Inspection on 21/11/05 for Hillside Residential Home

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillside Residential Home 14/10/08

Hillside Residential Home 03/10/07

Hillside Residential Home 09/11/06

Hillside Residential Home 13/03/06

Hillside Residential Home 21/03/05

Hillside Residential Home 03/08/04

Hillside Residential Home 21/01/04

Hillside Residential Home 23/06/03

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

CARE HOMES FOR OLDER PEOPLE Hillside Residential Home Alcester Road Hollywood Birmingham West Midlands B47 5NS Lead Inspector N Andrews Unannounced Inspection 09:20 21 November 2005 st 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 Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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 Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillside Residential Home Address Alcester Road Hollywood Birmingham West Midlands B47 5NS 0121 430 2126 0121 430 6306 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) Mr Christopher Michael Higgins Angela Christine Griffiths Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may also accommodate 2 named people with a dementia illness. 21st March 2005 Date of last inspection Brief Description of the Service: Hillside is a detached, purpose-built property situated in a secluded, semi-rural position on the outskirts of Birmingham. The property stands in its own grounds surrounded by lawns and set well back from the main road at the end of a driveway. The registered provider lives in his own, separate, first floor accommodation adjoining the premises. There are car-parking facilities at the front of the premises. The property is registered as a care home providing residential i.e. personal, care for a maximum of 17 older people above the age of 65 years who may also have a physical disability. The home may also accommodate two named people with a dementia illness. The home is a single storey building. Therefore, all of the service users are accommodated on the ground floor in 15 single bedrooms and 1 double bedroom. All of the single bedrooms, except one, had an en suite facility. At the time of the inspection one of the double bedrooms was being used as a single room. There were 16 service users, one of whom was in hospital, and one vacancy. The home’s main aim is to provide a warm, homely environment for the service users and to provide individual care. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. The inspection included a tour of part of the premises. Time was spent with the registered manager assessing the progress made by the home in implementing the requirements and recommendations arising from previous inspections. Some of the service users’ records and staff files were inspected and individual discussions were held with four service users and two members of staff. The service users with whom discussions were held expressed their satisfaction with the standard of care provided. One service user said that the staff treated the service users with kindness and respect. Another service user said that the staff ‘always knocked the door’. Another service user said ‘Most of the staff are very good and some of them will do anything you ask them to’. One of the members of staff was described as ‘a little treasure that did everything properly and didn’t seem to forget anything’. One of the service users felt that the home had difficulties in ‘keeping the staff’. The service users expressed their satisfaction with the activities provided. However, one of the service users said that they would welcome the ‘opportunity to be taken to the shops’. The service users also expressed their confidence about raising any concerns they had with the staff and felt that any complaints would be treated seriously and responded to quickly and appropriately. Three of the service users confirmed that they were ‘free to get up and go to bed when they wanted to’. The comments about the standard of food were less positive. One service user described the food as ‘alright’. Another said ‘the food could be better’. Two service users said that the food ‘lacked variety’. Two of the service users felt that the standard of food had ‘gone down’. The two members of staff with whom discussions were held spoke positively about the home. They both confirmed that they had been given a job description and a contract. Both members of staff said that they had completed the NVQ 2 training and that they felt well supported by senior staff. They stated that good relationships existed between the staff and between the staff and the service users. One member of staff said ‘It’s like one big family’. Asked what improvements they would like to see, they said that they would like parts of the home to be refurbished, a bigger laundry and a tail-lift minibus so that they could take the service users on more day outings. The home was inspected against 22 of the National Minimum Standards. One of the 22 Standards that were inspected was exceeded. Eight of the Standards were met, 12 were nearly met and one was not met. The number of requirements had fallen from 39 at the last inspection to 27. However, the number of recommendations remained the same i.e. 16. Despite the overall improvement, the number of requirements and recommendations remains unacceptably high. Efforts must continue to be made to reduce the number of Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 6 requirements and recommendations to a more satisfactory level. Enforcement action may be taken if these essential aspects of the home are not addressed within the timescales given. What the service does well: 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 Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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 Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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): 1, 2, 4 and 5 The home’s statement of purpose and service users’ guide provided the current and prospective service users with relevant information about the home. However, the contents of both documents needed to be improved. The service users had been issued with a statement of terms and conditions. Prospective service users had an opportunity to visit the home prior to admission. EVIDENCE: A copy of the home’s statement of purpose and service users’ guide were made available for inspection. The home’s response to the requirement that was made in regard to the statement of purpose as a result of previous inspections was assessed. The requirement was that the statement of purpose must be amended to include all the information detailed in Regulation 4 and Schedule 1. The statement of purpose contained relevant information on a range of important issues. However, the statement of purpose needed to be improved by the inclusion of, • The organisational structure of the care home, • The emergency procedure in the event of a temporary closure of the home, • A copy of the home’s complaints procedure, including the full address of the CSCI, Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 9 • Details of any specific therapeutic techniques provided. In addition, the references to the acting manager should be deleted and replaced by appropriate references to the registered manager. The requirement had not been fully implemented and still stands. The home’s response to the requirement that was made in regard to the service users’ guide as a result of previous inspections was assessed. The requirement was that a service users’ guide, that includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service user. The service users’ guide contained relevant information on a range of important issues. However, the service users’ guide also needed to be improved by the inclusion of, • The relevant qualifications and experience of the registered manager and staff e.g. NVQ qualification etc. • The address and telephone numbers of the Social Services Department, Age Concern and Advocacy Service on page 17, • Details of the special needs catered for e.g. service users with a physical disability and two service users with a dementia illness, and • The ‘Useful Telephone Numbers’ on page 18. In addition, the references to the acting manager e.g. on pages 4 and 18, should be deleted and replaced by appropriate references to the registered manager. The requirement had not been fully implemented and still stands. A copy of the home’s statement of terms and conditions, referred to as ‘Contract of Terms and Conditions’, was made available for inspection. The home’s response to the requirement that was made in regard to the statement of terms and conditions as a result of previous inspections was assessed. The requirement was that the statement of terms and conditions (contract) must be amended so that it includes all of the information in Standard 2.2 and a copy must be issued to each service user. The requirement had been implemented. The registered manager confirmed that all of the service users had been issued with a copy of the amended statement of terms and conditions. The registered manager is advised to check the statement of terms and conditions for typographical and grammatical errors. The home’s response to the requirement that was made in regard to Standard 3 as a result of previous inspections was assessed. The requirement was that a written assessment must be completed before the admission of any service user in accordance with the requirements of Regulation 14 and Standard 3 and the home’s assessment form must be amended to include all of the issues referred to in Standard 3.3. A copy of the form used by the home to assess the care needs of prospective service users was made available for inspection. The assessment form contained a reference to all of the aspects of care listed in Standard 3.3. The registered manager stated that the form had been used to assess all of the service users. The requirement had, therefore, been implemented. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 10 The registered manager confirmed that the staff were supported in the care that they provided for the service users by outside agencies. All of the service users were registered with a local GP. The district nurse visited the home twice a week to attend to the needs of one service user. The chiropodist visited every 6 to 8 weeks. The continence adviser visited as required. A consultant was monitoring the care of two service users with a dementia illness. The registered manager stated that none of the service users were in need at the present time of the help of an occupational therapist or physiotherapist. However, it was stated that the service users carried out exercises to music every Tuesday. The registered manager stated that the needs of one service user with a visual impairment were being appropriately met. The home did not have any service users that required the permanent use of a wheelchair. The home did not aim to provide for the needs of people from any specific ethnic, social, cultural or religious group. The registered manager confirmed that prospective service users were invited to the home prior to making a decision about admission. The registered manager and other staff also visited the prospective service users in their own homes or hospital wherever possible prior to admission in order to carry out the care needs assessment. The registered manager stated that it was the home’s policy to avoid admitting service users in an emergency. The home’s response to the recommendation that was made in regard to Standard 5 as a result of previous inspections was assessed. The recommendation was that a clear statement regarding the home’s policy on pre-admission visits and the four-week trial period following admission should be included in the service users’ guide. The recommendation had not been implemented and still stands. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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): 10 and 11 The service users were treated with dignity and respect. The home had a satisfactory policy and procedure in regard to dying and death and this was adhered to in practice. EVIDENCE: The home’s response to the four requirements that were made in regard to Standard 7 as a result of previous inspections was assessed. The first requirement was that a service user plan that covers all aspects of care as set out in Standards 7.2 and 3.3 must be drawn up with each service user in accordance with Regulation 15. A copy of the home’s care plan was made available for inspection. The care plan consisted of a collection of different forms including risk assessments, weight chart, fluid chart, bowel chart, professional contact/involvement record and description of client etc. The forms that referred specifically to a care plan were insufficient to ensure that all of the service users’ needs were met. The forms did not include a reference to all of the aspects of care referred to in Standard 3.3. For example, there was no reference to sight, hearing, communication, oral health, foot care, social interests, hobbies and religious and cultural needs. The care plan forms must be carefully and thoroughly revised and amended so that they contain all of the relevant information in the appropriate format in order to ensure that they serve their intended purpose. The requirement had not been Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 12 implemented and still stands. The second requirement was that clear specific and detailed guidance must be included in the service users’ plans to ensure the appropriate delivery of care. Where service users are unwell recording must include up to date tissue viability risk assessments and action being taken to maintain tissue viability. Recording must also include full information on food and fluid intake. The care plans of two service users were inspected. The district nurse had carried out and recorded a tissue viability risk assessment in respect of one of the service users. The registered manager stated that only the one service user needed a tissue viability risk assessment at the present time. It was noted that the service users’ food and fluid intake was being recorded. Therefore, these aspects of the requirement had been implemented. Records of the care provided were being maintained in the staff handover book and changes of care practice were recorded in the daily report book. The care plans lacked details of the action to be taken by the staff to ensure that all of the service users’ needs were being met. The registered manager acknowledged that the care plans needed to be improved. The registered manager stated that she intended to amend the format of the care plans in order to provide extra space to record clear, specific and detailed guidance for the staff. The requirement had not been fully implemented and still stands. The third requirement was that service user plans must include specific guidance for staff on dealing with any challenging behaviour manifested by service users. The registered manager stated that the requirement was no longer relevant to the home as none of the current service users presented any challenging behaviour. The requirement has, therefore, been deleted. The fourth requirement was that guidance for staff must make clear that any restraint of service users is only used as a last resort and that, in line with the home’s procedure, an incident report must be completed. A copy of the home’s policy ‘Dealing with Aggression Towards Staff’ was made available for inspection. It was noted that the policy contained an appropriate reference to both issues. The requirement had, therefore, been implemented. However, the policy did not state that all incidents involving physical restraint must be reported without delay to the CSCI in accordance with Regulation 37. The home’s response to the two requirements that were made in regard to Standard 9 as a result of previous inspections was assessed. The first requirement was that a self-administration procedure must be developed that includes the individual requirements of the two service users who administer medication given to them by their carers in the privacy of their bedrooms. The registered manager stated that only one service user now self-administered medication. The procedure for the self-administration of medication was written each month on the back of the service user’s MAR charts. The initials of the members of staff who give the medication to the service user and later return to collect the empty container were being recorded on the MAR charts. The requirement had, therefore, been implemented. However, a risk assessment had not been carried out and the service user had not signed a consent form agreeing to accept that she will be given medication. The second requirement was that handwritten Medication Administration Records (MAR) Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 13 charts must be checked and signed by two members of staff. The requirement had been implemented. The registered manager confirmed that the staff endeavoured to ensure that the service users’ privacy and dignity were respected at all times. The service users with whom discussions were held also stated that the staff respected their privacy. A pay phone was located in the main corridor and six service users had their own telephone. It was not possible, therefore, for all of the service users to make or receive calls in private. A mobile handset should be provided for this purpose. It was stated that, as a result of a recent change in policy, the clothes of deceased service users were no longer retained by the home. Consequently, all of the service users wore their own clothes at all times. The registered manager confirmed that all other aspects of Standard 10 were met. The home’s response to the requirement that was made in regard to Standard 10 as a result of the previous inspection was assessed. The requirement was that all locks on bathroom and toilet doors must be in working order. The requirement had been implemented. The registered manager outlined the practices and procedures that were carried out by the staff following the most recent death of a service user in the home. These reflected the principles and practices listed in Standard 11. The home’s response to the recommendation that was made in regard to Standard 11 as a result of the previous inspection was assessed. The recommendation was that the service users’ wishes regarding terminal care and the arrangements after death should be included in their care plans. The registered manager stated that the home had introduced a form to record the relevant details. However, the staff had had difficulty in obtaining the necessary information from the service users and/or their relatives. Consequently, the recommendation had not been fully implemented and still stands. Advice was given to the registered manager on this issue. The home had a policy and procedure headed ‘Care Procedure: In Case of Death’ that was made available for inspection. The home’s procedure contained details of good practice that were similar to all of the issues referred to in Standard 11. The reference to NCSC should be deleted and replaced by a reference to CSCI. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14 The home provided a range of social and leisure activities appropriate to the service users’ needs. The service users were enabled to maintain contact with their relatives and friends, to retain their links with the wider community and to exercise choice and control over their own lives. EVIDENCE: The home provided a range of social and leisure activities. These included Bingo and other board games, DVD’s and a karaoke machine. A ‘fitness and fun’ session was held every week and the hairdresser also visited weekly. Special events were celebrated including birthdays, Halloween, bonfire night, St Patrick’s Day and Christmas. A religious service was held in the home on the last Sunday in every month. It was intended that children from the local school would visit the home to sing Carols at Christmas. Outings had taken place to the Black Country Museum, Back to Back in Birmingham, Cadbury’s World and Stratford upon Avon. The registered manager stated that the service users were served breakfast in their bedrooms between 7:00 am and 9:00 am. The majority of the service users ate their lunch in the dining room between 12:30 pm and 1:00 pm. The teatime meal was served in the service users’ bedrooms at about 5:00 pm. The registered manager said that the service users began to get up at about 6:30 am and that most of the service users were up and dressed by 8:00 am. The service users usually started going to bed at about 8:00 pm. The registered manager confirmed that the service users were free to get up and go to bed at the times that they chose Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 15 and not at times that may be more convenient to the staff. The service users were enabled to maintain their individual interests e.g. knitting, crosswords and piano. The registered manager was asked to maintain a daily record of the social and leisure activities provided and the names of the service users who participated. The service users were informed verbally of the activities that were arranged. However, the registered manager intended to introduce a notice board that would be placed near the dining room. The notice board would be used to display details about activities and other relevant information. Although the registered manager felt that more could be done to increase the range of activities provided for the service users, there was sufficient evidence to show that this Standard had been met. The service users were able to receive their visitors in private and at any reasonable time and no unnecessary restrictions were imposed by the home. The service users’ right to choose whom they wished to see or not see was respected. The home’s response to the recommendation that was made in regard to Standard 13 as a result of the previous inspection was assessed. The recommendation was that relatives, friends and representatives of service users should be given written information, preferably in the service users’ guide, about the home’s policy on maintaining relatives and friend’s involvement with service users at the time of an admission to the home. The recommendation had not been implemented and still stands. The service users were encouraged to exercise choice and to retain their independence. The service users and/or their relatives handled their own finances. The home handled small amounts of money on behalf of one service user for personal expenses i.e. hairdressing. The home’s response to the requirement and recommendation that were made in regard to Standard 14 as a result of the previous inspection was assessed. The requirement was that information regarding the service users’ right of access to the records held about them by the home must be given to the service users, preferably in the service users’ guide. The requirement had not been implemented and still stands. The recommendation was that service users and their relatives and friends should be informed, preferably in the service users’ guide, of how to contact external agents, including advocates, who will act in their best interests. The recommendation had not been fully implemented and still stands. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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 17 The service users felt confident that their concerns and complaints would be listened to and dealt with appropriately. However, the details of the complaints procedure needed to be fully and accurately recorded. The service users’ legal rights were protected. EVIDENCE: The home had a complaints procedure. The complaints procedure was referred to in the statement of purpose and in the service users’ guide. The requirement that was made in regard to the complaints procedure as a result of the previous inspection was assessed. The requirement was that all references to the home’s complaints procedure must include the full address and telephone number of the Worcester office of the CSCI. It was noted that the statement of purpose did not contain the full details of the complaints procedure and did not include the address of the Commission. It was also noted that the copies of the complaints procedure that were held in the service users’ files did not contain the correct information. The requirement, therefore, had not been implemented and still stands. Two recorded complaints had been made against the home within the previous twelve months, one of which had been made direct to the CSCI. The complaint was about care practice and contained eight elements. Two elements of the complaint were upheld, four elements of the complaint were not upheld and two elements of the complaint were unresolved. There was evidence to show that the service users were supported to exercise their legal rights. The registered manager stated that none of the service users required the help of an advocate. Nevertheless, the service users’ guide should include details of the local advocacy service. (See Standard 14 above). Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 17 The registered manager confirmed that the service users were enabled to vote at the last election using the postal voting system. The home’s response to the three requirements and two recommendations that were made in regard to Standard 18 as a result of the previous inspection was assessed. The first requirement was that the home’s ‘Adult Abuse’ policy must be amended to include information for referring all allegations and suspicion of abuse to the Adult Protection Coordinator and to the CSCI. A copy of the home’s ‘Adult Protection and Prevention of Abuse’ policy was made available for inspection. The policy contained a relevant reference to the CSCI. However, the policy did not include a specific reference to the Adult Protection Coordinator (APC) or the address and telephone number of the APC or the full address and telephone number of the CSCI. The policy stated that various agencies, including the CSCI, must be informed of any allegations of abuse ‘within 24 hours’. The policy must state clearly that all allegations or suspicions of abuse must be reported to the CSCI without delay. The requirement had not been fully implemented and still stands. The second requirement was that all suspicions and/or allegations of abuse must be referred to the Adult Protection Coordinator and the CSCI. The registered manager stated that no allegations or suspicions of abuse had occurred since the previous inspection. The registered manager confirmed that she was aware that any such cases must be referred appropriately without delay. Therefore, the requirement was no longer considered necessary and was deleted. The third requirement was that the home’s whistle-blowing policy must be amended in line with the Public Interest Disclosure Act 1998 to allow referral of concerns to the CSCI without exhausting internal mechanisms first. A copy of the home’s ‘Whistle blowing Policy’ was made available for inspection. The policy did not state that members of staff could make a direct approach to the CSCI with their concerns at any time if they so wished. The requirement had not been implemented and still stands. The first recommendation was that a copy of the Department of Health guidance ‘No Secrets’ and information about the Worcestershire policy and procedure for the protection of vulnerable adults from abuse should be kept in the home. The recommendation had not been implemented and still stands. The second recommendation was that a policy should be developed and implemented regarding service users’ money and financial affairs, ensuring service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. A copy of the home’s ‘Management of Service Users’ Money and Financial Affairs’ policy was made available for inspection. The policy did not include a reference to all of the relevant issues. In addition, the policy contained an out of date reference to the NCSC. The requirement, therefore, had not been fully implemented and still stands. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 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, 22, 23, 25 and 26 The service users lived in clean, comfortable surroundings with adequate internal and external space. The service users’ bedroom/personal accommodation was of a high standard and suitable for their individual needs. The home had satisfactory laundry facilities. EVIDENCE: The service users lived in clean, comfortable and homely surroundings. There were no unpleasant odours. The home’s response to the recommendation that was made in regard to Standard 19 as a result of the previous inspection was assessed. The recommendation was that a programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented. The registered manager made available for inspection a record of the maintenance work that was carried out in the home. The record consisted mainly of repairs and replacements. The registered manager was advised to record in advance the items of work that should be carried out as part of the annual programme of routine maintenance and renewal. The registered manager stated that, in future, the rear of the maintenance book would be used to record all the items that needed to be renewed. The recommendation was regarded as having been implemented. The grounds Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 19 were kept tidy. The majority of the service users’ bedrooms had direct access to the grounds. There was a patio area leading to the home’s main entrance that the service users were able to use in warmer weather. It was not possible to confirm whether the building complied with the requirements of the local fire service as the letter from the Fire Safety Officer following the most recent visit was not available. The home had a lounge, dining room, conservatory and a small lounge that was designated as a room for service users that smoked. In addition, the same room was also used for hairdressing purposes. The service users had access to large, pleasant grounds with adequate space for outdoor activities. The standard of furnishings was satisfactory. The home’s response to the recommendation that was made in regard to Standard 22 as a result of the previous inspection was assessed. The recommendation was that the advice of a qualified occupational therapist should be sought in order to ensure that the home provides all of the recommended disability equipment and environmental adaptations to meet the needs of the service users. It was pleasing to note that a qualified occupational therapist had carried out an assessment of the home on 29 August 2005. Therefore, the recommendation had been partly implemented. However, not all the recommendations made as a result of the visit had been implemented e.g. the bath hoist had not yet been serviced. The registered manager confirmed that the bath hoists and mobile hoist had not been serviced within the past twelve months. As the recommendations relate to health and safety issues they must be addressed as a matter of priority. The home had level access throughout. Therefore, the service users were able to access all parts of the premises with ease. Handrails and grab rails were provided in corridors and in the communal bathroom and toilet facilities. One service user had a visual impairment. However, the registered manager confirmed that the service user’s needs were met without the provision of any special environmental equipment. A staff alarm call system was installed in all the rooms. It was confirmed that more storage space for storing wheelchairs and other items/equipment was needed. The home provided 15 single bedrooms and 1 double bedroom. At the time of the inspection the double bedroom was being used as a single bedroom. An en suite facility was provided in respect of 15 bedrooms. The double bedroom was in excess of 16 sq metres in size and all of the single bedrooms except one were above 10 sq metres. The home’s response to the two requirements that were made in regard to Standard 24 as a result of the previous inspection was assessed. The first requirement was that all of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users. The second requirement was that the floors in bedrooms 6 and 7 must be carpeted or provided with an acceptable equivalent floor covering. The bedrooms were inspected and it was Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 20 noted that there was no lockable storage in bedroom 15. It was also noted that there was no lock on the door to bedroom 8 and that the radiator was in need of repair. The floors in bedrooms 6 and 7 did not have any carpet. The registered manager stated that the relatives of the service users that were accommodated in bedrooms 6 and 7 had confirmed that they were satisfied with the bedroom flooring as it was and did not wish carpets to be provided. Nevertheless, the absence of carpets presents a potential hazard to the safety of the service users. Therefore, if the two service users do not have any objections, carpets must be provided. The requirements had not been implemented and still stand. All of the service users’ bedrooms except one had patio doors and all of the rooms were centrally heated. The home’s response to the requirement and recommendation that were made in regard to Standard 25 as a result of the previous inspection was assessed. The requirement was that checks on the temperature of hot water accessible to service users must be fully recorded. The requirement had been implemented. However, the registered manager intended to improve the recording system by including an additional column in the book in which the temperatures were maintained that would be used to specify the number of the service users’ bedroom. The recommendation was that the lighting levels in the home should be tested in order to ensure that they meet recognised standards i.e. lux 150. The recommendation had not been implemented and still stands. Emergency lighting was provided throughout the home. Thermostatically controlled mixer valves had been fitted to the hot water outlets used by service users. The temperature of the water issuing from the hot water outlets in three bedrooms and one bathroom was checked. It was noted that the temperature of the hot water in bedroom 12 was 52.6 degrees C. This was nearly 10 degrees C above an acceptable level i.e. 43 degrees C. The registered manager stated that a thermostatic mixer valve located in the loft controlled the hot water temperature for bedroom 12. The valve was clearly ineffective at the time of the inspection and needed to be repaired or adjusted. A notice of immediate requirement was issued at the conclusion of the inspection in regard to this matter. The premises were clean, tidy and free from unpleasant odours. The home employed one part-time member of staff for 20 hours per week to undertake domestic duties. The laundry was appropriately sited and contained satisfactory facilities including a hand washing facility. A copy of the home’s Infection Control Policy was made available for inspection. The policy contained information on all of the relevant issues. However, the wording of the policy needed to be adapted/amended in order to reflect the practices of the home, signed by the registered manager and dated. The references in the policy to the NCSC must be replaced by references to the CSCI. The home’s response to the two requirements and one recommendation that were made in regard to Standard 26 as a result of the previous inspection was assessed. The first requirement was that a risk assessment must be carried out regarding the handling of soiled linen, disinfection of commode pans etc and a sluicing Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 21 facility provided if necessary. The requirement had been implemented and the registered manager confirmed that a new sluice had been provided. The second requirement was that paper hand towels must be used in communal facilities. It was noted on the first day of the inspection that a paper towel dispenser had not been installed in either of the two bathrooms. However, a paper towel dispenser was installed in both bathrooms during the inspection. The requirement was, therefore, implemented. The recommendation was that the Environmental Health Officer should be asked to confirm whether the washing machine has the specified programming ability to meet disinfection standards. Since the previous inspection the home had purchased a new sluice and a new industrial tumble dryer. The recommendation, therefore, was no longer applicable and has been deleted. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 22 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 29 The home was committed to NVQ level 2 training and had exceeded the 50 target as laid down in the National Minimum Standards. The home’s staff recruitment practices were not sufficiently robust to ensure the protection of the service users and needed to be improved. EVIDENCE: The home’s response to the recommendation that was made in regard to Standard 28 as a result of the previous inspection was assessed. It was pleasing to note that 7 members of the care staff including 3 senior care assistants and 2 night care assistants had undertaken NVQ level 2 training and 2 assistant managers had undertaken NVQ level 3 training i.e. 9 members of staff. The home employed a total of 15 care staff. Therefore, over 50 of the care staff had attained a qualification at NVQ level 2 or equivalent. The recommendation had been implemented. It was also noted that other staff had commenced NVQ level 2 training and that two assistant managers had commenced NVQ level 4 training. The home’s response to the two requirements and one recommendation that were made in regard to Standard 29 as a result of the previous inspection was assessed. The first requirement was that all applicants for employment at the home must be asked to provide a full employment history. The files of three staff members were inspected. It was a matter of concern that the employment history of one member of staff went back only as far as 2000. The employment history of the second member of staff went back only as far as January 2005. The employment history of the third member of staff was also incomplete. The requirement had not been implemented and still stands. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 23 The second requirement was that a written reference from the last employer must be obtained. References must be checked for authenticity where doubts arise because of the way in which references are presented. A note of the check must be made. The files of three staff members were inspected. One file contained only one written reference. This was in the form of an undated testimonial. Another file contained two personal testimonials, one of which was undated and had no address. The requirement had not been implemented and still stands. The practice of accepting personal testimonials is unsatisfactory and unacceptable. Two relevant, written references, one of which must be from the applicant’s current or most recent employer, must always be obtained in respect of all prospective members of staff preferably before their interview and most certainly prior to their appointment. The recommendation was that the job descriptions of all the staff should be reviewed and, where necessary, revised in order to ensure that they accurately reflect the staff duties and responsibilities. Copies of the job descriptions in respect of the domestic assistant, senior care staff, care staff, trainee care assistant and night care assistant were made available for inspection. The job descriptions were satisfactory. The recommendation was regarded as having been implemented. It was also noted that, in respect of two of the staff whose files were inspected, there was no CRB disclosure check. The registered manager stated that an application had been made to the Criminal Records Bureau (CRB) for an enhanced disclosure check on behalf of both members of staff. However, the registered manager was reminded that disclosure checks from the CRB must be obtained for all new staff prior to their appointments. It was noted that all three files that were inspected contained a copy of the terms and conditions of employment (contract). The home’s response to the two requirements and one recommendation that were made in regard to Standard 30 as a result of the previous inspection was assessed. The first requirement was that all members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. The registered manager stated that three members of staff were receiving induction training and were intending to commence NVQ level 2 training in the near future. The requirement had been implemented. The second requirement was that all staff must have individual training development assessments and profiles. It was confirmed that individual records of the training undertaken by all the staff were maintained. In addition, the home also maintained a training matrix that contained the names of all the staff. The requirement was regarded as having been implemented. The recommendation was that the advice and guidance of the NVQ tutor should be obtained in writing regarding the need for staff that are placed on NVQ level 2 training to undergo TOPSS foundation training. The registered manager had attempted to implement the recommendation. However, the written evidence provided by the registered manager referred only to induction training and did not refer to foundation training. The recommendation had not been fully implemented and still stands. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 24 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 37 The registered manager was experienced and committed to the care of older people. However, the registered manager needed to undertake further training and to be provided with a job description to enable her to discharge her responsibilities fully. The staff felt well supported and the standard of record keeping was satisfactory. EVIDENCE: The registered manager had worked in the home for several years and, therefore, had relevant experience of caring for older people. Her application to become the registered manager was approved on 16 July 2005. The comments made by the registered manager throughout the inspection indicated her commitment to providing a high standard of care. The registered manager was undertaking the NVQ level 4 training. She hoped to complete the training in the near future and then to embark on the Registered Managers’ Award training. The registered manager stated that she had undertaken training in the care of people with dementia on 15 February 2005 and that she had also undertaken training in infection control and moving and handling on Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 25 23 November 2005. She had undertaken fire safety training on 10 August 2005. Training in supervision had not yet been undertaken. However, it was confirmed that this training had been arranged for 8 December 2005. The registered manager had not yet undertaken training in the protection of vulnerable adults from abuse or health and safety. The registered manager confirmed that she was receiving individual supervision and support from the director of care. However, she also stated that she had not yet been provided with a copy of her job description. The home’s response to the requirement and recommendation that were made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The registered manager stated that questionnaires had been introduced in order to seek the views of the service users and their visitors on the service provided by the home. However, the home did not have a full quality assurance system in operation. The requirement had not been implemented and still stands. The recommendation was that the results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. The registered manager confirmed that questionnaires had been issued to both service users and visitors. Only six responses had been received during August, September and October 2005. None of the responses were from service users. However, the results of the survey that had not been analysed or published. The registered manager stated that she intended to include the results in the home’s newsletter. The recommendation had not been fully implemented and still stands. The home’s response to the requirement that was made in regard to Standard 35 as a result of the previous inspection was assessed. The requirement was that service users’ money held for safekeeping must be securely stored and transactions fully recorded. The registered manager stated the home handled the money in respect of one service user. All of the other service users and/or their relatives handled their own money. The money that was handled by the home on behalf of one service user was limited to about £10 per week and was used for personal expenses. The money was kept in an envelope in a petty cash tin in a lockable cabinet. Therefore, the money was being held securely. However, the transactions regarding the money that was handled by the staff were still being recorded on an envelope. The home is required to maintain a record of the money that is kept on behalf of the service user including the date, the amount received and spent on the service user’s behalf and the purpose for which the money was spent. A small book should be kept for this purpose. The requirement had not been fully implemented and still stands. The registered manager said that other costs incurred by the service users e.g. hairdressing and chiropody, were paid for by the home and the service users’ relatives were invoiced. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 26 The home’s response to the requirement that was made in regard to Standard 36 as a result of the previous inspection was assessed. The requirement was that the supervision of care staff must include all aspects of practice, philosophy of care in the home and career development needs. The registered manager confirmed that the requirement had been implemented. It was also stated that, in addition to the registered manager, two assistant managers and six senior care assistants were responsible for supervision. Two training sessions had been arranged, one on 8 December 2005 and the other in January 2006, in order to train all the staff that were responsible for supervision. The records that the home is required to maintain were inspected. It was noted that the copy of the complaints procedure that was kept in the home’s policy and procedures folder contained an out of date reference to the NCSC. The reference to the NCSC must be deleted and replaced by a reference to the CSCI. Similarly, the home’s statement of the procedure to be followed in the event of accidents/incidents must include the name, address and telephone number of the CSCI. The same procedure and the procedure to be followed in the event of a service user becoming missing must include a clear statement that any accident or any event that adversely affects the wellbeing or safety of any service user must be reported to the CSCI without delay in accordance with Regulation 37. The procedure to be followed in the event of a service user becoming missing should also include a statement that the relatives of the missing service user must be informed without delay. The accident book was Data Protection Act compliant. The home’s response to the requirement that was made in regard to Standard 37 as a result of the previous inspection was assessed. The requirement was that copies of the written reports on the conduct of the home that are made following the monthly visits to the home by the registered provider’s nominated representative must be supplied to the CSCI as well as the manager of the home in accordance with Regulation 26. The requirement had been implemented. The home’s response to the ten requirements that were made in regard to Standard 38 as a result of the previous inspection was assessed. The first requirement was that the registered person must contact the Fire Safety Officer to obtain a copy of his earlier correspondence or to request a further inspection of the premises in order to ensure that all of his previous recommendations are carried out. The requirement had not been implemented and still stands. A notice of immediate requirement was issued at the conclusion of the inspection in regard to this matter. The second requirement was that all staff must participate in a fire drill by the date indicated. The requirement had been implemented. The third requirement was that fire drills must be held at least every six months. The requirement had been implemented. The fourth requirement was that fire doors must not be wedged open. Appropriate devices must be fitted to doors if they are to remain open. The requirement had not been implemented and still stands. A notice of immediate requirement was issued at the conclusion of the inspection in regard Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 27 to this matter. The registered manager stated that only four service users preferred to have their bedroom doors kept closed. The fifth requirement was that there must be at least one member of staff on duty at all times, day and night, who is trained in first aid to at least the level of an Appointed Person. It was pleasing to note that all the senior staff had undertaken first aid training at the Appointed Person level on 10 August 2005. The registered manager also confirmed that other members of staff had undertaken emergency first aid training in January 2005. However, none of the night care assistants had undertaken first aid training. The requirement, therefore, had not been fully implemented and still stands. The sixth requirement was that training in food hygiene, moving and handling, infection control, dementia-care and risk assessment must be provided for all the staff. The registered manager confirmed that all the staff would undertake training in food hygiene on 14 December 2005 and training in moving and handling and infection control would be undertaken on 23 November 2005. Training in the care of people with dementia had been undertaken in February 2005 by some staff including the registered manager. However, it was stated that there were six members of staff that had not undertaken this training. No date had yet been set for staff training in risk assessment. It was pleasing to note the arrangements that had been made to enable the staff to undergo most of the specified training. However, the requirement had not been fully implemented and still stands. The seventh requirement was that risk assessments must be carried out and recorded for all safe working practice topics covered in Standards 38.2 and 38.3 including fire safety, infection control and first aid. The registered manager confirmed that risk assessments had been carried out in respect of a number of safe working practice topics including fire safety, first aid, food hygiene, infection control etc. However, a risk assessment had not been carried out and recorded in respect of the security of the premises, moving and handling, and maintenance of a safe environment including kitchen equipment and laundry. The requirement had not been fully implemented and still stands. A notice of immediate requirement was issued at the conclusion of the inspection in regard to this matter. The eighth requirement was that a Legionella risk assessment must be carried out. The registered manager confirmed that the requirement had been implemented. The ninth requirement was that all substances hazardous to health must be locked away. The requirement had been implemented. The tenth requirement was that footplates must be attached to wheelchairs when service users are being assisted to move. The registered manager stated that four service users were transferred by wheelchair. It was confirmed that, in the case of three service users, footplates were always used. However, the fourth service user refused to have footplates attached to her wheelchair. The requirement was regarded as having been implemented. However, the service user should be asked to sign and date an appropriately worded form confirming her decision and this should be kept on her personal file held by the home. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 28 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 2 3 X 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 X 2 3 X 2 3 X 2 3 STAFFING Standard No Score 27 X 28 4 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 2 X Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 29 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 OP1 Regulation 4 Requirement The statement of purpose must be amended in accordance with the guidance given in this report in order to include all the information detailed in Regulation 4 and Schedule 1. (Previous timescale of 31/05/05 not met). The service users’ guide must be amended in accordance with the guidance given in this report in order to include all the information detailed in Regulation 5 and Standard 1 and copies given to all current, and any prospective, service user. (Previous timescale of 31/05/05 not met). A service user plan that covers all aspects of care as set out in Standards 7.2 and 3.3 must be drawn up with each service user in accordance with Regulation 15. (Previous timescale of 30/04/05 not met). Clear, specific and detailed guidance must be included in the service users’ plans to ensure the appropriate delivery of care. DS0000018507.V268727.R01.S.doc Timescale for action 31/01/06 2 OP1 5 31/01/06 3 OP7 15 31/01/06 4 OP7 15 31/01/06 Hillside Residential Home Version 5.0 Page 30 5 OP7 13,37 6 OP9 13 7 OP14 15 8 OP16 22 9 OP18 12,13 10 OP18 12,13 The plans must include the action to be taken to ensure that all aspects of the service users’ needs are met. (Previous timescale of 30/04/05 not met). The home’s policy on ‘Dealing with Aggression Towards Staff’ must state that all incidents involving physical restraint must be reported to the CSCI without delay in accordance with Regulation 37. A risk assessment must be carried out and recorded in respect of any service user who self-medicates and the service user asked to sign an appropriately worded consent form. Information regarding the service users’ right of access to the records held about them by the home must be given to the service users, preferably in the service users’ guide. (Previous timescale of 31/05/05 not met). All references to the home’s complaints procedure must include the full address and telephone number of the Worcester office of the CSCI. (Previous timescale of 31/05/05 not met). The home’s ‘Adult Protection and Prevention of Abuse’ policy must be amended to include information for referring all allegations of abuse to the Adult Protection Coordinator and to the CSCI. (Previous timescale of 30/04/05 not met). The home’s whistle-blowing policy must be amended in line with the Public Interest Disclosure Act 1998 to allow referral of concerns to the CSCI without exhausting internal mechanisms first. (Previous DS0000018507.V268727.R01.S.doc 31/01/06 31/12/05 31/01/06 31/01/06 31/01/06 31/01/06 Hillside Residential Home Version 5.0 Page 31 11 OP19 23 12 OP22 13,16,23 13 OP24 16 14 OP24 16 15 OP25 13,23 16 OP29 19 17 OP29 19 18 19 OP29 OP31 19 9,18 timescale of 30/04/05 not met). Written evidence should be provided to show that the home complies with the requirements of the local fire service. All the recommendations made by the occupational therapist as a result of the visit to the home on 29/08/05 must be implemented. All of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users, in accordance with the guidance given in this report. (Previous timescale of 31/05/05 not met). The floors in bedrooms 6 and 7 must be carpeted or provided with an acceptable equivalent floor covering. (Previous timescale of 31/05/05 not met). The temperature of the hot water from the hot water outlet in bedroom 12 must be reduced, regulated and maintained at 43 degrees C in order to prevent the risk of scalding. All applicants for employment at the home, including staff employed since 29 July 2005, must be asked to provide a full employment history. (Previous timescale of 21/03/05 not met). Two relevant, written references, one of which must be from the applicant’s current or most recent employer, must be obtained in respect of all prospective staff prior to their appointment. (Previous timescale of 21/03/05 not met). Disclosure checks from the CRB must be obtained for all new staff prior to their appointments. The registered manager must undertake appropriate training in health and safety and the DS0000018507.V268727.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 24/11/05 21/11/05 21/11/05 21/11/05 31/03/06 Hillside Residential Home Version 5.0 Page 32 20 OP33 24 21 OP35 17 22 OP37 17 23 OP38 12 24 OP38 23 25 OP38 13 26 OP38 13 27 OP38 13 protection of vulnerable adults from abuse. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 31/05/05 not met). A record of all money held by the home for safekeeping on behalf of service users must be kept in accordance with the guidance given in this report. (Previous timescale of 21/03/05 not met). The home’s complaints procedure and the procedures to be followed in the event of accidents or a service user becoming missing must be amended in accordance with the guidance given in this report. A copy of the Fire Safety Officer’s letter containing details of fire safety precautions must be obtained and the recommendations fully and satisfactorily implemented. (Previous timescale of 30/04/05 not met). Fire doors must be kept closed and not be wedged open. Appropriate devices must be fitted to doors if they are to remain open. (Previous timescale of 31/05/05 not met). There must be at least one member of staff on duty at all times, day and night, who is trained in first aid to at least the level of an Appointed Person. (Previous timescale of 30/04/05 not met). Training in food hygiene, dementia-care and risk assessment must be provided for all the staff. (Previous timescale of 30/04/05 not met). Risk assessments must be carried out and recorded for all DS0000018507.V268727.R01.S.doc 31/01/06 31/12/05 31/12/05 31/12/05 24/11/05 31/01/06 31/01/06 02/12/05 Page 33 Hillside Residential Home Version 5.0 safe working practice topics covered in Standards 38.2 and 38.3, including security of premises, moving and handling and maintenance of a safe environment, including kitchen equipment and laundry. (Previous timescale of 30/04/05 not met). 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 Refer to Standard OP5 OP10 OP11 OP11 OP12 Good Practice Recommendations A clear statement regarding the home’s policy on preadmission visits and the four week trial period following admission should be included in the service users’ guide. A mobile handset should be provided to enable the service users to make and receive telephone calls in private. The service users’ wishes regarding terminal care and the arrangements after death should be included in their care plans. The out of date reference to the NCSC in the home’s policy on dying and death should be replaced with a reference to the CSCI. A daily record of the social and leisure activities provided by the home and the names of the service users that participated should be maintained and a notice board on which information about such activities can be displayed should be introduced. Relatives, friends and representatives of service users should be given written information, preferably in the service users’ guide, about the home’s policy on maintaining relatives and friend’s involvement with service users at the time of an admission to the home. Service users and their relatives and friends should be informed, preferably in the service users’ guide, of how to contact external agents, including advocates, who will act in their best interests. A copy of the Department of Health Guidance ‘No Secrets’ DS0000018507.V268727.R01.S.doc Version 5.0 Page 34 6 OP13 7 OP14 8 OP18 Hillside Residential Home 9 OP18 10 11 12 13 OP22 OP25 OP26 OP30 14 15 OP31 OP33 16 OP38 and information about the Worcestershire policy and procedure for the protection of vulnerable adults should be kept at the home. The home’s policy regarding service users’ money and financial affairs should be amended so that it includes a reference to ensuring service users’ access to their personal financial records, consultation on finances in private, advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. The reference to the NCSC should be replaced by a reference to the CSCI. Adequate storage space for storing wheelchairs and other equipment should be provided. The lighting levels in the home should be tested in order to ensure that they meet recognised standards i.e. lux 150. The home’s Infection Control Policy should be amended in accordance with the guidance given in this report. The advice and guidance of the NVQ tutor should be obtained in writing regarding the need for staff who are placed on NVQ level 2 training to undergo TOPSS foundation training. The registered manager should be provided with a job description that enables her to take responsibility for fulfilling her duties. The results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties, including the CSCI. The service user that refuses to have footplates attached to her wheelchair should be asked to sign and date an appropriately worded form confirming her decision and this should be kept on her personal file. Hillside Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 35 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Residential Home DS0000018507.V268727.R01.S.doc Version 5.0 Page 36 - 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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