided into three units, which accommodate service users with a range of nursing and personal care needs. All rooms are single. The home is situated in the centre of Aylesbury and is close to shops and transport links. Fees range from £474.00 to £1143.00 Information about the home is available from the home by requesting a brochure and statement of purpose or by visiting the home. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of three days and included an unannounced one-day visit to the home. Prior to the visit all previous information about the home was reviewed. Comment cards were sent to residents and their families and to other professionals who have contact with the home. Fifteen residents, a general practitioner, district nurse and care manager returned the comment cards. The care of four residents was case tracked. Residents, staff and the manager were spoken to on the day of the unannounced visit. The home’s approach to equality and diversity was observed. What the service does well: Potential residents and their families are given information about the home and their needs are assessed prior to their moving to the home. Resident’s health and personal care needs are met in a timely and proactive way and residents have access to the local primary and secondary healthcare services. Medication is generally well managed. The standard of nursing care is good. Residents’ privacy and dignity is respected. Younger residents are encouraged to maintain their own interests and a programme of individual and group activity is being developed to bring interest and diversion for residents. Residents in the young disabled unit are encouraged to go out it they wish. The food is of a good standard and most residents enjoyed the meals. The home has a satisfactory complaints procedure with evidence that residents concerns are listened to and action is taken. Adult safeguarding and whistleblowing procedures are in place and understood by staff. The standard of the environment is generally good. Residents are encouraged to personalise their rooms and many had chosen to do so. The standard of cleanliness and of infection control is good. The staffing levels are adequate and staff have training to meet service users needs and to work safely. Thorough recruitment procedures are in place and the necessary checks are undertaken prior to staff commencing work. The home has an experienced manager and stable senior nursing and staff team. It is well run on behalf of residents. There is a quality assurance programme in place. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillside Nursing Home DS0000019229.V305794.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 Hillside Nursing Home DS0000019229.V305794.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Potential residents are given information about the home and their needs are assessed prior to moving, helping potential residents, their family and staff to assess whether the home can meet their needs. EVIDENCE: The care of the last resident to be admitted to the home was included in the case tracking. The records showed that a comprehensive assessment had been undertaken and had been reviewed. The assessment documentation used includes information about residents’ cultural and religious needs, which were recorded. The manager stated that a copy of the home’s Statement of Purpose could be provided in large print if needed. A second resident was moving to the home from hospital on the day of the unannounced visit. Her family were spoken to and they said that they had received information about the home. They were particularly pleased that when they had made the initial enquiry they had been encouraged to visit immediately, which they saw as a good sign and that the home had ‘nothing to hide’. They confirmed that their family member had been visited and assessed in hospital prior to being Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 9 transferred to the home and that they had had the opportunity to meet the nurse manager who would be caring for their mother as well as the home manager. The home does not offer intermediate care. Hillside Nursing Home DS0000019229.V305794.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s health, medication and personal care needs are met in a timely and proactive way. EVIDENCE: The care of four residents was case tracked. They had care plans in place, which had been updated regularly. The care plans on one unit were of a higher standard than some on other units although all had been completed and updated regularly. Daily entries had been made and signatures were clear. The needs of one resident from an ethnic minority had been recognised. The family told the inspector that they had been involved in the care plan and had unrestricted visiting, which they appreciated. The manager stated that a registered nurse from the Primary Care Trust reviews residents regularly. Most residents who were supported by care managers had been reviewed annually although not all. The manager stated that they were able to ask for a review at any time. The manager has a system set up to remind care managers when residents’ annual reviews are needed. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 11 The residents seen had had help with their personal hygiene and two residents spoken to said that they had been encouraged to do as much as they were able themselves. There was evidence that the resident’s risk of developing pressure damage was recorded and appropriate action taken. Several residents had moved to the home with pressure damage. This was recorded appropriately and healing progress monitored. Nutritional assessments were undertaken and residents were weighed regularly. The manager stated that residents could remain registered with their own General Practitioner if they wished and the general practitioner served the area. If not the manager felt that the home had good support from the local healthcare practices. There was evidence in the care plans that general practitioners visit regularly and one resident spoken to confirmed that she had seen her general practitioner that week. The opportunity for exercise in both the older peoples units and the younger disabled unit was limited and it is recommended that this area of care be developed further. There are medication policies and procedures in place and the nurses spoken to were familiar with these. One resident in the young disabled unit retains responsibility for her own medication and has locked storage in her room. A risk assessment is in place. This is good practice. The medication administration charts were completed accurately. Controlled drugs and refrigerated medication was stored correctly. Medication is delivered in dosette boxes by a local pharmacist. The system for collecting additional medication however should be monitored and reviewed regularly. One resident was prescribed antibiotics for a urinary infection but did not receive this medication for two days. The manager described the system which should have been in place, but was not followed on this occasion. The staff were observed to be speaking to residents courteously and to knock before entering their rooms. One resident said that his privacy was always respected. The staff spoken to said that all personal care is given in residents’ rooms. The general practitioner who returned the comment card said that he could see residents in private. All residents who returned the comment cards said that their privacy was respected. One unit within the home is run under contract with the local Primary Care Trust. Some residents may move to the home specifically for end of life care and the manager stated that the Primary Care Trust (PCT) is asking to use more of the beds in this manner. The organisation is currently negotiating with the PCT to ensure that staffing levels and training can meet the needs of this specific group of residents. There was evidence from a number of thank you cards that relatives were appreciative of the care that their family member received and of the support that they were given when a family member died. Hillside Nursing Home DS0000019229.V305794.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Younger residents are encouraged to maintain their own interests and a programme of individual and group activity is being developed to bring interest and diversion for residents. There is a need to consolidate the approach being taken to developing activities and to develop therapeutic activities for those with dementia to help them to retain their abilities for as long as is possible. EVIDENCE: The residents spoken to said that they had a choice as to when they went to bed and got up although one said that ‘I have to wait until they get to me as they are very busy’. Meals are at a set time although the chef said that meals could be provided outside of the set times if residents were out. On the day of the unannounced visit a Christian service was taking place. The home has three part time activities coordinators and they have begun to record resident’s interests and to develop individual and group activities. It is recommended that this work is developed and that carers are involved, to ensure that activity and diversion becomes a part of the every day routines. A weekly programme of activities is posted in the main entrance hall although residents do not receive their own copy nor do they receive an individualised plan. The activity coordinator spoken to was enthusiastic and is planning a number of outings and is shortly to introduce talking books. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 13 One resident spoken to from the young disabled unit said that he was waiting for the local taxi to take him to a day centre. He looked forward to his weekly outing. The home is on a level route to Aylesbury town centre and some residents from the young disabled unit visit the town frequently. Risk assessments were in place. Another resident however said that she had been in the home sometime and that the amount of activity had decreased. She could remember when there was an activity in each lounge every day, which was not currently the case. One staff member commented that the young disabled unit used to have their own dedicated programme, which was not now the case. There is also a need to develop therapeutic activity for those suffering from dementia and also therapeutic exercise to assist in maintaining mobility and joint flexibility for all residents. There is a four-week menu plan and residents have a choice of main meal. Three residents were spoken to at lunch. All said that they were alternatives if they did not like the choice on the menu. They did not feel that they had a chance to influence the menus although they were happy with this, as the food was generally very good. Ten of the fifteen residents who returned the comment cards said that they liked the food although five did not. On the day of the unannounced visit only one vegetable was served although the menu referred to ‘seasonal vegetables’. The chef said that this was because the steamer had been out of action for sometime and was awaiting repair. The chef said that special diets were available. One resident whose family were with her at mealtimes said that the home could provide a diet suitable to meet her cultural needs but that they preferred to bring in home cooked foods. There are no facilities for residents to make a snack or a drink although some residents in the younger disabled unit had facilities in their own rooms. Hillside Nursing Home DS0000019229.V305794.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints procedure with evidence that residents concerns are listened to and action is taken. Adult safeguarding and whistle-blowing procedures are in place and understood by staff, to protect service users from harm. EVIDENCE: There are complaints policies and procedures in place and a log is maintained of any complaints made. These were responded to promptly and an action plan developed to prevent a recurrence, where appropriate. The staff spoken to were aware of the complaints procedures and said that they tried to respond to concerns promptly to prevent them becoming a formal complaint. There are protection of vulnerable adult policies and procedures in place. Staff had received training in these and those spoken to were aware of the ways in which vulnerable people may be abused. There are whistle-blowing policies in place which the staff spoken to were aware of. There have been no formal complaints made to The Commission for Social Care Inspection and neither has the Commission been notified of any safeguarding concerns. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality is this outcome area is good. This judgement has been made using available evidence including a visit to the service. The standard of the environment is generally good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home is centrally located in Aylesbury and provides easy access for residents who wish to visit the town centre. The grounds are tidy and the front of the home has been upgraded to provide sitting space and easy access for wheelchairs. There is a programme of routine maintenance and records are kept. Some key equipment, however, had not been repaired in a timely way. One washing machine and the kitchen steamer are awaiting repair. The last Fire Officer’s visit was made in February 2005 and his recommendations have been implemented. The Environmental Health Officer visited in November 2005. Residents’ rooms are personalised and they are encouraged to bring in small items of furniture and their personal belongings. Service users have lockable storage. There are no double rooms. Some chairs were old and in need of repair in the resident lounges. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 16 There are infection control policies and procedures in place. There are processes in place to separate soiled items of clothing. One washing machine is in need of repair. There are hand-washing facilities in clinical areas and in residents’ rooms. The manager has contact with the local Health Protection Agency and takes their advice regarding specific infection control measures, which might be needed to combat the risk to residents of acquired infection. The home was clean and tidy on the day of the unannounced visit and there were no unpleasant odours. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. In general there are sufficient staff with the required skills and knowledge on duty to meet residents’ needs although staffing levels and training should be kept under review to ensure that their needs are met at night and that a wider group of staff have the specialist skills necessary to meet residents specialist needs. Recruitment processes are thorough and the required checks are undertaken to ensure that residents are protected from unsuitable staff. EVIDENCE: A staff record is kept. The rota reflected the staff on duty on the day of the unannounced visit. Some members of staff said that they felt that there were insufficient staff and that staffing levels had been reduced in the last year. All the residents who returned the comment cards said that they felt well cared for and that staff treated them well. One relative said that ‘although the nurses and carers do their best there is insufficient staff which negatively affects everyone who works here’. There was no evidence to show that residents personal and healthcare needs were not being met although the organisation should keep staffing levels under review, given the comments of some staff, residents and relatives during the visit. Two residents and one relative said that the night staff were sometimes ‘abrupt’ and one expressed real concern that her needs were not met at night and that she was afraid to call as ‘they are so busy’. The levels and training of night staff must be reviewed to ensure that residents needs can be met in a timely way. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 18 Eight of the forty-four care staff hold The National Vocational Qualifications (NVQ) in Care at Level 2 or above, six are undergoing the course and a further sixteen have signed up to undertake the course in the near future. None of the homes staff hold the NVQ Assessors award and external assessors are used to assess staff undertaking this qualification. The home does not yet meet the standard that 50 of carers hold this qualification but has a plan in place to do so. Four recruitment files were checked. All had the required documents, photographic evidence of identity references and Criminal Records Bureau disclosures. Protection of Vulnerable Adult (POVA) register checks had been undertaken prior to staff commencing work and the manager stated that those who commenced work once the POVA first had been received but before the full Criminal Records Bureau disclosure had been received were supervised. This was not recorded. The supervision arrangements for this group of staff should be improved in line with guidance published in 2004 by the Department of Health entitled ‘Protection of Vulnerable Adults scheme - A Practical Guide. There are training programmes in place and records are kept to show when mandatory training is completed. The manager said that she followed up all staff who did not undertake mandatory training. The staff spoken to confirmed that they had received mandatory training during the last year. One new member of staff described her induction programme. She had been assigned a mentor, which she found helpful. Some specialist training (gastrostomy care, wound care, bed rail and end of life care) has been undertaken since the last inspection although the training programmes could be further improved if specialist training to meet specific resident needs were implemented more widely for all staff as well as the basic mandatory training. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is an experienced well-qualified management team who are responsive to residents’ views and who provide residents with a safe and well run home in which to live. EVIDENCE: The manager is an experienced home manager, a qualified nurse and holds the National Vocational Qualification in Management at Level 4. The staff spoken to said that she was open to suggestion and that she created an open atmosphere in the home. She is supported by a senior team and the lines of accountability are clear. Southern Cross Healthcare undertakes regular quality assurance visits and a programme of audit is underway. An annual business plan is developed and the manager has devolved financial responsibility for managing the home within agreed budgets. The manager also said that if additional equipment was needed which had not been identified at budget setting a case could be made for its purchase. The manager holds a regular Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 20 evening surgery to speak with families who may not visit during the day. A family meeting is held regularly and minutes are taken. The manager reported a low turnout at these meetings. A 10 sample of residents and families are surveyed monthly to ascertain their views and action plan is developed. The findings of these surveys are posted in the entrance hall under the heading of ‘what we do well and what we could do better’. The response rate from families is low and it is recommended that the organisation consider, with residents’ consent, ways in which families, views could be ascertained. It is also recommended that the organisation seek the view of other stakeholders and staff on a regular basis. Action has been taken to address the requirements of previous reports in a timely way. Residents are enabled to maintain control of their finances if they wish. Those who wish to deposit small amounts of money for everyday expenses are assisted to do so. A computerised record is kept and receipts are given for all transactions. There are health and safety policies and procedures in place and health and safety meetings take place. There is an accident book. The maintenance records showed that necessary maintenance to ensure the safe working of equipment is undertaken. The fire log was up to date and the staff spoken to could describe the fire evacuation procedures. There are manual handling policies and procedures in place, equipment is available and staff have been trained in safe handling techniques. The kitchen was clean and tidy on the day of the unannounced visit and the appropriate temperature recording of refrigerators and foodstuffs was undertaken. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 22 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 2 Standard OP9 OP12 Regulation 13 16 Requirement Medication should be made available to residents promptly once it has been prescribed. Therapeutic activity plans should be developed for residents suffering from dementia. Timescale for action 31/10/06 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP12 OP12 OP15 OP19 OP23 OP27 OP30 Good Practice Recommendations Individual activity plans should be developed Individual and group exercise plans should be developed to assist residents to maintain mobility and flexibility in their joints. Innovative ways in which residents could be involved in menu planning should be considered. The worn chairs in the lounge should be replaced. The maintenance of essential equipment should be undertaken in a timely way. Staffing levels should be kept under review particularly at night. Specialist training programmes should be introduced to DS0000019229.V305794.R01.S.doc Version 5.2 Page 23 Hillside Nursing Home 8 OP29 9 OP33 ensure that a wider range of staff have training to meet resident’s specialist needs. The supervision arrangements for staff starting work after the POVA first check has been undertaken but before the full Criminal Records Bureau disclosure has been received should be improved in line with guidance published in 2004 by the Department of Health entitled ‘Protection of Vulnerable Adults scheme - A Practical Guide. The organisation should consider innovative ways of involving families and other stakeholders in the quality assurance programme. Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Seaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillside Nursing Home DS0000019229.V305794.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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