Inspection on 20/07/05 for Hillview Nursing Home

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 15/12/05

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 Unannounced 20th July 2005 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 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 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 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 Almondsbury Care Ltd Mrs Shirley Anne Ruane Care home with nursing 30 Category(ies) of Dementia - over 65 (30) registration, with number of places Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Places for up to 13 person for personal care. Registered for a total of 30 places in category DE(E) One exisiting 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 expereinced 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 CSCI. 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. Date of last inspection 13th January 2005 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day (5.5hrs) by CSCI Regulation Inspector Kathy McCluskey. A tour of the premises took place where a selection of bedrooms and all communal areas were seen. The deputy manager and nurse in charge were available throughout the inspection. The registered manager was not available for this inspection. The inspector met with the majority of service users, 5 staff and two visitors. The inspector was able to unobtrusively observe staff interactions with service users. Records relating to care, staff and health and safety were examined. The inspector would like to thank the service users, all staff and visitors 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 and the last announced inspection report. What the service does well: Hillview provides a safe and 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. The numbers of staff on duty are appropriate to meet the needs of service users. Two relatives spoken with stated that they were very happy with the care that their loved ones received. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 6 Service users and staff benefit from an effective management team who promote an open and inclusive style of management. The home has a satisfactory complaints procedure in place. No complaints have been received by the home since the last inspection and no concerns have been raised directly with the CSCI. Visitors informed the inspector that they would not hesitate in raising concerns should they have any. Service users, staff and visitors informed the inspector that they found the manager and her deputy approachable and supportive. Service users who were able to express a view stated that they liked living at the home and commented on the kindness of staff. 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. 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. One comment received was that, ‘there is always plenty to eat and drink’. The home’s care planning process is generally good though a requirement and recommendation have been raised at this inspection. Good information was available on how staff should meet the mental health/psychological needs of service users. Detailed assessments are also completed for nutritional needs, moving and handling, prevention of pressure sores and risk of falls. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. What has improved since the last inspection? Since taking over the home, the registered provider has been proactive in improving the standards of the environment. Major refurbishment has taken place to improve communal space on the ground floor. Bathrooms have been Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 7 refurbished and two additional level access showers have been installed. Some bedrooms and the communal areas have benefited from redecoration, new carpets and furniture. Although there are still some areas which would benefit from redecoration, it is acknowledged that the refurbishment and redecoration plan introduced by the company, is still on going. At the last inspection, requirements and recommendations were raised regarding the home’s procedures for the management and administration of medication. The inspector was able to see that these had been addressed. All medicines were seen to be appropriately stored with records completed. 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. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 Standard 6 is not applicable as the home is not registered to provide intermmediate care. Service users and their representatives are provided with the information they need to enable them to make an informed choice about moving to the home. The home’s procedures for the assessment of prospective service users requires improvement. 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. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 10 Any ‘Free Nursing Care’ element awarded is incorporated into the fees and is not refunded to the service user. 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. 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. Although the deputy manager confirmed that a pre-admission assessment had been carried out for the most recent admission, documented evidence was not available in the care plan examined for the most recent service user. There was no assessment available from other professionals and a care plan had not yet been drawn up (refer to Standard 7). In summary there was no information available to staff on the assessed needs of the service user. 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The home’s care planning process is generally good, though not consistent. The home’s procedures for the management and administration of medication are good. EVIDENCE: Five service user care records were examined at this inspection, one of which related to the most recent service user. No care plan was available for a service user who was admitted to the home in the first week of July and there was no assessment available from other professionals. Assessments relating to the risk of falls, pressure sores, nutrition and moving and handling needs had been completed, but no plan had been raised on how staff should meet these needs. No information was available on how to meet the mental health needs of the individual. The remaining care plans seen contained good information on the assessed needs of service users and interventions for staff were clear. Care plans were noted to be ‘personalised’ and up to date. Information for staff on how to meet the mental health/psychological needs of service users was very good. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 12 Assessments seen included; risk of falls, nutrition, moving and handling and risk of pressure sores. An assessment and care plan was also seen for one service user with a wound. Risk assessments were also seen relating to the use of bed rails. A selection of bedrooms were examined and it was noted that a number of service users were sleeping on a mattress on the floor. Assessments and the rationale for this were seen in the care plans examined. The inspector was also able to see evidence that this had been discussed with the service user’s representatives and was being kept under review. It has been recommended that more detail is recorded for each review which demonstrates the rationale for continuing with this. As previously mentioned, nutritional assessments are completed on admission and are kept under review. Care plans were also seen relating to nutritional needs. All service users are weighed on a monthly basis. A good supply of adjustable beds and pressure relieving equipment was seen to be in use. All service users are registered with a GP and the home maintains records relating to all visits from health care professionals. Service users able to express a view, informed the inspector that they were happy with the care they received. This was also confirmed by two relatives spoken with. The home’s procedures for the management and administration were examined at this inspection and were found to be well maintained. The inspector was able to see evidence that the requirements and recommendations of the last inspection had been addressed. All available Medication Administration Records (MAR) were examined and were found to be 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. Minimum and maximum temperatures are recorded daily for the ‘drugs fridge’. Temperatures were noted to be within the acceptable range for the storage of medicines though the home was advised to also record the current temperature. Medicines are only administered by the registered nurse on duty. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 and 15 Service users benefit from a range of communal areas and can choose where to spend their day. Service users benefit from a wholesome and varied menu. EVIDENCE: The home welcomes visitors at any reasonable time in accordance with the wishes/preferences of the service user. The inspector was able to meet with two relatives at this inspection and both stated that they could visit at any time and were always made to feel welcome. 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 that were able, were moving freely around the home. Two service users informed the inspector that they had chosen to remain in their bedrooms. Service users benefit from a wholesome and varied menu. A four week menu was examined and lunch was seen being served. Staff and the cook confirmed that some service users required a ‘pureed’ diet. It was positive to see that this Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 14 had been attractively presented and that the cook was enhancing the calorific/nutritional value of the meal. Service users were observed enjoying a ‘generous’ lunch and staff sat with service users offering assistance where required. Assistance was provided in a relaxed and respectful manner. Service users enjoyed lunch in a relaxed and unhurried manner and were offered more when finished. Jugs of juice were available on each table throughout the meal. Good stocks of dried and fresh foods were seen and the cook confirmed that there was always plenty of food. The kitchen appeared clean and well organised. Service users and relatives were positive regarding the meals offered at the home. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16, and 18 The home has a satisfactory complaints procedure in place. 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. Relatives spoken with at this inspection stated that they would not hesitate in raising concerns should they have any. The home has not received any complaints since the last inspection and no concerns have been raised directly with the CSCI. 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users live in a safe, clean and comfortable environment and can choose from a range of communal areas. Service users have access to an appropriate range of specialist equipment. EVIDENCE: Although the home is not purpose built, the ground floor has been suitably adapted, as part of the refurbishing programme, to meet the needs of service users. The inspector was able to see evidence that the programme of maintenance and refurbishment introduced by Almondsbury Care, was ongoing. 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. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 17 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. Compliance against these conditions was checked at this inspection and no concerns were raised. 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 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 inspectors. On examination, this indicated that a registered mental nurse (RMN), is on duty covering a 24 hour period. Morning shifts are covered by 5 care staff, 4 in the afternoon, 5 in the evening and 2 at night. The manager and clinical manager are generally on duty in addition to the qualified and care hours during week days. The home also employs kitchen staff, domestics, laundry staff and a maintenance person. Staff spoken with informed the inspectors that they felt there were always sufficient numbers of staff on duty at the home. In the absence of the registered manager, staff recruitment files could not be examined at this inspection. As no concerns were raised at the last inspection, this will be followed up at the next inspection. Newly appointed staff follow a TOPPS induction programme. This covers the initial induction programme and on-going training for staff. The clinical manager advised that she is planning training in dementia for staff. Progress will be followed up at the next inspection. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 37 and 38 Service users and staff benefit from an effective management team who promote an open and inclusive style of management. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. 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. At the previous inspection, Shirley demonstrated her commitment to improving the quality of the care delivered to service users living at Hillview. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 20 As Shirley was not available for this inspection, the progress regarding the registration on the NVQ4 in management could not be discussed and will be followed up at the next inspection. 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. Regular meetings are held for staff with records maintained. Service users, staff and relatives spoken to at this inspection stated that they found the manager and her deputy very approachable and supportive. The home displays appropriate and up to date employers liability insurance which expires on 16/10/05. All records seen at this inspection were well maintained, up to date and stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors to the home. This was ascertained by a tour of the premises, on discussion with staff and on examination of the following records: 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 16/05/05. 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 03/12/04. 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. HOT WATER OUTLETS/SURFACES – The home maintains records of weekly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. To reduce the risk of injury to Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 21 service users, all bath hot water outlets have been fitted with thermostatic controls. The home carries out weekly checks to ensure the prevention of legionella. This involves running taps and soaking shower heads. 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, 2 fixed bath hoists, 2 mobile hoists and 1 stand-aid were last serviced on 08/06/05. 6 wheelchairs were serviced on 02/03/05. The home’s call bell system was last serviced on 13/01/05. 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. This was last conducted on 17/07/05. Any bedrails in use are also included in these checks. Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x 3 x x 3 3 Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(1) Requirement The registered person must ensure that service users are fully assessed prior to admission and that a copy of the assessment is maintained in the service users care file. Timescale for action 12/08/05 for the identified service user and prior to admission for all future service users. 12/08/05 2. OP7 15(1) The registered person must ensure that a detailed care plan, which identifies clear instructions for staff is completed for the identified service user. 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. Refer to Standard OP7 Good Practice Recommendations Where all other alternatives have been explored and there is an assessed need for a service users bed to be removed, the registered person should ensure that more detail is recorded for each review which clearly demonstrates the rationale for this continued action. D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 24 Hillview Nursing Home Hillview Nursing Home D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 D53-D02 S54819 Hillview V231103 050705 Stage 4.doc Version 1.30 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!