Inspection on 06/05/08 for 42 Hillgrove Crescent

This inspection was carried out on 6th May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

42 Hillgrove Crescent 17/10/06

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

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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 28/09/2008.

CARE HOME ADULTS 18-65 Hillgrove Crescent, 42 42 Hillgrove Crescent Kidderminster Worcestershire DY10 3AR Lead Inspector Dianne Thompson Key Unannounced Inspection 6th May 2008 10:00 Hillgrove Crescent, 42 DS0000066857.V364844.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.V364844.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.V364844.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 registered manager (if applicable) Type of registration No. of places registered (if applicable) www.dimensions-uk.org Dimensions (UK) Ltd Mrs Sally Anne Parkes 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.V364844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 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 and Dimensions UK is the Care Provider. Details of fees for the service are included in the service user guide. Hillgrove Crescent, 42 DS0000066857.V364844.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 was an unannounced inspection visit to see what the home was like for the people who live there. Time was spent talking to some of the people who live at Hillgrove Crescent and some of the staff working there. We looked at some of the policies and procedures in the office with the senior staff on duty. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Hillgrove Crescent and the ways they plan to make the service better. A tour of the premises was also made. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI, has been included in this report. What the service does well: Information is available about the service, and what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Hillgrove Crescent provides opportunities and support for people to maintain their interests and any hobbies they may have. Hillgrove Crescent looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Hillgrove Crescent. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Hillgrove Crescent makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Hillgrove Crescent. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 6 People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. 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.V364844.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.V364844.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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Hillgrove Crescent has policies and procedures in place for assessing potential people to live at the home. Information about the service included in a Statement of Purpose and Service User guide is available for all enquirers and residents. There are currently no vacancies at Hillgrove Crescent. The admissions procedure states that people would be given an information pack containing a copy of the statement of purpose and service users’ guide on admission. An updated copy of the Statement of Purpose and the Service User Guide was made available during the inspection visit. The statement of purpose and the service users’ guide has been amended to provide information in a simplified format so that people can understand it. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 9 The admissions procedure states that full community care assessments would be required and Hillgrove Crescent would complete their own assessments. Care plans are to be written from the information gathered during assessments, visits and discussions with families and other interested parties. Surveys confirmed that information about the home is shared, and that people are kept up to date with important issues. Hillgrove Crescent, 42 DS0000066857.V364844.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 individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: Care plans for three people were viewed and all contained appropriate information about their needs and how they were to be met. Care plans set out in detail the action that needs to be taken by care staff to make sure that Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 11 all needs are met. Evidence shows that care plans are regularly reviewed, and are used as a working document. Information provided in care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. Details about the ways people communicate are provided. Staff said they are able to use this information, with the knowledge and understanding gained about the people they support to communicate more effectively. Each person keeps their records in their own room. Staff complete records with people who use the service to keep them informed as much as possible. Care plans are being updated and transferred into Dimensions formats. This includes alternative communication aids so that people who use the service can access information more easily. The abilities of people are diverse and individualised care plans are needed, such as widget symbols, audiotapes or the written word. Statements are included to explain where people have little or no understanding of the care plan process. Staff said they are fully aware of the plans and follow them to guide their practice. Each person is allocated a key worker to oversee his or her care. This allows staff to work on a one-to-one basis and contribute to the care planning process for each person. Risk assessments are completed to keep people safe, with suitable guidelines for assistance as necessary. This includes mobility, moving and handling, and the management of the risk of choking. Completed risk assessments show dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. Although it was noted that not all risk assessments were up to date the senior staff provided draft copies of assessments that are ready to be printed to confirm that reviews are taking place. A relative’s view of the care and support provided at Hillgrove Crescent is that their relative ‘is well cared for and is very happy’. Other surveys confirmed that care given is what they expected or agreed with the service. Hillgrove Crescent, 42 DS0000066857.V364844.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. People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Hillgrove Crescent are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. Various recreational activities are offered. Evidence was seen in care plans to show daily routines and support given for specific interests. Activities are recorded in each persons care plan. Activities on offer include shopping, attending Worcester Snoezelen, eating out, visits to the cinema, going on Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 13 holidays, attending the day centre at Meadow Mill, and going to college in Kidderminster. Occasional trips are arranged and seasonal celebrations are also organised. Trips include visits to the local pub and garden centres. Hillgrove Crescent has a pleasant garden and people are encouraged to spend time there, particularly in the summer. Regular meetings are held with the people who use the service and discussions include menus and activities. Minutes of these meetings are kept. Evidence shows that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirmed that they are made welcome and offered a drink. Records show that varied and nutritional meals are provided and alternative meals where these have been chosen. People are offered meals, with snacks and drinks available throughout the day. People are consulted about their choice of food and diets. Support is given for people who find it difficult to eat and need help. Staff confirmed that they do this in a sensitive way that lets people to eat at their own pace. The manager states in the AQAA that the service plans to continue to look at developing the menu options to make sure that healthy and varied meal options are maintained. Hillgrove Crescent, 42 DS0000066857.V364844.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. Individual health and personal care needs are being well met by the staff at Hillgrove Crescent. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Hillgrove Crescent has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Care plans include detailed information about each person’s health needs. These plans sets out how health needs are to be met. Records show that regular checks and monitoring are being carried out. At the time of the inspection visit the admin team were in the process of transferring care plans to the new Dimensions format. The manager states in the AQAA that information is being updated during this process. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 15 Evidence shows how information is used to make any changes to each persons support if it is needed. People have good access to medical support through their Primary Health Care team as required. This includes Occupational Therapists, Physiotherapists, Dentists and GP. A record of visits to the doctors or other medical professionals is maintained. Healthcare records were discussed with the senior member of staff. Although accurate records are being maintained, the content of the information recorded needs to be developed. Advice was given about the need to record follow up actions where concerns have been identified, such as skin soreness. Information should show whether healing has taken place and show an indication of the time this took. For each incident there should be an audit trail of action taken, through to recording when healed. The senior staff member said this would be discussed at the next team meeting. Staff were observed providing support for people in a respectful way, making sure that dignity and self esteem was important for each person. Although communication with people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. A policy and procedure is in place for the administration of medication. All the staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. Medication is stored securely and given to people at the right time and full records are kept which show this. A Medication sheet in each care plan gives details of currently prescribed medication. Medication administration was observed and medication records are completed appropriately. Hillgrove Crescent, 42 DS0000066857.V364844.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): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. Policies and procedures are in place to make sure that people who use the service are protected from abuse. EVIDENCE: Hillgrove Crescent has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the AQAA that no complaints have been made to the service. The CSCI has not received any complaints about Hillgrove Crescent. As people who use the service are totally dependent upon staff for their care, staff confirmed they would advocate for people should there be any concerns. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. There are specific policies and procedures on the protection of vulnerable adults from abuse and the ‘whistle blowing’ for staff. Staff receive training in abuse awareness, and the staff on duty confirmed this. Staff also confirmed the procedures they would follow should they suspect abuse or have any concerns. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 17 Staff confirmed that people who use the service are supported in the management of their finances. The senior staff member said that money and accounts for people living at Hillgrove Crescent are audited each month as part of the regular monitoring process. People are supported to keep their monies and valuables in their rooms, in a suitable locked safe. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Hillgrove Crescent enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted. Hillgrove Crescent is a detached bungalow in a quiet residential street currently providing a home for four people who have learning disabilities and a physical disability. There is 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 people to use locally. The property is accessible, comfortable and provides a homely environment for the people who live there. The home is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 19 All cleaning materials are locked in the laundry room. Staff were observed wearing suitable protective clothing for the work they were doing, and confirmed that they were familiar with the procedures regarding the control of infection. Records show that staff have been given training in health and safety matters. The manager states in the AQAA that ‘new furnishings have been purchased for the home’ and that ‘people have beds which suit their needs’. Some additional slabs have been fitted since the previous inspection that has improved access to the garden. Further slabs are to be laid so that the garden is more accessible for everyone. Some areas of the home have recently been decorated and people who live in the home have been involved in the choice of colours and style. The manager states in the AQAA that work to the property during the coming year will include ‘to divide the large bedroom into a smaller bedroom and bathroom’, and ‘to lower work surfaces in the kitchen to allow people in wheelchairs to access kitchen’. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Hillgrove Crescent. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Hillgrove Crescent. EVIDENCE: Hillgrove Crescent has a committed and stable staff team. Staff spoken to confirmed that the team are very well motivated and work hard to improve the lives of the people who use the service. People commented in surveys that they were generally satisfied with the service and the staff. Hillgrove Crescent operates a recruitment policy and procedure to ensure that everyone completes an appropriate application form and that suitable references are obtained including one from their most recent employer. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 21 Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. An induction checklist was seen which shows that staff cover all areas during their induction programme. It is evident that up to date training information is provided as part of Induction training for new staff. The Learning Disability Award Framework has been replaced with the Learning Disability Qualification. Regular staff training is provided. Staff complete mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults. A record is maintained for all training completed with dates of planned refresher courses identified on the training matrix. Staff confirmed they receive regular training, and one person talked about the NVQ training they are currently completing. Four staff out of the team of seven has an NVQ qualification and the remaining three people are working towards achieving their NVQ’s. Staff appeared to be enthusiastic and well motivated. They stated they are well supported and are given the opportunity to share their views and opinions at staff meetings. Comments included ‘love the variety of working in the home’, ‘being able to help people to live well is what we are about’ and ‘the staff team works well here’. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 22 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 service is well managed and staff receive the leadership and support they need. Dimensions monitors Hillgrove Crescent in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Sally Parkes has many years experience working with people with learning disabilities. Sally is a qualified learning disability nurse, and has completed her Registered Managers’ Award (RMA). Sally regularly completes training relevant to her position as registered manager of Hillgrove Crescent, including first aid and vulnerable adults training. Management responsibilities within the service are also shared with a senior support worker. They are both involved in organising day-to-day activities, Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 23 health and safety promotion, staff supervision and induction. Sally was away on annual leave at the time of the inspection visit, but the inspection process was well supported by the senior support worker on duty. Staff confirmed that the manager is approachable and supportive. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The AQAA is where the manager tells us about the service provided at Hillgrove Crescent and the ways they plan to make the service better. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the service is being run. These visits include interviews with staff and people living in the home. An audit of relevant aspects of the service, including records, environment, complaints received, finance and safety is also completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Hillgrove Crescent’s quality assurance and monitoring system that is intended to form an annual development plan for the service. This report includes the views of people who use the service, stakeholders and interested parties. Supervision of care staff includes all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and staff confirmed that regular supervision takes place. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. Risk assessments are carried out and recorded for safe working practices including the use of power packs for wheelchairs, and the use of slings on hoists. The records relating to accidents within the home are completed in full and are accurately maintained. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 X Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations Health care records should be developed to show a complete account where a health concern is raised. Hillgrove Crescent, 42 DS0000066857.V364844.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V364844.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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