Care Home: Hillview

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What the care home does well People living in the home continue to be positive about the care and support they receive. One person said their relative `feels safe and is well looked after`. Another person said ` I am always made welcome when I visit the home` and told us their relative`s key worker kept them informed of any changes. One person said that they and their relative were `110% happy with Hillview`, `Nothing seems too much trouble here`. People living at Hillview receive a good standard of personal care that recognises their individual preferences and supports their dignity. One person told us `they care so much my relative always looks nice and colour coordinated which they always liked`. People have a choice of freshly cooked meals, which they enjoy. People are living in a fresh, clean well maintained home. What has improved since the last inspection? Staff are now receiving planned training on supporting people with specific medical conditions. This is to make sure people living in the home receive the specific care and support they need There is a greater awareness of the need to make sure any specific risks associated with someone`s care are clearly recorded on admission and kept under review. The continued development of a person centred approach to identifying and responding to people`s needs means that staff have a clearer understanding of how to respond to people as individuals and involve them in decisions about their lives. The home has introduced an audit process for medication, which is working well and is able to identify any shortfalls quickly. A requirement made for the satisfactory completion of records made when medicines are given to residents has been met. In cooperation with the Commission B&M Care identified and provided the resources and support needed to improve the quality of care provided to people living in the home. This is reflected in the revised quality rating we have given this service. The manager, Mrs Denise Mudie, has been approved and registered by the Commission as being a suitable person to carry out this role. This will provide residents with the stability and accountability they need to make sure the home is run in their best interests. What the care home could do better: The improvements identified in this report need to be maintained and taken forward so people can be confident the care and support they receive will continue to reflect best practice. Assessments of staff competency to administer medicines need to be recorded to show they have achieved the required standard to do this safely and make sure they are reassessed at regular intervals according to company policy. CARE HOMES FOR OLDER PEOPLE Hillview 17 Collett Road Ware Hertfordshire SG12 7LY Lead Inspector Sheila Knopp Unannounced Inspection 14th January 2009 08:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillview DS0000019430.V373617.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. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillview Address 17 Collett Road Ware Hertfordshire SG12 7LY 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) 01920 469428 01920 469428 FP hillview@bmcarehomes.co.uk www.bmcare.co.uk Colley Care Limited (Trading as B & M Care) Ms Denise Mudie Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th August 2008 Brief Description of the Service: Hillview is owned and operated by B&M Investments Limited, which is a private company. The home is registered to provide personal care and accommodation for up to 36 older people. Hillview is situated in a residential area of Ware, close to the town centre, with easy access to bus and rail services. It is a large house, which has been converted and equipped for use as a residential care home for older people. The accommodation is arranged over three floors and is, with one exception, in single rooms. Seven of the bedrooms have en-suite facilities. There is a passenger lift to all floors and the home is adapted for wheelchair use. There are gardens to the front and rear of the home, with car parking provided at the rear. A wooden decking area has been created at the front of the home, to provide an additional communal sitting area. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective clients. Copies can be obtained on request from the manager. The current charges (correct on 14/1/09) range from £420.14 for residents funded by Hertfordshire County Council and £525 for people who fund themselves. Hillview DS0000019430.V373617.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. We (The Commission for Social Care Inspection) carried out this key unannounced inspection between 08:50 am and 14:40 pm. One inspector was present for 5 hours 50 minutes. In addition to this a pharmacist inspector was present for part of this visit to review the systems for managing medicines within the home. We talked to 9 (39 ) residents individually and in groups during our time in the home. The timing of our visit enabled us to observe the support provided to residents as they started the day and their contact with staff during the morning and over lunchtime. This key inspection was carried out to follow up the issues raised as a result of our key inspection on 27th August 2008 and random inspection on 14 November 2008. The random inspection also included a pharmacist inspector. We have reviewed the information we have received about this service between our inspections. This includes the action plan provided by B&M Care following our last key inspection. We also had a meeting with senior representatives of the company. The views of 3 residents, 5 relatives, 4 staff and a visiting therapist and health care professional who completed survey forms have also been included in this report. As this is our second key inspection we have included information from our earlier reports where standards have been met or we feel information has not changed. We have not needed to make any legal requirements as a result of this inspection as B & M Care have now made sure that the necessary quality assurance and auditing procedures are in place to identify and address issues as they arise. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Staff are now receiving planned training on supporting people with specific medical conditions. This is to make sure people living in the home receive the specific care and support they need There is a greater awareness of the need to make sure any specific risks associated with someone’s care are clearly recorded on admission and kept under review. The continued development of a person centred approach to identifying and responding to people’s needs means that staff have a clearer understanding of how to respond to people as individuals and involve them in decisions about their lives. The home has introduced an audit process for medication, which is working well and is able to identify any shortfalls quickly. A requirement made for the satisfactory completion of records made when medicines are given to residents has been met. In cooperation with the Commission B&M Care identified and provided the resources and support needed to improve the quality of care provided to people living in the home. This is reflected in the revised quality rating we have given this service. The manager, Mrs Denise Mudie, has been approved and registered by the Commission as being a suitable person to carry out this role. This will provide Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 7 residents with the stability and accountability they need to make sure the home is run in their best interests. 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. Hillview DS0000019430.V373617.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 Hillview DS0000019430.V373617.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): Standards 1, 2, 3, 4 & 5 (standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have the information they need to help them make a choice about using the service and will receive a contract setting out the terms and conditions of their stay. People looking to use the service will be involved in an assessment of their needs to make sure the home is suitable and any risks associated with their care are identified. EVIDENCE: To assess if suitable arrangements are in place for people considering moving into Hillview we have reviewed the information from our last inspection and followed through the admission of a new resident. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 10 Our last key inspection told us that people were impressed with the information and support the manager provided. They said they were encouraged to visit the home to look around at a time convenient for them. One person who completed out latest survey said they had looked around the home and had ‘tea and a talk with the manager’. Residents said they had received enough information about the home before they moved in. We were able to confirm that people who are funding their own care or supported by the Local Authority receive a contract setting out the terms and conditions of their stay. A resident who had come to live in the home since our last visit confirmed they were happy with the care and support they were receiving. They had settled in and said ‘I like it here’ and it’s ‘very good here’. The care records we reviewed and our discussions with staff confirmed this resident had received the staff support and intervention needed to enable them to regain independence and maintain their health. Our previous key inspection identified problems with identifying risks present at admission which may affect the care of individuals and lack of staff training in relation to specific conditions of old age. This visit confirmed risk assessments have been reviewed and staff have received updated training on managing the care of people with Parkinson’s disease and diabetes. Staff confirmed the training had given them greater insight into the care needs of these individuals. Hillview DS0000019430.V373617.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): Standards 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The continued development of person-centred care means people are experiencing a more individual approach. People can be confident they will have access to the community health and social care professionals they need to maintain their health and well-being. People can now be confident that there are systems in place to make sure that they receive their prescribed medicines safely and where possible people can continue to manage their own medicines. EVIDENCE: To assess whether people were receiving the care they need according to their needs assessment we met with 4 residents and reviewed their care records. The people we saw during our visit had been supported to achieve a high standard of personal care that reflected their individuality, personal choices and maintained their dignity. People told us the hairdresser was very good. An Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 12 optician and chiropodist were seeing people on the day of our visit. Residents had access to fluids throughout the day. Staff have guidelines to make sure they prompt and encourage people to drink plenty of fluids. Our discussions with one resident and a review of their records identified that staff had acted quickly and in their best interests to involve community health care professionals at an early stage to promote good outcomes for the individual concerned. A resident said there are ‘good doctor services’. People moving in from the local area may not all be able to keep their own General Practitioner because of the way two local surgeries allocate their work. Our last inspection identified lack of clear guidelines and training for staff carrying out duties delegated by the community nurses. The individual concerns were addressed quickly. The manager reported that there is currently no need for staff to involve themselves in these areas of care. She is aware of the guidance available should decisions need to be made in the future. A pharmacist inspector examined practices and procedures for the safe handling, use and recording of medicines. Storage provided for medicines is secure to protect residents and the temperatures of the storage areas are monitored and recorded regularly. This ensures that medicines are stored correctly and maintains their quality. Records are made when medicines come into the home and when they are disposed of. Records are also made when medicines are given to residents and, although a few discrepancies were found, these are generally of a good standard, providing a clear audit trail of medicines in use. The home had introduced an audit process for medicines, which is working well and picking up any discrepancies quickly so that they can be investigated. The cupboard used to store nursing supplies contained some dressings and other items that had been prescribed for people no longer resident in the home. It is important that such items are disposed of promptly and not used for the treatment of other people. We expect this to be managed by the home rather than make a requirement on this occasion. One person was provided with a medicine by their family but there was no record made of this or of any agreement with the resident’s doctor that this was acceptable. Again, we expect this to be managed by the home rather than make a requirement. Any changes or additions to medication record forms are signed and dated by the person making the entry and they are checked by a second person. The recommendation made about this on the last inspection has therefore been implemented. A few people look after their own medicines, particularly inhalers, and the risk to themselves and other people in the home had been assessed well but did not include a date when this would be reviewed. Medicines are only given to residents by suitably trained care staff. The level of training provided is good and certificates of attendance at such training are kept in staff training files. The company have a competence assessment process in place to ensure that people who handle medicines are competent to Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 13 do so but these assessments have not been done. We expect this to be managed by the home rather than make a requirement on this occasion. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home continue to experience an improving service in relation to the range and frequency of activities available and the quality of the meals being served as these areas continue to be closely monitored and residents asked for their views. People are supported to maintain contact with their family and friends and staff are taking steps to promote more activities outside the home. EVIDENCE: The care plans we saw enable staff to record information from a person centred perspective and staff continue to receive training in this approach. People living in the home or people who are close to them are being encouraged to add life history details to the records so staff know more about their lives, preferences and aspirations. Residents are also being involved in reminiscence projects. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 15 A programme of activities is displayed for people to see. We were able to see from the records of activities taking place that there is focus on providing people with a range of things to do. From the one to one interaction of board games and manicures to group activities such as cake decorating, quizzes and bingo. A weekly trolley shop enables people to buy things for themselves. Arrangements are made for people to maintain their religious observance and a monthly ecumenical service is held in the home. One person told us their relative ‘enjoyed the church service’. We observed during this visit and our earlier random inspection that people were bright, alert and occupying themselves watching the television, knitting and doing crosswords. Residents interact with each other talking about their lives and commenting on the information in newspapers. Staff appear to be more confident in initiating activities and spontaneous opportunities for social interaction. They also demonstrated during discussions that they are aware of the need to support residents who are not so able to speak out for themselves. Our last key inspection report identified that staff needed to consider their approach to enabling residents to go out. A staff car is available to take individual people out but the manager may wish to explore the availability of suitable community transport to take small groups out for trips. One of the residents told us about a trip to the pub they had enjoyed and a group of residents went out for a Christmas meal. The home employ activity organisers who attend meetings with other organisers within the company to share ideas. Further training for the current staff is planned. During our last random inspection we observed that residents were enjoying a leisurely breakfast, freshly prepared for them as they got up. One resident confirmed they had enjoyed a cooked breakfast at the weekend. The dining room tables are attractively set with flower arrangements, tablecloths and linen napkins. Staff have clear instructions on making sure people have plenty to drink and drinks were available to people in their rooms and lounge areas. The menu continues to be discussed with residents and changes made accordingly. Lunch on the day of our visit was greatly enjoyed. Choices are available and special diets supported. Details of each person’s food preferences and portion size are available to the kitchen staff so they can respond appropriately. Fresh fruit is available for people to pick up throughout the day. Visitors to the home feel welcome. One person told us they took their relative out. A visitor said we are ‘always offered a drink tray which is very good’. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live in the home are confident they will be listened to and any concerns they have will be taken seriously. People can be reassured that staff are receiving the training and supervision required to protect people and promote positive care practices. EVIDENCE: We have not received any complaints about this service and there have been no new referrals, under Hertfordshire County Council Safeguarding procedures, that would indicate concerns about people in the home, since our last key inspection on 27th August 2008. On-going investigations and monitoring by Hertfordshire Social Services arising out of concerns identified early in 2008 are due to be concluded with a final meeting. Between our visits social services have reviewed funded services users and their care plans to make sure they are receiving the care they need and the care plans reflect a person centred approach. B&M care have fully co-operated with the on-going reviews and investigations. This visit confirmed that the action plan put in place to address the issues raised at that time is still in place. This includes monitoring moving and handling, fluid intake and increasing social stimulation. As a result of the action taken the manager reports a reduction in falls, hospital admissions and urinary tract infections. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 17 The manager reported that no complaints have been received about the service provided at Hillview. The complaints procedure is made available to people on admission and displayed in the home. We also saw a folder of cards and letters thanking staff for the service provided. Everyone who completed survey forms (100 ) for our last key inspection said they knew how to make a complaint. None of the people we spoke with during this visit or who completed survey forms raised any concerns about the care and support they receive or the approach of staff. People reported positive relationships with staff. Residents confirmed staff were sensitive to their needs when carrying out personal care. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with a fresh, clean, comfortable, hygienic, well maintained home to live in which meets their needs. EVIDENCE: Hillview provides people with a comfortable fresh, bright home that is well maintained and furnished and decorated in a style familiar to the people who live their. Our last inspection confirmed there is a programme of redecoration, refurbishment and upgrading of the environment to make sure standards are maintained and everyday wear and tear addressed. We reported that the front of the home had been extended to include a narrow conservatory area off the main lounge opening on to an external decked seating area with views over Ware. The garden to the side of the house had also been made more Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 19 accessible and a gazebo and new seating provided to make it a more attractive area to sit in. People are able to add personal possessions to their rooms to make them feel comfortable and at home. Bathing aids and adaptations are available for those who need assistance. The manager’s annual self assessment stated that plans for improvement over the next 12 months include the creation of en-suite facilities where possible, a shower room and activity area. The provision of a shower room would provide people with further choice in their personal care. Our last inspection confirmed that the manager has access to current infection control guidance and the necessary equipment to promote good hand hygiene is available in the areas required. Since that visit she has attended updated infection control training organised by the Herts & Beds Health Protection Unit. We have advised that the Department of Health Infection Control Audit, ‘Essential Steps’, is completed to demonstrate current and continued compliance with national infection control standards. The laundry service provides people with smart well laundered clothing and the laundry assistant makes sure clothes are labelled and returned to the correct person. The laundry equipment and infection control systems enable staff to wash items at the correct temperature. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident suitably recruited and trained staff will be provided in sufficient numbers to meet their personal care needs. EVIDENCE: The rotas indicate that currently for 23 residents in addition to the manager, 4 care staff work during the morning from 8am – 2pm with 4 staff working from 2pm – 8am. Three staff work at night. This includes a senior carer on each shift. Bank staff are available to cover additional shifts or unexpected gaps. A member of staff told us that a positive aspect of this home was being able to spend time with residents. Agency staff are no longer used which, means people living in the home are supported by people they know. There is a separate rota for the housekeeping, catering, maintenance, laundry and activity staff. At our last key inspection we reviewed the personnel records of 4 staff to check that the manager is recruiting staff safely. This showed us that two references and a criminal records bureau check (CRB) are being obtained before people start work. The staff files had details of the specific training people had received since joining the home and there is a central training plan Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 21 so courses and updates can be booked accordingly. The manager reported that no new staff have been recruited since our last visit. A member of staff who completed a survey between our visits confirmed their was a rigorous approach to chasing up references and making sure a clear CRB had been received before they were given a date to start work. New staff receive an induction that meets the Skills for Care requirements for social care workers. The number of staff completing NVQ qualifications continues to increase to meet the required standard of 50 on each shift. Overall the staff who completed surveys were positive about the need to provide good standards of care, the support they receive from senior staff and the training they are provided with. Issues related to communication and teamwork are being addressed by the manager. Details of the specific training provided to staff in relations to Parkinson’s disease, diabetes, dementia and managing challenging behaviour have been provided. The staff we interviewed were positive about the training they have received and could give examples of how this had changed their approach. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 22 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): Standards 31,33,35 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. B & M Care have taken the steps required to reinstate the management and quality assurance systems which had been allowed to drift following frequent changes of manager. People are able to give their views on how the service is being run as part of the homes quality assurance programme and that there are suitable health & safety procedures in place to keep them safe. EVIDENCE: This visit, our earlier random inspection and a formal meeting with representatives of the company have confirmed a positive approach to providing the resources needed to address management issues, which had Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 23 developed over several years before the appointment of the current manager. The requirements we have made as a result of previous inspections have now been met. Since our last key inspection Denise Mudie has completed the Commissions process for registering managers under the Care Standards Act. She reported she is due to complete the Registered Managers Award (RMA), which is the standard qualification for managers of care services. We have asked for confirmation when this is completed. People continue to be confident in the manager’s approach. The company have quality auditing & monitoring systems in place that include seeking the views of people using the service. The manager advertises drop in surgeries for relatives. There has not been a high uptake so this is being reviewed. The manager feels this is because she has a lot of contact with residents and visitors during the course of her work. A resident told us ‘the new manager Denise will always listen to what I say. Resident and staff meetings are held. The minutes of the most recent staff meeting tells us the manager is encouraging staff to look at effective teamwork, communication and creating a positive culture within the home. The company have an annual cycle of quality review covering all aspects of the service. This has now been fully introduced at Hillview. A copy of the annual report will be made available to residents and stakeholders. We have also requested a copy. People are able to deposit small amounts of money in the office for safekeeping. The records and money held are audited regularly by the manager and company. A spot check during our last key inspection showed us that 2 signatures are recorded for money deposited and withdrawn. Receipts are kept to support any transactions and the records tallied with the amount of money available. Staff receive regular supervision. There is a plan of supervision in place to make sure it is carried out regularly and we were able to confirm from the records and our discussions with staff that this was being adhered to. Staff confirmed they felt able to raise issues and were listened to. A member of staff told us ‘It is nice to have one to one’s, so you can have a few minutes to discuss anything and receive constructive feedback’. There is a training plan in place to make sure staff receive the regular health & safety training they need to promote safe working practices. Our previous visits have confirmed that staff have received updated moving and handling training. The hot water systems are regulated to prevent accidental scalding. Windows on upper floors are fitted with restrictors to prevent accidents and radiators have cool to touch surfaces. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 24 During our last key inspection we found that the records of safety checks were up to date. Accident and incidents are recorded on monitoring forms and reviewed as part of the company’s auditing procedures. In response to our last key inspection the manager has familiarised herself with the company fire safety procedure and risk assessment required under fire safety legislation. The risk assessment had been reviewed and we saw records of the fire safety checks and fire drills carried out. Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 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 x x x x x x 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 x x 3 Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 26 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 Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 27 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 Hillview DS0000019430.V373617.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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