Inspection on 01/02/07 for Hillcrest Avenue (40)

This inspection was carried out on 1st February 2007.

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

Hillcrest Avenue (40) 12/01/06

Hillcrest Avenue (40) 21/07/05

Hillcrest Avenue (40) 28/09/04

Hillcrest Avenue (40) 06/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Hillcrest Avenue (40) 40 Hillcrest Avenue Chertsey Surrey KT16 9RE Lead Inspector Sandra Holland Unannounced Inspection 1st February 2007 10:45 Hillcrest Avenue (40) DS0000013495.V327697.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 Hillcrest Avenue (40) DS0000013495.V327697.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. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest Avenue (40) Address 40 Hillcrest Avenue Chertsey Surrey KT16 9RE 01932 571978 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) Welmede Housing Association Ltd Mrs Thelma A Miskelly Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2), Physical disability (3) of places Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate 3 residents with both LD (Learning Disabilities) and PD (Physical Disabilities) within the total persons accommodated The age/age range of the persons to be accommodated will be: OVER 50 YEARS 12th January 2006 Date of last inspection Brief Description of the Service: Hillcrest Avenue is a small home providing accommodation and support for up to five people with learning disabilities. Up to three service users may also have physical disabilities and two service users can be over 65 years of age. The home is run by Welmede Housing Association and the staff are employed by the North Surrey Primary Care Trust (NSPCT). Welmede runs a local network of homes for people with learning disabilities. The property is a bungalow specifically adapted to the needs of service users, situated in a quiet residential avenue on the outskirts of Chertsey. Accommodation is provided in single bedrooms with spacious communal areas and an attractive garden. Car parking is available on the front drive or on the road. The fees at this service are £ 1296.00 per week. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) and was carried out under the CSCI “Inspecting for Better Lives” process. Mrs Sandra Holland, Link Inspector carried out the inspection over five hours. A team leader assisted with the inspection initially and Mrs Thelma Miskelly, Registered Manager arrived shortly after. All five service users who live at the home were met with and two staff were spoken with. All areas of the home were seen and a number of records and documents were sampled, including medication records, service users’ individual plans and staff training records. A pre-inspection questionnaire was supplied to the home and this was competed and returned within the requested timescale. Some of the information from the questionnaire will be referred to in this report. A full review of the information held about the service was also carried out before the visit. A number of CSCI feedback cards were supplied to the home for distribution to service users, relatives or visitors and healthcare professionals. These are supplied to obtain independent feedback as to how the service is meeting the needs of the people living there. One feedback card was completed and returned by a relative and one by a support worker. Both gave positive feedback and the relative made an additional positive comment. The inspector would like to thank the service users and staff for their hospitality, time and assistance. What the service does well: The needs of service users are fully assessed before they move into the home to ensure that they can be met. A major part of the assessment is making sure a new service user will fit into the household and get on well with the people already living at the home. Detailed individual plans have been drawn up to give staff clear guidance about how service users like and need to be supported. The plans are well written, regularly reviewed and include assessments of risks to service users. The health and welfare needs of service users are very well met, with regular checks and prompt referrals if changes are noted in a service users’ health. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 6 Service users appear to be very happy with the service provided and were very proud to show their bedrooms and the home in general. All areas of the home were attractively decorated and furnished in a homely style and were clean and freshly aired. Service users are very well supported to maintain and develop their skills and leisure interests and to be active members of their local community. The home supports and encourages service users to keep in contact with their family and friends. A very small team of staff support service users. Members of staff spoken with said that they are happy working at the home and some had worked there for a number of years. Staff members and service users were observed to have a relaxed, friendly relationship and there is a homely atmosphere in the home. What has improved since the last inspection? What they could do better: To safeguard service users from fire, doors that are designed to close automatically when the fire alarm is activated must not be wedged or propped open. CSCI must be notified of any event affecting the well-being or safety of service users, as required under Regulation 37. (Regulation 37 requires services to inform CSCI of events such as accidents, serious illness or outbreaks of infectious disease). Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 7 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. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 8 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 Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 9 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. Standard 2 was assessed. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users have been fully assessed before their admission to the home. EVIDENCE: The manager was able to provide detailed information about the assessment process which would be carried out to ensure the home could meet the needs of a prospective service user. This was detailed in relation to the most recently admitted service user, who joined the home just over a year ago. As most prospective service users would be supported financially by a local authority, a care management assessment would be carried out and a copy of the assessment would be obtained. The home would carry out their own assessment, either at the existing home of the prospective service user or at the service. Any prospective service user would be invited to visit the home on a number of occasions, usually of increasing length. The prospective service user would be invited to stay for a meal and possibly overnight, if it appeared that the home may be suited to the service user. A focus of the pre-admission assessment Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 10 would be to ensure that the prospective service user was compatible with the existing service users and to minimise any effects or disruption a new service user may have on them. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is excellent. Standards 6, 7 and 9 were assessed. This judgement has been made using available evidence including a visit to this service. Individual plans are available to guide staff to the specific support needs of service users. The individual plans include the support required to manage risks to service users. Service users are well supported to make decisions. EVIDENCE: Detailed and informative individual plans have been drawn up for each service user to describe their support needs and the services and facilities the home provides to meet these needs. The individual plans that were seen were in good order, contained the required information and had been regularly reviewed. The needs of service users have been prioritised in their individual plan and goals have been set to meet those needs. A plan has also been developed to guide staff to the actions required to achieve the goals. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 12 Behavioural guidelines have been drawn up where necessary, to inform and guide staff about behaviours which may challenge, how to prevent these and how to manage them if they should occur. It was clear that staff had a good knowledge and understanding of the service users’ individual needs. The manager stated that a computer-based system of recording the information in the individual plans is being introduced, as this makes it easier to read, review and update the plans. It was noted that the new care plans recorded service users’ wishes, needs, strengths and choices for each of the areas covered. To enable service users to be as independent as possible, assessments of risks to service users have been carried out. These included ways of preventing the risks and ways to reduce any risks. It was noted that an assessment had not been carried out regarding a specific risk to a service user, as required following the last inspection, although the manager carried out the assessment during the course of this inspection. It was observed that service users require assistance in almost all activities of daily living, including making decisions. Staff advised that to enable service users to make decisions, they offer a selection of items, such as clothes to wear, foods or things to buy when out shopping. Staff advised that they take service users known preferences, likes and dislikes into account when supporting them to make decisions. Staff were observed to offer service users a choice of drinks or refreshments and to respect the choices which were made. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 13 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 and 17. Quality in this outcome area is excellent. Standards 12, 13, 15, 16 and 17 were assessed. This judgement has been made using available evidence including a visit to this service. Service users are very effectively supported to take part in a range of activities and to be active members of their community. Service users are offered a well balanced diet. EVIDENCE: Each service user’s preferred activities are recorded in their individual plan and some service users were pleased to talk about the activities they take part in. The range of activities include, snoozelem sessions, visits to pubs and restaurants, bingo, shopping, visits to places of interest and ten–pin bowling. Staff advised that service users are not able to hold jobs due to the limitations of their disabilities. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 14 Service users were observed to come and go to their activities throughout the inspection. Two service users went to a cookery class and were pleased to eat the food they had cooked for their lunch. Other service users spent the morning relaxing at home, looking at books and watching television. All the service users went out in the afternoon to a bingo session at a local community centre. A “floating support worker” is provided to support a service user for one afternoon each week the manager advised. This is provided by the Welmede organisation which runs the home, to enable service users to have one to one support in addition to staff at the home. The manager stated that service users are actively supported and encouraged to maintain family contacts, by sending cards for special occasions such as birthdays and Christmas. Families are welcomed to visit service users and some service users go out regularly with their families when they visit. From information supplied with the pre-inspection questionnaire, it was clear that service users are offered a well-balanced and varied selection of meals, which take their personal needs and preferences into consideration. Staff advised that the main meal of the day is served in the evening and is taken family style as a group with staff. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. Standards 18, 19 and 20 were assessed. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way that they prefer and their healthcare needs are well met. Medication is appropriately managed. EVIDENCE: Staff were observed to provide personal support discreetly and in a manner that promoted service users’ independence, privacy and dignity. Service users were encouraged to be independent and staff offered support only if it was needed. From speaking to staff and from records seen, it is clear that service users are supported by a number of healthcare professionals and that their healthcare needs are well met. Service users have received support from healthcare professionals including dentists, opticians, general practitioner (GP), speech and language therapist and hospital specialists. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 16 Records showed that changes in service users’ needs or health have been responded to, and staff have taken prompt and appropriate action. This has included seeking medical or other advice and requesting referrals to specialists if needed. It was noted that service users are also supported to attend routine checks to maintain their health. Medication is supplied by a local pharmacy the manager advised, and is stored appropriately in a central, locked cupboard. Only staff who have received training in this, administer medication. The amounts of medication held were checked with the medication administration record (MAR) and were correct and no gaps in the MAR were noted. It was noted that the stocks of medication held are not carried forward to new MAR charts. This is recommended to make it easier to check stocks, to ensure a clear audit trail can be followed, and to safeguard service user’s medication. Sample signatures of staff who are authorised to administer medication were held, along with a signed consent by the service users’ GP, for the administration of homely remedies. These are medications that can be purchased and do not need to be prescribed. These are rarely given the manager advised, as service users are usually seen by their GP if a change in their health is noted. A recommendation has been made regarding Standard 20. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. Standards 22 and 23 were assessed. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure has been drawn up in a way that is more suited to the needs of service users. Staff are aware of their responsibilities in the safeguarding of service users. EVIDENCE: A complaints procedure is available in written or easy read forms and it was noted that the “Service user’s guide to complaints” has been developed in a more service user-friendly style. The manager stated that as the service users are not able to use these due to the limitations of their disabilities, an explanation of the procedure has been given to service users and has been recorded in their individual plan. It was clear that some service users would have to rely on staff to understand that they were unhappy or dissatisfied in any way, as they may not be able to explain this to staff. Staff stated that service users are able to communicate their unhappiness in specific individual ways, which are known to staff and are recorded in their individual plans. This would usually be shown by a change in behaviour, which staff would monitor to establish the reason it has developed. Any changes would be recorded and reported to the manager to ensure that appropriate support was provided and that any relevant procedures were followed. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 18 From information in the pre-inspection questionnaire, it was noted that no complaints had been recorded during the last year. A relative who had completed and returned a CSCI feedback card indicated that they are aware of the home’s complaints procedure. From speaking to staff it was clear that they are aware of their responsibilities in safeguarding service users. Staff stated that they would report any concerns or suspicions of abuse to the manager or person in charge. If needed, staff knew that they could also refer any concerns to an on-call manager or to other agencies outside the home. In the event of an allegation of abuse, the manager stated the home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. An up to date copy of the procedure is kept in the home, along with the “No Secrets” guidelines and the North Surrey Primary Care Trust adult protection guidelines. These are available for staff to refer to if required. Service users’ monies for day-to-day use are securely held for safekeeping and individual records of these are maintained. Staff advised that these are checked by two staff at the change of each staff shift and to further safeguard service users, two signatures are recorded for each transaction. The amounts of monies held were checked with the records held and these accurately matched. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. Standards 24 and 30 were assessed. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, safe environment, which is suited to the needs of those living there, and is very clean and hygienic. EVIDENCE: The home is attractively decorated in cheerful colours and is bright and airy. It is well furnished and equipped in a homely style to meet service users’ needs. Each service user has their own bedroom and a service user was very willing and happy to show their room. Bedrooms have been made individual with service users’ own belongings, including pictures, ornaments and soft toys. The home is bungalow with a level front door entrance and all areas are fully accessible, even to wheelchair users. The home blends well with other neighbouring properties, being of a similar size and style. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 20 It was observed that a number of doors, including service users’ bedroom doors were wedged open, although stickers on the doors said “fire door to be kept shut”. This is referred to at Standard 42 which refers to health and safety. All areas of the home were seen to be very clean and well presented and appeared hygienic. Liquid hand cleanser and paper towels were provided in all appropriate places to prevent the spread of infection. A separate laundry room is available, is positioned away from food storage and preparation areas and the laundry equipment has appropriate programmes. It was noted that personal protective equipment, including aprons and gloves are provided for staff, although a member of staff on duty advised that they prefer not to use some of these items. It is recommended that this is recorded and that an assessment is carried out of any risks associated with this choice. A recommendation has been made regarding Standard 30. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 21 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 and 35. Quality in this outcome area is good. Standards 32, 34 and 35 were assessed. This judgement has been made using available evidence including a visit to this service. Service users are effectively supported by a small team of staff who are appropriately recruited and trained. EVIDENCE: From the information supplied in the pre-inspection questionnaire it was clear that service users are supported by a very small team of staff. The manager stated that bank staff are supplied by the North Surrey Primary Care Trust if required, to cover any sickness or holiday absences that cannot be covered by the home’s staff. Wherever possible, staff known to the service users are supplied to ensure continuity and consistency of support. Staff advised that they provide support to service users in all aspects of running the home, including shopping, cooking, domestic and laundry tasks. Staff also provide support with transport and a variety of activities. It was noted that only one member of staff was present at the home with three service users when the inspector arrived. Another member of staff was on Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 22 duty but had taken service users to their classes and gone on to do shopping. It is recommended that staffing levels are reviewed, to ensure sufficient staff are available to meet service users’ needs. It is also recommended that an assessment is carried out, of the risks associated with leaving a lone member of staff. A number of staff have undertaken and achieved National Vocational Qualifications (NVQ) in care, to level 2 or above and the home has met the recommended target of fifty percent of trained staff. Staff were observed to interact well with service users, listening to what they said and giving time for service users to respond. Staff were open, cheerful and welcoming. The manager stated that although no new staff had been recruited since the last inspection, she was able to explain in detail the thorough recruitment process that is carried out. To safeguard service users, all staff are required to undertake a Criminal Record Bureau (CRB) disclosure and these had been carried out. Staff training records were seen and covered training required by law and training to develop knowledge and skills. These included medication training, food hygiene training, first aid, fire training and the safeguarding of vulnerable adults. The manager advised that one member of staff has undertaken equality and diversity training and others are to undertake this. The staff team is made up of male and female staff which reflects the service user group. The staff group is of mixed cultural and racial backgrounds and the service users describe themselves as British. A recommendation has been made regarding Standard 32. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. Standards 27, 39 and 42 were assessed. This judgement has been made using available evidence including a visit to this service. Services users benefit from a well run home. The health, safety and welfare of service users are promoted and protected, although one shortfall in this was noted. EVIDENCE: It was evident that the manager is very experienced in the support and care of service users with learning disabilities, is well qualified and experienced for her role and is ably supported by a deputy manager. The management team have created an open and inclusive atmosphere and provide clear direction and leadership. From the outcomes for service users, it is clear that the service is effectively managed. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 24 The manager stated that she will be retiring from the home in June 2007 and the process of recruiting a new manager has already been started. To review the quality of the service provided, a service users’ satisfaction questionnaire was supplied to service users in December 2005 and service users were supported by their key-workers to complete these, the manager stated. The manager advised that the Welmede organisation are in the process of developing a new system of assessing the quality of the services provided. As previously mentioned, CSCI feedback cards were supplied to the home to obtain independent views of the quality of the service. One relative and a healthcare professional completed these and returned them. Both indicated satisfaction with the support and care provided and the relative included a complimentary comment. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home are carried out appropriately, and to the required frequency, to promote the safety and welfare of all who live and work there. The home’s insurance certificate and health and safety at work poster are displayed as required. It was noted from the documents sampled, that a small number of incidents had occurred which had not been notified to CSCI as required under Regulation 37. This regulation requires homes to notify CSCI of events that occur in the home and affect the welfare of residents, including serious illness, accidents and theft. As mentioned at Standard 24 which relates to the premises, it was noted that a number of doors in the home were wedged or propped open. These doors were marked with signs stating “fire door to be kept shut” and are designed to close automatically when the fire alarm is activated. Preventing these doors from closing will not safeguard against the spread of fire or smoke. The member of staff on duty removed the wedges and props immediately this was brought to her attention. Requirements have been made regarding Standards 41 and 42 and two recommendations have been made regarding Standard 42. Hillcrest Avenue (40) DS0000013495.V327697.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 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 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 x 3 X 3 X 2 2 X Hillcrest Avenue (40) DS0000013495.V327697.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. 1 Standard YA41 Regulation 37 Requirement The registered person must notify CSCI without delay, of any incident affecting the well-being or safety of any service user, as specified by Regulation 37 of The Care Homes Regulations 2001 (As Amended). The registered person must ensure that all parts of the home to which service users have access are so far as reasonable practicable, free from hazards to their safety. Specifically, doors designed to close when the fire alarm is activated must not be wedged or propped open. Timescale for action 01/02/07 2 YA42 13 01/02/07 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 OP20 Good Practice Recommendations It is recommended that the amount of any stock of medication held is carried forward to new MAR charts, to DS0000013495.V327697.R01.S.doc Version 5.2 Page 27 Hillcrest Avenue (40) 2 3 4 YA33 YA42 YA42 enable checking to be carried out and a clear audit trail to be followed. It is recommended that staffing is reviewed to ensure sufficient staff are available to meet the needs of service users. It is good practice to assess the risks involved in leaving a lone member of staff at the service with service users. It is good practice to maintain a record of any staff who choose not to wear the personal protective equipment provided in the home, and to assess any risks to the staff or service users arising from this choice. Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hillcrest Avenue (40) DS0000013495.V327697.R01.S.doc Version 5.2 Page 29 - 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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