CARE HOMES FOR OLDER PEOPLE
Hillyfield Rest Home Barnes Lane Milford-on-Sea Lymington Hampshire SO41 0RP Lead Inspector
Marilyn Lewis Unannounced Inspection 26th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hillyfield Rest Home Address Barnes Lane Milford-on-Sea Lymington Hampshire SO41 0RP 01590 642121 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) hillyfieldresthome@tesco.net Hillyfield Rest Home Ltd Jane Mary Harmer-Manning Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: Hillyfield Rest Home is registered to provide personal support and accommodation for 16 older people. The home has been extended to provide 16 single bedrooms, all en suite. A conservatory has been built to extend the lounge, providing a large, light area. The garden is currently being renovated. The home is situated in a residential area of Milford-on-Sea and within walking distance of the village shops. Information provided by the registered manager on the 9th March 2007 stated that fees ranged from £2110 to £2913 per calendar month. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection, including a site visit that took place unannounced on the 26th March 2007. During the site visit the inspector toured the home and met with eight residents, two visitors, two staff members, the registered manager and the registered provider. Records seen included those for medication, care plans, risk assessments, staff training and recruitment. What the service does well:
All residents spoken with gave very positive comments about the quality of care provided at the home and felt they were treated with respect at all times. Relatives visiting said that they were very satisfied with the excellent care provided at the home. Residents said that they felt they were involved in all aspects of life at the home and were able to discuss ‘anything’ with the registered manager or the provider. It was evident during the visit that the registered manager and provider had a very good rapport with the residents, visitors and staff. The home provides prospective residents and their relatives with clear information about life at the home and they are able to visit the home to meet residents and staff before making a decision about taking a place there. To ensure the home can meet their care needs a full care assessment is undertaken for anyone wishing to take a place at the home. Residents are involved in their care planning and said that they knew what was written in their plans and agreed that the information reflected their wishes. The care plans provided clear information for staff supporting the residents. Residents said that they liked being able to maintain their independence while accepting assistance for those tasks they were unable to complete alone, such as bathing. Staff had received training in the safe handling of medicines and followed the home’s clear procedures for dealing with medication. Residents who wished and were assessed as able to do so were responsible for the administration of their own medication. Their ability to do this was kept under review and they
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 6 were advised to allow staff to take the responsibility when it became unsafe for them to continue. Residents at the home said that they valued their independence and appreciated being allowed to make their own decisions and keep control over their daily lives. Residents said that they enjoyed the social activities provided that included quizzes and visiting entertainers but particularly the mini bus trips and the recent village show. The village show had been organised by the management of the home and had raised funds for the local school. The residents are reasonably mobile and some walk into the village to the shops or to meet friends as they wish. All residents said that they enjoyed the food provided, most of which was home cooked. Lunch and supper were usually taken in the very pleasant dining room but residents were able to have their meals in their rooms if they wished. Residents felt that any complaints would be taken seriously and records seen indicated that quick actions were taken if required to resolve a complaint issue. Staff were aware of the procedures to follow should abuse be suspected and had received training in the protection of vulnerable adults. Residents said that they felt safe being cared for by staff and living at the home. The home has an ongoing programme for redecoration and refurbishment and the home looked well maintained with furniture in a good standard of repair. Residents said that they liked their rooms that looked spacious and contained many personal items. All the residents’ rooms are fitted with en-suite facilities. Residents also said that they enjoyed spending time in the very pleasant lounge and conservatory. The home follows robust procedures for the recruitment of staff which includes checks with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults (POVA) to ensure staff are suitable to work with residents. Staff said that they had good opportunities to attend training sessions and to obtain qualifications. Nine of the seventeen carers hold National Vocational Qualifications (NVQ) level 2 or above and four more are due to start the course. Staff receive mandatory training including health and safety, moving and handling, food hygiene, first aid and infection control. The home’s policies and procedures have been reviewed annually and provide staff with up to date information on care practices. Health and safety information is available for staff and during the visit staff were seen to use safe working practices, including storing hazardous substances such as cleaning fluids safely. The kitchen looked clean and food was stored appropriately. Records seen indicated that maintenance checks on the lift, fire safety equipment and utilities were undertaken regularly. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are provided with clear information about life at the home and are able to visit before making a decision to take a place there. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. EVIDENCE: The home’s Statement of Purpose and Service User Guide provide clear information about life at the home. The documents include details of the qualifications and experience of the registered manager and the organisational structure of the home. The documents also clearly state that admission to the home is restricted to those who are able to provide some measure of self-care and a reasonable level of mobility. Emergency admissions are not accepted.
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 10 A copy of the contract provided for residents, the complaints procedures and the last inspection report are contained in the information provided for prospective residents and their relatives. The registered manager said that no one is admitted to the home without a care needs assessment. The assessment is undertaken at the prospective resident’s home or they are able to visit Hillyfield and the assessment is undertaken during the visit. A resident confirmed that the registered manager had visited it her at home, before a place at the home was offered. The resident said that the registered manager had given her time to discuss her needs and had also talked with relatives to gain more information. Assessments seen for two residents, one of whom had been admitted since the last inspection indicated that all aspects of care needs were assessed including medical history, mobility, personal care needs and nutrition. Two residents said that they visited the home with relatives and saw their room and met with other residents before they made their decision to take a place there. One of the residents said that staff were very friendly and the visit was relaxed and interesting. The home does provide short term care if a room is available but it does not provide intermediate care and therefore standard 6 is not applicable. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in their care planning, feel they are treated with respect and their health care needs are being met. Residents, who are assessed as able to do so, administer their own medication and all residents are protected by staff following the home’s clear procedures for the safe handling of medicines. EVIDENCE: Care plans seen for four residents provided good information on the assessed care needs of the residents and staff actions required to meet those needs. The plans included the resident’s likes and dislikes and preferences for participating in daily activities such as what time they liked to get up and go to bed. The plan for one resident stated that there was a poor sleep pattern but that the resident was unconcerned about it and did not wish to take medication to settle at night and staff had respected the wishes.
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 12 The plans included medical issues, personal care needs, psychological well being, mobility, continence and nutrition. The residents spoken with said that they were able to perform some personal care tasks for themselves but required a little help and support from staff to complete the tasks. The residents said that they appreciated being able to maintain as much independence as possible. Risk assessments including those for mobility and risk of falls were contained in the plans. The registered manager said that she would be completing risk assessments for residents using the mini bus and walking into the village alone. The care plans had been signed by the residents and residents spoken with said that they knew what was in their plans and agreed that they reflected their wishes. Staff on duty said that the care plans gave them clear information that was easy to follow. The plans seen had been reviewed monthly. The records seen indicated that the resident’s health care needs were being met with visits by GPs and to hospital outpatients departments documented. One resident said that when she had felt unwell, staff quickly asked the GP to visit. Visits by district nurses were also recorded and advice had been sought from the nurse specialising in continence care. Residents said that they visited their opticians and dentists as they wished. The home has clear procedures for the safe handling of medicines. The procedures include those for residents who wish to self- administer their own medication. The residents’ abilities to self-administer were kept under review and one resident who had previously been responsible for her own medication had recently been reassessed as not able to do so and the staff were now administering the medicines. The district nurse was providing support for one resident who self-administered insulin. The home has systems in place to ensure that medicines brought into the home are recorded and for the disposal of medication. Medication records seen had been completed appropriately. Only staff who have received training in the safe handling of medication are able to give out the medicines to residents. During the visit to the home staff were observed knocking doors and waiting before entering rooms and they spoke with residents and visitors in a friendly and caring manner. Residents said that staff were very kind and caring and they felt that they were treated with respect at all times. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents feel that they are supported to maintain their independence and exercise choice and control over their lives, receive visitors as they wish, participate in activities that meet their needs and wishes and enjoy wellbalanced home cooked meals. EVIDENCE: The residents’ interests including religious and cultural needs are documented in their care plans and daily records seen indicated that these needs were being met. Residents at the home have a reasonable level of mobility said that they liked to remain as independent as possible and ‘do their own thing’. Some residents walked into the village to the shops or to meet with friends and they also spoke of enjoying trips on the minibus, which were arranged twice a week. One resident was currently away from the home for a few days visiting relatives. During the visit residents were observed choosing where they wished to spend time, in the very pleasant lounge and conservatory or in their own rooms and
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 14 some were getting ready to go out for a walk. Residents said that they had plenty to do with quizzes arranged and entertainers visiting weekly. Residents also said that they enjoyed spending time sitting and chatting or reading their newspapers. One resident said that she appreciated being able to spend time alone in her room as she wished. The home has recently arranged for a show to be put on in the village to raise funds for the village school. The show included musical items from a ‘Barber Shop’ and a supporting artiste. The registered manager said that the show had helped to form links with the local school and enable the residents to participate in a community activity. Residents said that they had really enjoyed the show. A minister from a local church visits the home monthly to give communion to those who wish to attend and residents are able to attend church services as they wish. Residents said that they were able to receive visitors as they wished and records seen indicated that relatives and friends frequently visited the home. Two relatives visiting said that they were always made to feel very welcome and they thought that the home provided excellent care. The home has a system in place whereby a member of staff prepares the meals for the residents. The staff member who was preparing the lunch on the day of the visit said that she had received training in food hygiene and certificates seen confirmed this. Menus seen indicated that residents were offered well-balanced meals. Lunch on that day was homemade quiche, new potatoes, carrots, peas and a cheese sauce followed by lemon mousse and Amaretti biscuits. Although no choice was indicated on the menu displayed in the dining room, residents said that they were able to have an alternative if they did not wish the main choice. One resident said that ‘we only have to ask and we can have what we like’. The staff member said that putting an alternative choice on the menu had been discussed recently and new menus coming up shortly would have a choice indicated. All the residents said that they really enjoyed lunch and commented that the food was always very good. Residents usually eat their main meals in the dining room but are able to take their meals in their rooms if they wish. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel that any complaints will be taken seriously and acted upon and they are protected by staff awareness of the prevention of abuse. EVIDENCE: The home has a complaints procedure that indicates who will investigate the complaint and timescales for the process. Complaints records seen indicated that all complaints were taken seriously and acted upon. One resident who found the noise from the television difficult as she retired early and her room was over the lounge, was able to move room when another became vacant. Residents said that they knew about the home’s complaints procedures. Four residents said that they would discuss any concerns they had with the registered manager or the provider and they felt that any actions needed would be taken quickly. Staff spoken with were aware of the procedures to follow should abuse be suspected. The home’s policies and procedures for the prevention of abuse including ‘Whistle Blowing’ were readily available to staff. In the past the home had followed the correct procedures when an allegation of abuse was made. The allegation was unfounded and no further action was required. Records seen indicated that staff had received training in the prevention of abuse.
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 16 Staff recruitment records seen indicated that checks were made with the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA). The staff member was not able to commence work until at least a POVAFirst had been obtained and then worked under supervision until the CRB was received. This provided assessment that new staff members were suitable to work with the residents. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Hillyfield provides residents with a clean and homely environment that is maintained to a very high standard. EVIDENCE: The home is a large detached property that has been extended to provide accommodation for sixteen residents. The accommodation is over two floors for residents, with a separate section of the first floor used for management staff offices. All areas of the home looked clean and well maintained with decoration and furniture in a good state of repair. The lounge and conservatory is bright and airy with plenty of light coming in from the large windows. Residents said that the chairs in the lounge were very
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 18 comfortable and that they enjoyed spending time in the room. Since the last inspection a new large plasma television has been purchased. Residents are able to take their meals in the separate dining room, which is also a very pleasant room. All residents are accommodated in single rooms with en-suite facilities. The rooms are spacious and well decorated. Some of the rooms have recently been refurbished and new flooring has been provided in one room. Residents said that they had been able to bring many personal items into the home with them including small items of furniture, pictures and ornaments. The personal items made each room look individual and residents spoken with said that they liked their rooms and one resident commented that she ‘has everything she needed, it was like home’. Residents are able to have a key to their room if they wish. The home has sufficient bathroom and toilet facilities and all those seen looked clean. All the residents in the home are reasonably mobile and no one requires the use of specialist equipment such as hoists. Where a resident requires help getting in and out of the bath, a motorised or mechanical bath lift is provided for the specific use of that resident. The kitchen and laundry are domestic in style and looked clean and in good order. Staff had received training in infection control and protective clothing such as disposable aprons and gloves was available for staff and they were seen to use it as needed. The gardens to the rear of the property have been landscaped and provide a pleasant place for residents and their visitors to sit. The registered manager said that further work was required as in some areas of grass had not covered the area as thickly as wished. There is a small parking area to the front of the property. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the sufficient number of staff employed at the home and residents are supported and protected by the home’s robust recruitment procedures and good staff training. EVIDENCE: Staffing levels at the home reflect the level of independence of the residents. In the mornings there are two carers and one carer/cook on duty and in the afternoons two carers. At night there is one ‘awake’ carer and one ‘sleep in’. The registered manager or provider or both are on duty during the day and are on call at night. The registered manager said that staffing levels are flexible to meet the changing needs of the residents and to allow for leisure activities such as the mini bus trips and the village show. Staff on duty on the day of the visit said that they felt there were enough staff on duty for each shift and residents also felt there were sufficient on duty. The home does not employ agency staff. Staff said that they were encouraged and supported by the management team to attend training sessions and obtain qualifications. Nine of the seventeen
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 20 care staff hold NVQ level 2 or above in care and another four were due to start the course. The home has robust procedures for the recruitment of staff. Records seen for two staff members indicated that the procedures were followed. The records contained all the information required including a completed application form, two written references and that proof of identity had been checked. Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks had been completed and the records indicated that staff had not been allowed to start work at the home until at least a POVAFirst had been obtained, to ensure staff were suitable for work with the residents. Applicants had been given a job description and were provided with a contract when they started work at the home. Staff spoken with said they were given good opportunities to attend training sessions and records seen confirmed that staff received training in mandatory topics such as food hygiene, first aid, prevention of abuse, medication and infection control. The registered manager was arranging training for the four staff members who required a refresher course on moving and handling. Staff had not received training in caring for residents with diabetes but the registered manager had obtained information on diabetes for staff. Training in the form of providing information and following up with discussion groups had just been completed for all staff in Epilepsy. All new staff members completed an induction course that followed the guidelines of Skills for Care. The induction was undertaken over two or three months and covered all aspects of care provision. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run in the best interests of the residents whose safety is protected by the safe working practices operated there. EVIDENCE: The registered manager Mrs Jane Harmer-Manning is a registered midwife who has been involved in the management of the home for the last four years. Mrs Harmer-Manning has completed the Registered Managers Award. Mrs HarmerManning is well supported by the registered provider. It was evident during the visit that the registered manager had a good rapport with residents, visitors and staff who all spoke highly of the support they
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 22 received from her and also her willingness to spend time talking with and listening to them. The registered manager said that since the last inspection a survey in the form of a questionnaire had been completed to obtain the views of residents on the quality of care provided. Letters of thanks and praise were also retained as information on the satisfaction of care given. The information obtained indicated that residents and their relatives were very satisfied with the quality of care provided. Residents also had the opportunity to voice their opinions in the monthly resident meetings. Records were kept of the meetings and these were made available for all residents. Residents spoken with said that they felt at ease discussing life at the home during the meetings. The new television had been purchased following discussions at a meeting where residents felt the screen of the previous television had been too small and made it difficult for all to see. Residents said that they were also kept up to date with any staff changes. Two relatives also said that communication was very good and that they could speak with the registered manager or provider at any time. Staff meetings are often held as part of the training sessions. Staff spoken with said that they felt able to discuss any issues about the care provided at the home. The home does not handle any finances for the residents. This is stated in the home’s Statement of Purpose. Residents or their relatives are responsible for their own finances and are provided with a lockable container to keep money as they wish in their rooms. The home has policies and procedures in place for all care practices including equal opportunities, acceptance of gifts, accidents and continence promotion. and the documents seen had been reviewed on an annual basis to ensure information available for staff was up to date and relevant to the service. Records seen indicated that all staff received an annual appraisal and supervision that included feedback on staff performance, was taking place but was not recorded as formal supervision at least six times a year. Staff said that the registered manager frequently worked alongside them, did spot checks on the quality of the care they were providing and supervised them in an informal manner. The registered manager said that she would ensure supervision was more formally recorded. Records seen indicated that staff received training in fire safety and fire drills were taking place. However the method for recording the staff attendance at fire drills needed to be improved to indicate which staff members had attended each drill. This would allow staff attendance to be checked to ensure all staff had attended drills. The registered manager said that the systems for recording fire drills would be changed immediately.
Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 23 Staff received training in health and safety and information on health and safety issues was displayed in the home. During the visit staff were observed to use safe working practices and hazardous substances such as cleaning fluids were safely stored. Maintenance records seen indicated that regular checks were made on the electrical equipment, fire safety equipment and gas and water systems. Checks had also been completed for the lift and call alarm system. Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 4 4 4 4 4 4 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 4 4 4 x 3 3 3 3 Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillyfield Rest Home DS0000055641.V330133.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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