Inspection on 15/12/05 for Hillview Nursing Home

This inspection was carried out on 15th December 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 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

Hillview Nursing Home 18/12/09

Hillview Nursing Home 25/02/09

Hillview Nursing Home 26/02/08

Hillview Nursing Home 31/05/07

Hillview Nursing Home 22/06/06

Hillview Nursing Home 20/07/05

Hillview Nursing Home 13/01/05

Hillview Nursing Home 10/08/04

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

CARE HOMES FOR OLDER PEOPLE Hillview Nursing Home 34-36 Berrow Road Burnham-on-sea Somerset TA8 2EX Lead Inspector Kathy McCluskey Announced Inspection 15th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillview Nursing Home DS0000054819.V263572.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. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillview Nursing Home Address 34-36 Berrow Road Burnham-on-sea Somerset TA8 2EX 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) 01278 783192 01278 783192 hillview@almondsbury.fsnet.co.uk Almondsbury Care Limited Mrs Shirley Anne Ruane Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Places for up to 13 person for personal care. Registered for a total of 30 places in category DE(E). One existing named service user under the age of 65 years in the category DE to remain at the home with no further admissions for service users under this category. One existing named service in the category MD(E) to remain at the home with no further admissions for service users under this category. The existing Manager to be supported by a named Clinical Manager who is suitably qualified and experienced RMN (Part 3 or 13 of the NMC Register) and will work a minimum of 30 hours per week at the home. In the event of Room 11 being vacated by the current service user, no further admission to this bedroom until work to increase the size of the bedroom has been carried out and approved by the NCSC. The following bedrooms should not be used for service users who require the use of a hoist or wheelchair to mobilise or staff assistance with regard to moving and handling; Rooms 2, 10, 17, 22, 23 and 26. 20th July 2005 6. 7. Date of last inspection Brief Description of the Service: Hillview Nursing Home is situated approximately 1 mile from the seaside town of Burnham-On Sea. The home is registered with the Commission for Social Care Inspection to provide nursing care for up to 30 people not less than 65 years of age who suffer with dementia. Within this provision, the home is registered for up to 13 places for personal care. Conditions of registration are detailed later in this report. Currently Social Services have a block booking on 15 of the 30 beds at the home. Hillview is owned by Almondsbury Care Ltd. The Responsible Individual is Mr K.Smith. The Registered Manager is Ms Shirley Ruane. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day (7.5hrs) by CSCI Regulation Inspector Kathy McCluskey. At the time of this inspection, 26 service users were living at the home. The inspector was able to meet with all service users, though not all were able to express a view. Service users appeared relaxed and comfortable in their surroundings. The registered manager was available throughout the inspection and the clinical manager was available for part of the inspection. No relatives/visitors requested to speak with the inspector and no CSCI comment cards were received. Ten completed CSCI comment cards were received from service users, all of which required staff assistance to complete. Five indicated that they liked living at Hillview and felt safe and well cared for. Eight indicated that they were treated well by staff. Service users spoken with at the inspection stated that they felt well cared for and that the food was excellent. Staff spoken with did not raise any concerns with the inspector. Staff indicated that they felt well supported and had good training opportunities. A tour of the premises was conducted where the majority of bedrooms and all communal areas were seen. The inspector would like to thank the service users, management and staff for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Hillview provides a comfortable environment for older people who have dementia. Service users are cared for by appropriately trained registered nurses and care staff. The home provides 24 hour nursing care. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 6 The numbers of staff on duty are appropriate to meet the needs of service users. Service users and staff benefit from an effective management team who promote an open and inclusive style of management. A range of interesting activities and appropriate stimulation are provided for service users. The clinical manager has taken the responsibility for ensuring that all service users benefit from this. The clinical manager has been attending a local reminiscence centre to gain further ideas, knowledge and equipment. On the day of the inspection, service users enjoyed viewing clothing from the 1940’s through to the 1970’s. During the inspection the inspector was able to unobtrusively observe staff interactions with service users. Staff were heard communicating with service users in a kind and respectful manner. Service users benefit from a wholesome and varied diet. The inspector was able to observe service users enjoying lunch. Choices were offered. Meals, including special/soft diets were attractively presented and portions were generous. Service users enjoyed lunch in a relaxed an unhurried manner. Staff sat with service users and offered assistance where required. This was carried out in an unhurried and respectful manner. Service users spoken with stated that they liked the food. Since taking over the home, the registered provider had been proactive in improving the standards of the environment. Major refurbishment had taken place to improve communal space on the ground floor. Bathrooms had been refurbished and two additional level access showers were installed. Some bedrooms and some communal areas benefited from redecoration, new carpets and furniture. As there has been no apparent further progress in this area, a requirement has been raised. What has improved since the last inspection? At this inspection, the inspector was able to see evidence that the requirements and recommendation raised at the last inspection had been addressed. The care records of the two most recent service users were examined and both contained documented evidence that an assessment had been carried out prior to admission. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 7 A care plan was seen to be in place for one service user identified at the last inspection. The registered manager has ensured that appropriate risk assessments, which identify the rationale for action, are in place for service users who require nursing on a mattress on the floor. What they could do better: The standard of décor in the majority of corridors is poor. Paint is badly chipped on doors and skirting boards. This is also the case in some communal areas and bedrooms. It has been required that the registered provider provides the CSCI with a programme of planned redecoration and refurbishment, which includes timescales. Two adjustable beds were noted to have inappropriate mattresses in place. They were domestic type mattresses and were too short for the bed. This could pose a risk of entrapment and/or injury to service users. Headboards were also missing on both beds. An immediate requirement was issued. An upstairs bedroom window was cracked. A replacement window had been purchased but required fitting. An immediate requirement was issued. The home’s care planning system is generally good but improvements have been required in relation to the prevention of pressure sores and the wound management. The home has a complaints procedure in place and had received one complaint since the last inspection. Insufficient documentation was in place. It has been required that details of staff supervision sessions are fully documented, signed by both parties and that the staff member should be given a copy. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 8 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. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 9 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 Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 10 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, 3, 4 and 5. Standard 6 is not applicable. Prospective service users are provided with the information they need to make an informed choice about moving to the home. The home’s procedures for the assessment of prospective service users has improved. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. Copies are made available to service users, prospective service users and their representatives. These documents are also displayed in the reception area of the home and include a copy of the home’s last CSCI inspection report. The home’s current fee range is between £449.50 to £497.00 per week and fees are determined upon the assessed needs of an individual. Any ‘Free Nursing Care’ element awarded is incorporated into the fees and is not refunded to the service user. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 11 Extra charges are met by service users for newspapers, hairdressing, trips/outings, personal toiletries/items and special requirements. The home also makes additional charges for transport and for staff time to escort service users to and from appointments. Service user contracts/financial agreements were not available at the home. The inspector was informed that these are held at the companies head office. It has been recommended that copies are maintained with the service users care records at the home. The manager or her deputy visit a prospective service user and carry out an assessment to ensure that the assessed needs and aspirations of the individual can be met by the home. Documented evidence of pre-admission assessments were seen in the care records for the two most recent service users. Prospective service users and/or their representatives are invited to visit the home prior to making a decision. Service users move to the home initially on a 4 week trial period. This is to ensure that all parties are happy with the placement. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 12 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 The home’s care planning procedures require improvement. The home’s procedures for the management and administration of medication are good. EVIDENCE: The care records for the two most recent service users were examined in detail at this inspection. Risk assessments had been completed for the prevention of pressure sores, falls, nutrition and moving and handling needs. Care plans had not been raised where service users had been assessed as being at risk of developing pressure sores. The inspector was able to see that both service users were using pressure relieving equipment but this was not reflected in a plan of care. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 13 The inspector was informed that two service users were being treated for pressure sores. Care plans were in place to address this, which identified details regarding the wound and the dressings prescribed. No information was recorded relating to the frequency for dressing the wound or a review date. Records indicated that wounds were being dressed on a regular basis, though frequencies varied. This was discussed with the registered manager who agreed to address. The inspector was able to see evidence that both service users had received input from a G.P and district nurse. A good supply of adjustable beds and pressure relieving equipment was seen to be in use. Inappropriate mattresses were in place on two of the adjustable beds seen (refer to Standard 38) Bed rails were seen to be in place where there was an assessed need. Risk assessments were seen in the care plans examined. The manager stated that, due to their needs, some service users required the use of a ‘bean bag’ in lounges rather than an arm chair. The inspector discussed the need to complete risk assessments for this, which would clearly identify the rationale for use. These should be kept under review. The manager devised a risk assessment at the time of the inspection and agreed to complete these. This will be followed up at the next inspection. The home’s procedures for the management and administration for medication were examined and was found to be well maintained. All medicines were found to be securely stored with MAR charts appropriately completed. Photographs of service users are used to aid identification. No excessive stocks of medicines were seen and all medicines were appropriately stored. At the time of this inspection, no controlled drugs were prescribed. Medicines are only administered by the registered nurse on duty. The home’s last pharmacy advice visit was carried out by Moss Pharmacy in Burnham on Sea, on 30/08/05. During the inspection, staff were observed assisting service users in a manner which respected their privacy and dignity. Hillview Nursing Home DS0000054819.V263572.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, 14 and 15 The provision of activities has improved. Service users are offered meaningful and varied activities. Service users benefit from a wholesome and varied diet. EVIDENCE: Since the last inspection, the clinical manager has taken responsibility for activities in the home. Given the needs and abilities of service users living at the home, many service users now benefit from stimulating one to one time with staff. Detailed social histories were in place for some service users, which provided useful information for staff. The manager stated that obtaining this information for some service users was proving difficult as they had no next of kin and were unable to express their preferences themselves. On the afternoon of the inspection, the clinical manager and some of the staff were ‘modelling’ original clothing from the 1940’s through to the 1970’s. The inspector was able to see very positive reactions from some service users. Service users were encouraged to touch the clothes and talk through memories that they might have. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 15 The clinical manager has been attending a local reminiscence centre on a regular basis to gain ideas and equipment to assist with the provision of stimulating activities for service users. This is felt to be very positive. Detailed records are maintained for each individual, which also identifies the outcome for service users. This is felt to be very positive and the clinical manager should be commended for her enthusiasm and commitment. The home welcomes visitors at any reasonable time in accordance with the wishes/preferences of the service user. No relatives/visitors requested to speak with the inspector at this announced inspection. In accordance with their plan of care, service users are able to choose how and where to spend their day. This was evident on the day of the inspection. Service users appeared relaxed in their surroundings and were observed utilising all communal areas. Those who were able, were moving freely around the home. One service user informed the inspector that they chose what time they retired to bed and got up in the morning. Service users benefit from a wholesome and varied diet. On the day of the inspection service users were observed enjoying a roast beef lunch. Prior to lunch the inspector heard staff offering service users a choice of lunch. One service user had chosen ham off the bone, eggs and mashed potatoes. Service users able to express a view informed the inspector that there was ‘always plenty to eat’, ‘always a choice’ and that the food was ‘excellent’. Soft diets were seen to be attractively presented and staff were observed assisting service users in an unhurried and respectful manner. Hillview Nursing Home DS0000054819.V263572.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, 17 and 18 The home needs to demonstrate that complaints are managed in accordance with its’ complaints procedure. The home takes appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home has a complaints procedure, which is displayed in the reception area of the home. The home has received one complaint since the last inspection. Records were examined and the inspector advised the manager to ensure that records demonstrated that agreed timescales had been met and that the outcome had been communicated to the complainant. Staff are made aware of the home’s whistle blowing policy and information on ‘elder abuse’. These documents are also displayed in the main reception area of the home. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The registered person must ensure that a satisfactory programme of decoration/refurbishment is followed. Service users have access to an appropriate range of specialist equipment. EVIDENCE: The majority of bedrooms and all communal areas were examined at this inspection. The home benefits from a large lounge/dining room with a smaller area off, and two additional lounge areas. All communal areas are situated on the ground floor. On the day of this inspection, service users were observed utilising all areas. Service users appeared relaxed and comfortable in their surroundings. Although some areas have benefited from redecoration and refurbishment, progress since the last inspection has been slow. Several areas of the home Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 18 still require attention. The majority of corridors need re-decoration. Doors and skirting boards were very badly chipped. This was also the case in a number of bedrooms. A large number of bedrooms still need redecoration and refurbishment. Carpets need replacement in some communal areas and some bedrooms. The linoleum type flooring in one bedroom was very badly marked/worn. These areas were brought to the attention of the manager at the time of the inspection. It has been required that the registered person provides the CSCI with a satisfactory programme of redecoration/refurbishment, which identifies acceptable timescales. There are two level access showers, two assisted baths and one unassisted bath. Grab rails are appropriately sited and a nurse call system is installed throughout the home. Wheelchairs are accessed for service users on an individual assessed need. The home has three mobile hoists and a stand-aid. Moving and handling belts and slide sheets are also available. The home has a good supply of adjustable beds. Bedrooms consist of 16 single rooms 3 of which have en-suite facilities. There are 7 double bedrooms, 1 of which has en-suite facilities. All bedrooms are fitted with a wash hand basin as a minimum. 8 single rooms and 2 double rooms fall below the National Minimum Standards for space. As a result the home has conditions added to its Registration Certificate. The home takes appropriate steps to reduce the risk of the spread of infection. Hand washing facilities are appropriately sited throughout the home and staff have access to protective clothing. All areas seen at this inspection were clean and free from malodours. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home provides an adequate number and skill mix of staff who have been appropriately trained. EVIDENCE: Copies of a 2 week staffing rota were made available to the inspector. Suitably qualified registered nurses provide 24 hour cover. In addition to the registered nurse, mornings, afternoons and evenings are covered by 5 care staff. Nights area covered by one qualified nurse and two care staff. The manager and clinical manager are generally on duty in addition to the qualified and care hours during week days. As previously mentioned in this report, the clinical manager has become more involved in activities for service users. The home also employs kitchen staff, domestics, laundry staff and a maintenance person. No concerns were raised regarding staffing levels or meeting service users assessed needs. The registered manager advised that of the 13 care staff employed, 8 have achieved an NVQ level 2 or above. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 20 Staff spoken with were positive regarding the ‘in-house’ training on dementia they had received. Staff indicated that they were satisfied with the training opportunities offered by the home. Two staff recruitment files were examined. These contained all appropriate information. Newly appointed staff follow a TOPPS induction programme. This covers the initial induction programme and on-going training for staff. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Service users and staff benefit from an effective management team who promote an open and inclusive style of management. The home’s arrangement for ensuring the health and safety of service users require improvement. EVIDENCE: The home is effectively managed by Shirley Ruane. Shirley is a registered general nurse with experience in caring for older people. She is supported by a registered mental nurse, Julie White. Shirley is a moving and handling, food hygiene and fire trainer. Shirley is currently working towards the Registered Managers Award. Staff spoken with at this inspection were positive about the management style at the home. The manager and her deputy are very much ‘hands-on’ and both have a good knowledge of the assessed needs of service users. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 22 Service users and staff spoken with stated that they found the manager and the clinical manager supportive and approachable. The views of staff are sought through regular staff meetings. Minutes are maintained. Formal meetings for service users are not felt to be appropriate. Any concerns/views of service users would be recorded in the individual’s plan of care with action taken as appropriate. The home formally seeks the views of relatives and visiting professionals on an annual basis. This was last done in April this year. A selection of completed questionnaires were viewed and comments were noted to be positive. The home manages ‘pocket monies’ for service users where requested. Records of transactions were examined at this inspection. Receipts are obtained for all purchases. The registered manager is currently the only signature for transactions. It has therefore been recommended that all transactions are confirmed with two staff signatures. The inspector was able to see evidence, from the staff files examined, that staff receive regular supervision sessions though the manager is not always fully documenting issues/topics discussed. The manager was advised to ensure that supervision sessions are fully documented and signed by both parties. The staff member should also be provided with a copy of this. All records seen at this inspection were stored in accordance with the Data Protection Act 1998. The home’s procedures for ensuring the health and safety of service users, staff and visitors were examined and a tour of the premises was carried out. The findings were as follows: FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems and monthly checks on emergency lighting. Records are maintained. Fire detection systems and fire fighting equipment are serviced by an outside contractor on an annual basis. This was last recorded as 17/11/05. All staff received fire training by an external trainer on 17/11/05. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out 26/01/05. The home has an up to date electrical hardwiring certificate which expires in February 2010. GAS SAFETY – The home’s last annual gas safety check was conducted on 12/12/05. The certificate was seen at this inspection. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 23 ACCIDENTS – The home maintains appropriate records for all accidents. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. Accidents are analysed monthly by the registered manager and action to address is taken where appropriate. HOT WATER OUTLETS/SURFACES – Records seen did not demonstrate that all bath hot water outlets and showers had been checked to ensure that they were within HSE recommended limits. This was immediately rectified by the registered manager at the time of the inspection. A new form was devised which identified each bathroom. Progress will be followed up at the next inspection. Bath hot water outlets checked by the inspector at the time of the inspection, were within HSE recommended limits. To reduce the risk of injury to service users, radiators are fitted with a guard. EQUIPMENT SERVICING – All equipment relating to the transportation of service users is serviced by an outside company in accordance with LOLER regulations every 6 months. The home’s passenger lift was serviced on 29/09/05, 2 fixed bath hoists, 2 mobile hoists and 1 stand-aid were last serviced on 12/11/05. To ensure the safety of service users, all upstairs windows are restricted, radiators covered and wardrobes are secured to the wall. The home records weekly checks to ensure continued safety. The inspector noted that an upstairs bedroom window had a large crack. Although this had been ‘taped’ this could pose a serious risk to the service user or other service users who may wander into the bedroom. The manager was able to show the inspector the new window, which had been awaiting installation. An immediate requirement was issued at the time of the inspection. Two adjustable beds were noted to have been fitted with inappropriate mattresses. The mattresses in use were for a domestic type bed and were therefore too short. This could increase the risk of entrapment and/or injury to the service users. Neither bed was fitted with a headboard. An immediate requirement was issued at the time of the inspection. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 2 2 3 1 Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that care plans are fully reflective of assessed needs. Particular attention should be given to the prevention of pressure sores. The registered person must ensure that wound care plans contain sufficient detailed information to ensure continuity of care. The registered person must demonstrate that complaints are investigated in accordance with the home’s complaints procedure. The registered person must provide the CSCI with a planned programme of redecoration and refurbishment which also identifies timescales The registered person demonstrate that all staff are appropriately supervised. Copies of supervision records should also be signed by both parties and a copy given to the employee. The registered person must DS0000054819.V263572.R01.S.doc Timescale for action 10/01/05 2. OP8 12(1) 10/01/05 3 OP16 22(3)&(4) &17 Sch 4 10/01/05 4 OP19 23(2)(b) 10/02/05 5 OP36 18(2) 17/02/05 6 OP38 13(4) 15/12/05 Page 26 Hillview Nursing Home Version 5.0 replace the identified broken window and must ensure that all adjustable beds are fitted with appropriate mattresses and headboards. An Immediate requirement was issued Evidence was forwarded to the Commission that the broken window had been replaced. 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 Refer to Standard OP2 OP35 Good Practice Recommendations The registered person should ensure that copies of service users contracts/financial agreements are maintained at the home. The registered person should ensure that, where the home manages monies for service users, that all financial transactions are confirmed with two staff signatures. Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Hillview Nursing Home DS0000054819.V263572.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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