Inspection on 17/10/06 for 42 Hillgrove Crescent

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

42 Hillgrove Crescent 06/05/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Hillgrove Crescent, 42 42 Hillgrove Crescent Kidderminster Worcestershire DY10 3AR Lead Inspector Dianne Thompson Unannounced Inspection 17th October 2006 10:00 Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 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 Hillgrove Crescent, 42 DS0000066857.V316071.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 Adults 18-65. 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. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillgrove Crescent, 42 Address 42 Hillgrove Crescent Kidderminster Worcestershire DY10 3AR 01562 746987 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of home manager (if applicable) Type of registration No. of places registered (if applicable) www.dimensions-uk.org Dimensions (UK) Ltd Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1), Physical disability (4), of places Physical disability over 65 years of age (1) Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23.2.2006 Brief Description of the Service: 42 Hillgrove Crescent is a detached bungalow in a quiet residential street providing a home for five people who have learning disabilities, all of whom also have a physical disability and one of whom is over 65 years of age. Service users bedrooms are individually decorated and furnished, with a shared lounge and kitchen/diner and specialist bathing facilities. Local shops and access to public transport are situated on the nearby Bromsgrove Road. The home has its own vehicle for service users to use locally. The home aims to provide a homely environment promoting independence and dignity. Service users receive personal care and support to live as ordinary a life as possible in the community. This involves staff teaching skills and creating opportunities on behalf of individual service users. Service users are encouraged to participate in the running of the home and share in the general household activities. The home is committed to helping service users to achieve valued and fulfilling lifestyles. Sally Parkes is the home manager. Dimensions (UK) Ltd is now the care provider for the service, having registered with the Commission for Social Care Inspection on 1st April 2006. The current fee for the service range from £94.45 per week. Charges which are additional to the fee include: • • • • • • Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider or in the funding authority contract Holidays Major extra outings Hairdressing Lease vehicle Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Hillgrove Crescent. This was the home’s first inspection since Dimensions (UK) Ltd registered as the care provider. The main purpose of this inspection was to see what the service at Hillgrove Crescent was like for the people who lived there. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider’s representative was used to inform this report. Time was spent with the home’s manager and staff on duty. Three service users were at home; one service user was unwell and waiting a GP visit. Two service users were attending day centres. What the service does well: Information is available about the services offered at the home to help people choose whether or not to live at Hillgrove Crescent and if the home will meet their needs. Service users are helped and supported to lead active and interesting lives at Hillgrove Crescent. They are also supported to stay in touch with their families and to develop friendships. The home offers a well-balanced diet and promotes healthy eating for the welfare of all service users. Personal and healthcare needs are written in care plans and provide information to make sure that care is provided in a way that service users like. The home has a medication policy and procedure to make sure that all medication is given and stored safely for the protection of service users and staff. The home’s complaints procedure has easy to understand information about how to complain. Staff support service users to have their say and to share any concerns they may have. Hillgrove Crescent is a safe, spacious and very comfortable home. The home is kept clean and tidy. There are enough staff at the home, and the staff are trained to help them support service users. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 6 The home makes sure that suitable staff are employed and that all necessary checks are made to make sure that service users are kept safe. Service users are involved in the recruitment and selection process for new staff. The home is well managed with an open and positive approach. 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. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Detailed information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Hillgrove Crescent and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose has been amended to provide up to date information about the home to help prospective service users decide if they wish to live at Hillgrove Crescent. The service user guide is being updated and evidence was seen to demonstrate this. The home manager said that copies of the revised Statement of Purpose and Service User Guide would be accessible to all, including visitors to the home. All service users receive copies of relevant information prior to moving into the home, which is offered in preferred formats, e.g. symbols/pictures, audio and large print. There are no vacancies at the home, but an admissions policy and procedure is in place should a vacancy arise. The home’s assessment process is very detailed and the manager and service users care records demonstrate that the home receives full information about prospective service users, their Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 9 background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to previous homes or schools, and discussions with family members. Introductory visits and stays are arranged at the home prior to admission. During the introduction to the home prospective service users are given a copy of the statement of purpose and service user guide. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about users assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Service users are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: Service user care plans are detailed and informative. The plans show monitoring of identified goals, and how these are to be facilitated and achieved. Staff have information to make sure that all care is provided in a preferred and consistent way that encourages independence. A person centred care plan (PCP) approach is being developed and the careplanning format shows service users will be supported in planning and reviewing their care, and in expressing their wishes and goals. An Area Path map has been completed for Dimensions, and a Path will be completed for the Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 11 home. The Path map process will provide staff with the knowledge and experience to support service users in completing their PCP’s. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in service user files to make sure all staff have the necessary information to provide quality care. Where service users have severe problems understanding speech a statement is included in their care plans which emphasises the way in which individuals have developed strategies for making sense of their day to day environs, and making their basic needs known to others. There may be insufficient understanding to be able to take part or contribute effectively in planning meetings, but staff adapt to service users abilities to make sure participation is encouraged at all times. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. Plans are reviewed regularly or as any changes in need occur. Staff said they are fully aware of the plans and clearly use them to guide their practice. Risk assessments are included in care plans. However, agreed actions or responses should be included where a risk of choking or aspiration has been identified. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: The home provides a wide range of activities for service users, both in-house and within the local community. All activities are organised to take into account the individual needs and preferences of all service users, seeking to ensure everyone has the opportunity to participate. Activities are recorded in individual diaries providing a clear record of individuals’ lifestyles. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 13 External activities include cinema, shopping, attending Worcester Snoezelen, eating out, visits to the cinema, going on holidays, attending the day centre at Meadow Mill, and going to college in Kidderminster. Access to art therapy in Lea Castle and day centre activities will cease, as Dimensions are now the service provider. The home is developing a system to help people to plan activities. Key workers are to develop a menu of activities that would be reviewed regularly. The home would benefit from specific day care staff to coordinate activities for all service users to make sure that alternative options are sought and maintained. A Halloween party is being planned at one of Dimensions homes in Worcester, and service users at Hillgrove have been invited. Activities within the home include watching TV and video’s, listening to music, involvement in daily routines, e.g., being present during the cleaning of bedrooms although service users may be unable to do the physical task; receiving foot spa and hand massage. Evidence was seen which demonstrates that regular contact with friends and family is supported. The home provides well-balanced meals and special diets for individuals where required. Alternative options, special diets and preferred choices are catered for. Records of all food and drinks taken are transferred into individual care plans. There is evidence that probes are used to check the temperature of cooked meats and the relevant information is recorded. Food offered is varied, healthy and appropriate to individual needs. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. The plans provide information and promote consistency of care and support for all service users in a way that takes into account their preferences. The home has a clear medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide detailed information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. Individual mobility and handling guidelines, that includes a risk assessment, are completed for each service user. This ensures that all staff are informed and work to preferred and agreed procedures. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 15 Staff said they are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Records of all physical checks are completed where service users have particular health related issues e.g. weight and fluid intake. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. Records of weight checks are inconsistent. For example, risk assessments identify the need for a response if there are variations in weight of 4lb or more, but the lack of regular weight checks do not enable accurate monitoring. Service users and the home are well supported by medical services, which includes GP’s, audiologist, ophthalmologist, epilepsy consultant, Speech and Language Therapist, psychiatrist, dentist, community learning disability team, occupational health, and dietician. Arrangements are in place for preventative health services, e.g. dental checks and annual health screening. Staff on duty and the home manager said that all personal care is given in private to promote dignity for all service users. The manager is aware of the specialist services that could be needed to support service users and how to access them. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. All staff are trained in first aid. The manager is looking for suitable storage cabinets so that medication can be safely stored in service users bedrooms. Appropriate Storage of Medication information has been supplied to the manager. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 23, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are protected by easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: During the inspection visit staff were observed engaging with service users in a supportive and respectful way. The home’s complaints procedure is available in signs and symbols for service users. The home has received compliments from carers and members of the public on the standard of care and support that staff provide. The home has received a complaint in respect of the trees in the garden causing damage to a neighbour’s fence. This is being addressed. No complaints have been made to the CSCI since the previous inspection. The home has relevant policies for service users’ protection. Policies and procedures are available which advise and guide staff in protecting service users. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Hillgrove Crescent provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. The home will benefit from the planned redecoration. EVIDENCE: Hillgrove Crescent is a detached bungalow in a quiet residential street, with a shared lounge, with a kitchen/diner and enclosed rear garden. The lounge looks out onto the garden. There is a ramp leading to the garden where there is a fishpond and summerhouse. Local shops and access to public transport are situated on the nearby Bromsgrove Road. The home has its own vehicle for service users to use locally. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 18 The inspector was given a tour of the building that included service user bedrooms. All service user bedrooms are individually decorated and furnished, and reflect service users particular interests and hobbies. Some of the bedrooms, and the hall and stairs are scheduled for redecoration. The shared bedroom has screens, which are used to ensure privacy when both service users are present and personal care is needed. This room has sensory equipment that is used regularly, and curtains that are used as backdrops for the projector. Other specialist equipment within the home includes symmetrikit chairs, overhead hoists, specialist bath and pressure flow mattress. Stimulatory equipment in service users bedrooms such as lamps, projectors, mobiles, rope lights, and wind chimes are available. The home is looking to purchase power packs for wheelchairs to assist in supporting people out and about. There are rope lights on the wall in the hall to assist service users finding their way around the home, particularly where people have sensory impairments. The aqanova bath had been out of operation awaiting parts for over 6 weeks. The ordered part (handset) arrived during the inspection visit. Service users have been unable to have a bath, and this has raised health and safety issues for staff during this time. Contingency arrangements should be made with suppliers or contractors for repairs to be carried out in a suitable timeframe. Additionally the home should consider the condition and age of the bath and whether a replacement bath would be more appropriate. The premises are clean and tidy, although the paintwork needs to be refreshed and the backing tiles to the hand basin in the kitchen need cleaning. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. All cleaning materials are stored in locked cupboards in the laundry room. A gardener is employed at the home for a few hours per week to keep the gardens tidy. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained and staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The home has a committed staff team who work to provide quality care for the people living at Hillgrove Crescent. The manager also said that the change over to Dimensions (the new provider) has been relatively smooth, and that service users and the staff team have coped with this very well. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 20 Staff complete the mandatory health & safety training such as fire safety, first aid, food hygiene, moving & handling and infection control. Other training courses include communication, safe handling of medicines, abuse, working with people we support and managing challenging behaviour. Other training such as epilepsy is arranged as required. All newly employed staff undertake the LDAF Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, service users and safety matters. The manager confirmed that all prospective staff complete an appropriate application form and that required references are obtained including one from their most recent employer. An enhanced CRB and POVA (police) check is undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Evidence was seen from the staff supervision planning record that staff receive regular structured supervision from the management team. Staff meetings are held regularly and minutes are maintained. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed with an open and positive approach. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The home manager, Sally Parkes has been in post for approximately one month. Sally was previously a registered manager at another Dimensions Care Home. Sally will need to submit an application to CSCI for consideration as registered manager for Hillgrove Crescent. Sally has undertaken a range of relevant training courses that includes Our Approach (including quality outcomes), Our Purpose (including listening and Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 22 enabling), Equality and Diversity, and Fire Training for Managers course. Sally has completed the Registered Managers Award. Management responsibilities in the home are also shared with a senior support worker. They are both involved in organising day-to-day activities, health & safety promotion, staff supervision and induction. Staff confirmed the manager is approachable and supportive. In respect of management support from the provider Dimensions has Training and Human Resource Officers who are available to advise and support the home. Service manager meetings are held monthly and the manager confirmed that she and the home are being supported. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include service users, stakeholders and interested parties views on the service provision. Records show that monthly checks of the fire safety system & equipment, water temperature & storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health & safety training topics. Generic risk assessments are in place that includes the home’s vehicles. Hillgrove Crescent, 42 DS0000066857.V316071.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 Adults 18-65 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 3 Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA19 Regulation 12 (1) a, 17 (a) 23 (1), a &b 23 (2) j Requirement Timescale for action 30/11/06 2. YA30 The home must make sure that adequate records are kept to promote accurate monitoring. Specifically this refers to the completion of weight charts. 30/11/06 Contingency arrangements should be made with suppliers or contractors so that repairs to equipment are carried out within a suitable timeframe. Additionally the home should consider the condition and age of the bath and whether a replacement is more appropriate. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Risk assessments are included in care plans. However, agreed actions or responses should be included where a risk of choking or aspiration has been identified. DS0000066857.V316071.R01.S.doc Version 5.2 Page 25 Hillgrove Crescent, 42 2. 3. YA12 YA42 The home would benefit from specific day care staff to coordinate activities for all service users to make sure that alternative options are sought and maintained. The premises are clean and tidy, although the paintwork should be refreshed and the backing tiles to the hand basin in the kitchen need cleaning. Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Hillgrove Crescent, 42 DS0000066857.V316071.R01.S.doc Version 5.2 Page 27 - 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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