Care Home: Hillside Nursing and Residential Home

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well Residents who spoke to the inspector liked the staff who cared for them, they said staff were "brilliant". Relatives are made to feel welcome, and can visit anytime. Relatives reported that the home kept them in touch with what was happening to their relative in the home. One wrote that the home "answers all our concerns we have about our relative and they are very friendly towards us." The relaxed atmosphere of the home supports residents to meet with other residents, their visitors and talk to staff. Staff are given clear guidance on how residents must be cared for according to their particular needs. Staff understand their roles clearly and receive regular training to maintain and improve their skills. Care plans are regularly reviewed, with the resident and relatives if they so wish.The provider has a comprehensive quality assurance policy, which includes regular audits of the home by visiting managers, and audits by the manager, with resident meetings backed up with individual discussions. The activities coordinator is expanding the range of activities to try and suit as many residents as possible. One relative told us that the home was fairly new to them and they had not been able to judge all of the services, but from what they had seen of it, they had no complaints. What has improved since the last inspection? The new extension provides a spacious sun lounge with access to a deck area, and new rooms which are en-suite and well appointed. The refurbished areas improve the facilities for residents and make the accommodation brighter and more cheerful. At the same time as the extension was built, the home upgraded the fire doors to meet the requirements of fire legislation. The maintenance and documentation in the kitchen have improved and now satisfy the environmental health standards. Additional staff hours have been allocated to the laundry to ensure that residents` clothes are washed and ironed and returned to them quickly and in good condition. What the care home could do better: No requirements have been made from this inspection. However we were told about how the home intends to improve its services. The manager told us of her intention to encourage more relatives to become involved in the care planning, and where possible to help accompany residents on trips out. There are plans to train more staff to complete risk assessments. An additional administrator will be employed to ensure deadlines are met for recording and documentation. On the day of inspection there were 31 residents being cared for. The manager explained that this was to enable any alterations to facilities and changes ofrooms when the home became registered to provide nursing care as well as its current category. Application would shortly be made to the Commission to register this additional category. CARE HOMES FOR OLDER PEOPLE Hillside Residential Home 20 Kings Hill Great Cornard Sudbury Suffolk CO10 0EH Lead Inspector John Goodship Unannounced Inspection 9th April 2008 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 Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Residential Home Address 20 Kings Hill Great Cornard Sudbury Suffolk CO10 0EH 01787 372737 01787 319506 hillside@caringhomes.org 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) Stour Sudbury Limited Mrs J Warner Care Home 44 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (44) of places Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2007 Brief Description of the Service: Hillside Residential Home is owned by Stour Sudbury Limited, part of the Caring Homes organisation. The home is a large detached building located in a residential area on the outskirts of Sudbury. Although there are no shops within walking distance, there is a Public House located close by, and the town of Sudbury offers a range of shops and amenities. The home has accommodation for 44 people in single rooms, 28 of which have en-suite facilities, and located on two floors. There are two dining rooms, three lounges including a sun lounge, three assisted bathrooms, and two assisted shower rooms The first floor also has its own treatment room and communal kitchen. There is a passenger lift and stairs to the first floor. There are two patio/decking areas, with a wheelchair accessible ramp leading to the front door. The range of fees charged at the date of this inspection was: £355.00 £585.00 per week. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection visit was unannounced and covered the key standards, which are listed under each outcome group overleaf. We looked at the outcomes for the residents to assess the quality of care given by the home. This report includes evidence gathered during the visit together with information already held by the Commission for Social Care Inspection. The inspection took place on a weekday and lasted three hours forty minutes. The manager was present throughout, and was helpful in providing ready access to records, and conducting a tour of the home. We spoke to five residents either in the lounge or in their room, and we spoke to staff while they were going about their work. We also toured the home. We also examined care plans, staff records, maintenance records and training records. A questionnaire survey was sent to the home by the Commission for completion by residents, relatives and staff. One resident, three relatives and three staff replied . Their answers to the questions and any additional comments have been included in the appropriate sections of this report. The manager was required for the first time to complete an Annual Quality Assurance Assessment (AQAA) which asks the manager to tell us about what the home has done to improve care in the last twelve months, and to tell us what plans it has for further improvements. Information from this assessment has been included as appropriate in this report. What the service does well: Residents who spoke to the inspector liked the staff who cared for them, they said staff were “brilliant”. Relatives are made to feel welcome, and can visit anytime. Relatives reported that the home kept them in touch with what was happening to their relative in the home. One wrote that the home “answers all our concerns we have about our relative and they are very friendly towards us.” The relaxed atmosphere of the home supports residents to meet with other residents, their visitors and talk to staff. Staff are given clear guidance on how residents must be cared for according to their particular needs. Staff understand their roles clearly and receive regular training to maintain and improve their skills. Care plans are regularly reviewed, with the resident and relatives if they so wish. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 6 The provider has a comprehensive quality assurance policy, which includes regular audits of the home by visiting managers, and audits by the manager, with resident meetings backed up with individual discussions. The activities coordinator is expanding the range of activities to try and suit as many residents as possible. One relative told us that the home was fairly new to them and they had not been able to judge all of the services, but from what they had seen of it, they had no complaints. What has improved since the last inspection? What they could do better: No requirements have been made from this inspection. However we were told about how the home intends to improve its services. The manager told us of her intention to encourage more relatives to become involved in the care planning, and where possible to help accompany residents on trips out. There are plans to train more staff to complete risk assessments. An additional administrator will be employed to ensure deadlines are met for recording and documentation. On the day of inspection there were 31 residents being cared for. The manager explained that this was to enable any alterations to facilities and changes of Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 7 rooms when the home became registered to provide nursing care as well as its current category. Application would shortly be made to the Commission to register this additional category. 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. Hillside Residential Home DS0000024418.V362124.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 Hillside Residential Home DS0000024418.V362124.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): 1,3,4. Standard 6 is not applicable to this home. Quality in this outcome area is excellent. Prospective residents have full information about the home, which is up to date and comprehensive. It is sufficient to enable them to decide if they wish to move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose had been updated in August 2007 to include information about the four additional rooms, which were registered with the Commission on 27 July 2007. This document set out clearly the information required by the regulations such as the criteria for admission, the management and staffing of the home, with staff qualifications, fire precautions, family contact, and how to complain. In addition, it described the monthly visits by the regional manager, who was named, with the invitation to meet her if a resident or relative wished. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 10 The Service Users Guide had also been updated. It set out clearly and briefly the information which residents needed to know to help them settle in the home, and it answered questions most frequently asked. Topics included medication, hairdressing, personal money, activities, smoking, meal times, telephones, and fees. Also included with the residents’ information pack was a sample activities programme for the week, a suggested clothing list for new admissions, a detailed breakdown of the fees charges for rooms with different facilities, and a helpful description of the role of a keyworker. The AQAA reported that pre-admission assessments were undertaken to ensure the home could meet residents’ needs. These were seen in two files examined. They were completed on a proforma which covered key areas of a person’s daily care needs as well as other activities of their life. In one file, there was also the Social Care Services assessment leading up to the decision that the person needed full-time residential care. There were also assessments made within the first 24/48 hours of admission to confirm previous assessments of need and to enlarge the knowledge of the person so that a full care plan could be drawn up thereby ensuring that residents’ needs are met. Hillside Residential Home DS0000024418.V362124.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): 7,8,9,10. Quality in this outcome area is good. Residents can expect staff to identify and review their care needs to ensure appropriate care is given. Their safety is protected by the home’s medication procedure and medication audits. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examoned two care plans. These showed a similar format throughout, conforming to a policy of regular, usually monthly, reviews. One resident told us that they were involved in the reviews and the care plans recorded this. Risk assessments, for falls and pressure areas for example, were complete and were reviewed monthly. One plan held the resident’s consent to the use of bedrails for their safety, and both held consent forms allowing staff to administer their medication. The Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 12 home monitored all residents’ nutritional health using the Malnutrition Universal Screening Tool. One resident could no longer be weighed on the weighing chair because of their size. This was a consequence of their medical condition for which there was guidance in the plan for staff on the control of their weight. One resident had been provided by Social Care Services with an overhead hoist for their room. Their plan contained a detailed moving and handling assessment with clear instructiopns for staff on, for example, moving the resident in bed, and rolling them in the bed. This plan had been done by a qualified assessor from the provider company. Care plans also held a daily record of personal care given, which included bathing, bowel care, haircare, shaving, dentures, nails and a bedroom check. This record was audited monthly, together with the care plans. We examined the records of other audits which covered cleaning and catering, and medication. These audits were up-to-date. These audits formed part of the home’s quality assurance policy to ensure standards in these areas were maintained for the health and safety of residents. Visits by health professionals were recorded in the care plan. One resident had suffered several falls. The GP was asked to review them and a CVA was diagnosed. One resident who had a high dependency on carers said that they were well looked after. “The staff are brilliant.” We examined the medication records for the two residents whose care plans we followed. These were properly completed with no gaps in signatures for administration. Training records showed that all staff administering medication had received training, including two night staff. We examined the records of the fortnightly medication audit, which was carried out by the manager. This was done with a checklist format and included a ’Corrective action sheet’ where necessary. The manager also gave each member of care staff responsible for administering drugs an annual competency assessment. Hillside Residential Home DS0000024418.V362124.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): 12,13,14,15. Quality in this outcome area is good. Residents can expect social activities to be well-managed, creative and provide daily variation and interest for people living in the home. Relatives and friends are assured of a welcome. Residents can expect to be offered a choice of nutritional meals with a choice of where they take them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had had an activities coordinator for some time. They had done a training course on the provision of activities which would stimulate mobility and mental alertness, and be geared where possible to the needs and interests of each resident The coordinator had asked residents what they would like to do. From their replies they had developed a number of activities for residents to take part in small groups, as residents preferred these. They had also been able to fit in one-to-one sessions with some residents who did not take part in group activities. The coordinator was seen talking to a resident in their room. One resident reported that they were aware of the activities offered but chose Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 14 not to take part. Another was looking forward to the quiz that afternoon as it was always fun. All activities were recorded and a separate record kept for each resident. The activities programme for the week was on the notice board. Each afternoon was broken up into short sessions. The coordinator explained to us that residents preferred this pattern which enabled a wider range of activities to be programmed that resident s could dip in and out of. Examples of activities were: conversation on the days news, bingo, arts and crafts, board games reminiscence, painting, sing-a-long and quizzes. The latest edition of the home’s newsletter listed some of the outings, to Corncraft at Monks Eleigh, and to Sudbury market. Outside entertainers were booked, and there were themed nights for instance at Halloween. A computer had been installed in the sun lounge the week before the inspection for the use of residents. No one admitted to using it yet. The March 2008 report of the regional manager (under regulation 26) had noted that the Easter bonnet competition was about to be judged while they were there. The ladies were sitting with the hats that they had made awaiting the judging. The cook had baked special Easter biscuits for the occasion. Relatives who replied to the survey said that the home kept them up-to-date with what was happening with their relative. All said that the home helped the residents to keep in touch with their families. One relative wrote, “They answer all our concerns that we have about our relative and are very friendly towards us”. The lunch was served in the dining rooms on each floor, and looked tasty and in sufficient quantity. The tables were laid with tablecloths and tablemats. The AQAA stated that the choice of sandwich fillings offered at suppertime had been improved. This had followed comments made to us at the previous inspection. The nutritional status of all residents was subject to the Malnutrition Universal Screening Tool, which collated information on a persons body mass index, weight loss and the presence of acute disease. The measurements were recorded in each person’s care plan. The measurements were recorded in each person’s care plan to show changes which might need further intervention or referral for medical help. Hillside Residential Home DS0000024418.V362124.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): 16,18. Quality in this outcome area is good. Residents and relatives can be assured that their concerns and complaints will be investigated and action taken. Their safety is protected by the staff’s training and awareness of the vulnerability of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home included details of its complaints policy in each resident’s information file. Summaries were also included in the statement of purpose and service users guide. A copy of the procedure was also displayed in the reception area. The address for the Commission for Social Care Inspection was now out-of-date but the manager told us it would be changed. The relatives who replied to the survey all confirmed that they knew how to raise concerns or make a complaint. One resident said: “ I just go and talk to the manager.” We examined the home’s complaints log. There had been seven verbal complaints or concerns which had been logged in the past twelve months. Six had been substantiated and one partly substantiated after the manager had investigated. Issues raised included laundry matters, the attitude of one carer, the brightness of the external lighting, and the cleanliness of one room. In all cases, the action taken was recorded. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 16 The manager had recently referred another allegation by a resident against a carer to the Suffolk Adult Safeguarding Board. After appropriate investigation and discussion with the Safeguarding Officer, the allegation was not upheld. It was recorded that the resident’s relative agreed with this finding. The manager had also reported the matter to the Commission as required. It was noted that the correct action had been taken by the manager to protect the resident pending investigation. Training records showed that staff had attended sessions on the protection of vulnerable adults over the past two years. When questioned, staff were able to identify possible abuse scenarios and correctly explain the action they would take. The cash float for one resident was checked. The cash tallied with the balance in the cash book, and with receipts. This showed that the home had a proper system for the safekeeping of residents’ money. Hillside Residential Home DS0000024418.V362124.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): 19,20,21,22,24,25,26. Quality in this outcome area is good. Residents can be assured that they live in a safe and well-maintained home, and that they will be encouraged to personalise their rooms as much as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The extension to provide four additional bedrooms, a sun lounge and an assisted bathroom had been completed in July 2007, when the additional beds were registered with the Commission. All rooms were en-suite. At the same time, one of the existing bathrooms had been refurbished, another assisted toilet and bathroom had been installed, the fire doors had been upgraded, a new shower room had been installed, and a new ramp access the front door was in place. The dining room on the ground floor had also been Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 18 refurbished. The high standard of the new and refurbished areas did show up the need to carry this through to the corridors particularly on the first floor above the dining room. Door numbers were still awaited for the new rooms although each had the occupant’s name. Room numbering was not in a logical sequence which we found confusing. However staff told us that it was not a problem for them. They did not think it was confusing for residents who knew where their rooms were and went by their names on the door not the number. The home shared two maintenance staff with the sister home on the same site. One of them was seen discussing job priorities with the manager. One relative had written in their survey that clothes needed to be properly ironed. This comment had also been seen in the home’s complaints log. The manager explained that additional dedicated laundry assistant hours had been introduced to improve the consistency of the service. The Environmental Health Officer (EHO) of the local authority had visited the home on 20/07/07. They noted that the home used the Safer Food, Better Business documentation. Several items of this needed to be completed or updated. The temperature of re-heated meals was tested by the catering staff but not recorded. On a return visit in January 2008, the EHO reported that there had been much improvement since the previous visit, increasing the level of food hygiene for the protection of residents. Residents’ rooms continued to be personalised with their own items which helped to give a homely and familiar feel to the rooms. A resident who was in one of the new rooms showed us round and said they were very pleased to be in there. Hillside Residential Home DS0000024418.V362124.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): 27,28,29,30. Quality in this outcome area is good. Residents and relatives can be assured that residents’ needs will be met by the numbers and skill mix of staff and that the home will provide training to ensure that the staff are competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota for the week was examined. All shifts were planned with the appropriate staffing levels. The number of care staff rostered and present on the early shift on the day of the inspection was sufficient for the needs of the 31 current residents. Although no agency staff had been used in the three months to December 2007, some shifts were being covered by agency staff at the time of our inspection because of staff vacancies. The manager explained that she tried to organise the rota so that agency staff were on duty during the day, and that she tried to cover gaps in night duty by internal staff. There had been one occasion in 2007 when due to sickness there was only two staff on one shift. This had been notified to the Commission. There were three male carers on the staff and the manager told us that a resident could choose not to have a male for personal care tasks. There was no male carer on duty on the day of inspection. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 20 We examined the training spreadsheet which showed that training was organised either by using the provider’s own trainer, or by using internal trainers, and DVD training packages. The deputy manager had recently completed a ‘Training the trainer’ course in moving and handling. All staff had been through the appropriate induction and skills training, with refreshers at intervals. All mandatory courses were being arranged and attended, with a training matrix on the wall to show progress through the year. These covered, for example, fire safety, food hygiene, first aid, moving and handling and infection control. 50 of care staff had completed an NVQ at Level 2 or above. There was currently one carer studying for that qualification. Two personnel files for recently appointed staff were examined. All identification and protection checks had been made before the individuals started work. Training records showed that there was a full induction and training programme for each person, with a Skills For Care log with dates and signatures. Hillside Residential Home DS0000024418.V362124.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): 31,33,35,36,38. Quality in this outcome area is good. Residents and relatives can expect the home to be well run, by competent staff. Their safety is assured by the home’s health and safety practices. Residents can be assured that there is a system for obtaining their views on the running of the home to ensure it is run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home was qualified to NVQ Level 4 and was experienced in the care of older people. She was supported by regular visits from the Regional Manager, and company financial and estates support. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 22 The provider had a comprehensive quality assurance process. A monthly visit report by the Regional Manager acted as the report required by Regulation 26 of the Care Homes Regulations. It was also a useful management document identifying the need for action and whose responsibility it was to take action. There was a system of monthly audits by the Manager, with a full audit of the home annually. It required an assessment of all areas of the operation of the home, together with any remedial action required. There were numerous audits including cash, care records, training, and medication, ensuring that there were means of identifying changing care needs, using competent staff with proper protective procedures. We examined the report which the regional manager as the responsible individual completed on their last visit to the home. It was comprehensive and detailed. It picked up comments made by residents and by staff. Some shortfalls in the standards of cleanliness and maintenance were detailed with action points for the manager or the provider. Residents’ and relatives’ meetings were advertised on the notice board, occurring at two monthly intervals. However the manager reported that as only the same six residents turned up for these meetings, she made a point of talking to other residents and recorded their comments. We noted the record made on 20 March 2008 which included comments about activities, and how appreciative one resident was of the visit of the activities coordinator to their room. Staff meetings were also held monthly. We examined the minutes of the one held on 25 March. Issues covered included staffing matters, laundry, and the behaviour of a relative. There was a regular planned and recorded programme of staff supervision. Sessions took place every two months, and there was also an annual appraisal. Staff were able to confirm that these sessions took place and that they were helpful. These processes provided residents with competent staff, up-to-date with procedures and training, for the delivery of their care needs. During the inspection, the fire alarm sounded. Staff immediately went to the staff assembly point for instructions. It turned out to be a false alarm, and staff returned to the residents to re-assure them. The home’s fire risk assessment had been updated last year to cover the additional rooms and services. All fire checks on the alarm system, the equipment and the emergency lighting were recorded and were up-to-date. The maintenance staff tested the temperature of the hot water outlets as part of their regular room checks. These were logged. Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 23 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 1 2 3 4 5 6 Score ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 Score 4 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 17 X 18 3 3 3 3 3 X 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 X 3 X 3 3 X 3 Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 24 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 Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hillside Residential Home DS0000024418.V362124.R01.S.doc Version 5.2 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!