Inspection on 13/11/07 for Hillcrest House

This inspection was carried out on 13th November 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 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

Hillcrest House 14/03/07

Hillcrest House 15/03/06

Hillcrest House 25/05/05

Hillcrest House 04/03/05

Hillcrest House 02/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hillcrest House Church Hill Stalbridge Sturminster Newton Dorset DT10 2LR Lead Inspector David Smith Key Unannounced Inspection 13th and 15th November 2007 10:00 Hillcrest House DS0000026817.V345959.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 House DS0000026817.V345959.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 House DS0000026817.V345959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest House Address Church Hill Stalbridge Sturminster Newton Dorset DT10 2LR 01963 363861 01963 363496 H5032@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mrs Vanessa Elaine Leach Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2007 Brief Description of the Service: Hillcrest House, formerly two cottages, has been carefully extended and converted to accommodate up to seven adults with learning disabilities. Mencap operates the service and service users have licence agreements with the propertys landlord Western Challenge Housing Association. The home provides single room accommodation and all service users’ rooms have been decorated and personalised for each individual. Hillcrest House is within easy walking distance of the village and all the local amenities including shops, library, pubs and restaurants. The home is on a main bus route for accessing the larger towns of Gillingham and Yeovil where leisure centres, theatres and cinemas are available. The home supports people to access local transport such as taxis and buses. The aims and philosophy of the service seek to promote the independence of service users by providing the support necessary to achieve their chosen lifestyles and by providing opportunities for service users to develop and learn new skills that enhance their personal independence and confidence. The home is staffed 24 hours of the day. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home as part of a Key Inspection of this service. The review of evidence and pre-inspection planning involved reviewing the report of the last Key Inspection carried out in March 2007 and the service history, which details all contact with the home including notifications of significant events which they have reported to us. We (the CSCI) provided the home with their Annual Quality Assurance Assessment (known as an AQAA) and a range of survey forms for students, their relatives, carers, advocates and health professionals, prior to my visit. The AQAA was completed in detail and returned to us, however at the time of writing this report no surveys have been received. I gathered additional information during my visit through informal discussions with a number of service users, the Acting Deputy Manager and care staff. Interaction and communication between staff and service users was also observed during my visit. Care plans and associated records were examined together with accident and incident reports, staffing records, Risk Assessments, complaints procedures and health and safety records. I was also provided with a tour of all communal areas of the home, the garden area and invited by some service users to view their own rooms. The inspection process was concluded with a discussion with the Registered Manager by telephone on 15/11/07. What the service does well: Each service user I spoke with said they were happy living at the home and are well supported by staff. One person said “this is the best home I have lived in”. The service remains focused on the people who live in the home and their views are actively sought. This ensures each service user is supported to determine their own service. The home is well run. The ethos of the service is clear, well communicated and remains focused on positive outcomes for each service user. The staff team are friendly, professional, and very confident and were observed to engage well with service users and others who visit the home. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 6 The home actively seeks support from other professionals to help improve the quality of the service it provides to each person. There remains good organisational support for the home, with effective monitoring and quality assurance systems in place. This helps to ensure an accountable service for each person involved with the home. The health and safety procedures remain clear and safe working practices are being maintained. This ensures a safe living and working environment. 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. Hillcrest House DS0000026817.V345959.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 Hillcrest House DS0000026817.V345959.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have access to detailed information in order to make informed choices about where to live. Each service user knows the home will meet their needs and aspirations, that their introduction to the home will be tailored to them and that the terms and conditions will be clearly explained. EVIDENCE: The home has a comprehensive Statement of Purpose, which has been recently updated. Each service user also has their own guide to the service, which the home has tried to adapt into an accessible format in accordance with the person centred philosophy of the home. Both documents detail the facilities, services and ethos of the home. Service users are only offered a place in the home if the Manager is confident that the home can meet their needs and aspirations and anyone new will complement the existing group of people who live in the home. The home does not accept emergency admissions. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 9 One service user has moved into the home since the last inspection. This individual’s care records contained an initial support plan, assessment information and additional useful information from health professionals and the individual’s family. All of this information had been used to ensure the support needs for this person could be met by the home. The home ensures that each person’s transition into the home is managed in a person centred way. This process is determined through discussion with the service user, their family, funding authority and the home’s staff team. The staff I spoke with told me the newest service user did visit the home prior to moving in and stayed overnight. They are using the first month of their stay as an extended assessment period, to enable the staff to build their relationship with them and to further develop their support plan and risk assessments. Each service user is provided with Mencaps’ ‘statement of terms and conditions’, which describes each person’s service and their rights and responsibilities whilst living in the home. Each service user and the home’s manager sign this document, which is good practice. The housing association, Western Challenge, also provide each individual with their own ‘licence Agreement’ describing the rights and responsibilities as a Tenant. Hillcrest House DS0000026817.V345959.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that the service provided to each individual takes into account their personal preferences, supported by both written information in care plans and risk assessments which are subject to ongoing review. Service users are consulted on, and participate in, all aspects of life in the home. EVIDENCE: Three service user support plans were examined in detail and these provided comprehensive information on the areas of support each person required. Each plan had been written in an individual way and covered key areas of support people required, such as domestic tasks, health care, communication and work towards their goals. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 11 The home continues to adapt information into a format which each service user can access. For example, ‘Person Centred Plans’ are being developed and I was shown one which has been completed. This plan is written in plain English and contains photographs in each section to support the text. The plan is divided in to heading such as ‘things I like to do’, ‘my room’ and ‘my friends’. Each person keeps their own support plan in their bedroom and staff ask permission before entering any information in them. Other care records are stored securely in the home’s office when they are not being used. Regular formal review meetings are held, which include service users, their families, staff members, Social Workers and their Co-ordinator (one member of the staff team who works closely with one service user). Each service user is supported to prepare for, plan and attend their review meeting. These meetings are clearly recorded and the outcomes used to update individual support plans. In addition to these formal reviews, each support plan is reviewed in-house approximately every eight weeks. Each Co-ordinator will go through the support plan with the particular service user and discuss areas of support and progress towards any goals. The Co-ordinator then produces a report, which is discussed by the staff team, so that each member of the team can have input into this review. This is good practice. Interactions between staff and service users were observed at various times during my visit. These demonstrated the staff had a good knowledge of the support needs of service users and how to communicate effectively. Discussion between the deputy manager, staff members and myself also confirmed this. Each service user I spoke with said they decided what they would like to do and that staff members always listened to them and acted on what they said. It is evident that each person has different ways of making choices, such as one person using a pictorial daily planner, and these are explained within each support plan. There are regular service user house meetings, the last of which was held on 25/10/07. The records of these meetings show that attendance is good, with a wide variety of topics discussed. The views of service users are taken seriously and acted upon wherever possible. Care and support is provided within a risk assessment framework. Healthy risk taking continues to be encouraged and supported, as evidenced within the wide range of opportunities and activities service users are able to enjoy. Each of the person centred risk assessments I examined were detailed and have been regularly reviewed. Hillcrest House DS0000026817.V345959.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has opportunities and appropriate support to access leisure and educational facilities both locally and in the wider community including holidays, day trips and visits to family and friends. Service users rights and responsibilities are recognised in their daily lives. A healthy and balanced diet for each individual is promoted. EVIDENCE: The home has a person centred approach in supporting each service user to develop. The records maintained within the home enable each persons progress towards their goals to be assessed and the support provided adapted accordingly. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 13 Each service user has their own timetable of activities. These show regular access to local community facilities such as Colleges, Day Services, shops, cinema, bowling, swimming pools and the library. Each person is encouraged to be as independent as possible, for example enabling them to do their own shopping, cooking and housework. The service users I spoke with said they did a variety of things. They told me they are able to choose what they wish to do and were happy with helping with the day-to-day chores within the home. One person told me “I really like living here” and another said they had lived in a few different homes but they “liked living here best”. Staff spoken with explained that they work hard to ensure each person is provided with opportunities to do things which they enjoy. Each person is seen as an individual and is respected as such. On the day of my visit, some service users were attending college or day services, others went out with staff shopping and one person was supported to attend a review meeting. Each person is supported to maintain close contact with their families and friends, with some individuals often staying with their families at weekends or during holiday periods. The home continues to operate an ‘open house’ policy and there are no restrictions on visiting. Service users can see their friends and relatives in the privacy of their own rooms or in one of the two communal lounges. Each individual is supported to organise and attend a holiday. Two service users told me of their last holiday to Swanage, where they stayed in a caravan. Each service user’s right to privacy is respected. Each person is offered a key to their bedroom, based on their ability to use one safely. The individuals I spoke with said they could lock their bedroom door if they chose to do so and they also told me staff always knocked on their door and waited for a response before entering their room. Each individual chooses their own menu each week. They will then shop for and cook their own meals with the appropriate level of support from the staff team. This arrangement was agreed by the people who live in the home and still appears to be very popular with them. The records of the meals each person eats show a wide range of food, which provide both a healthy and balanced diet. Hillcrest House DS0000026817.V345959.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in their preferred manner and their personal and healthcare support needs are well met. The policy relating to administration of medication ensures service users’ welfare and safety. EVIDENCE: The care documentation in place for service users provided clear guidance for staff on how they should support those living at the home with their personal care. The care plans examined showed that service users were registered with a local GP, dentist, optician and chiropodist. Other specialist services are accessed when an identified need arises. Care records show the home is supported by Psychologists, Speech and Language Therapists, Occupational Therapists and other relevant health care Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 15 professionals. Contact with each professional is recorded and forms part of each persons care plan. The home wishes to develop individual ‘Health Action Plans’ for each person who lives in the home and to make these as user friendly as possible. This would certainly enhance each person’s support plan and therefore the progress towards their development will be reviewed at the next inspection. There is a core of experienced staff who have a good knowledge of service users’ healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It remains evident that the management and staff spoken with are sensitive to the personal, healthcare and emotional needs of those living in the home. The home uses the Boots Monitored Dosage System of medicine administration. This system is well managed. Medication is stored securely in a locked cabinet in the office on the ground floor. The details of any medication regularly taken by service users is noted in their support plan, together with details of any possible side effects. Each service user medication record was correctly completed, signed by staff with no gaps evident in the records. Each member of staff is provided with training relating to medication administration. Hillcrest House DS0000026817.V345959.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 and 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 supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear policies and procedures are in place in order to protect service users from the likelihood of abuse, neglect and self-harm. EVIDENCE: The home has a formal Complaints Policy, an Adult Protection Policy and a Whistle Blowing Policy, which staff can use in confidence to raise any issue or concern they have regarding the service. The information provided on the home’s AQAA confirmed that there have been no complaints during the last twelve months. We have not received any concerns or complaints direct regarding Hillcrest House. Each person who lives in the home has an accessible complaints procedure, which staff go through with them every two months to ensure each service user understands the policy and knows how to make a complaint. Each service user I spoke with told me they are happy living in this home, felt safe living here and knew who to speak to if they were to become unhappy. They are also able to raise issues during regular house meetings. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 17 There is very little ‘challenging behaviour’ displayed by people who live in the home and support plans contain guidelines and risk assessments which explain how to support individuals if they become distressed or present behaviours which may be perceived as challenging the service provided. Each individual is supported to manage their own finances, with all financial records being checked by the home’s Manager and the Area Service Manager. Each support plan contains a list of each service user’s personal items (known as an ‘inventory’), which is kept up to date. Staff are provided with appropriate training, such as Protection of Vulnerable Adults and are subject to enhanced Criminal Record Bureau disclosures. The home maintains records of accidents and incidents. It also notifies us of any significant event which occurs within the home. Hillcrest House DS0000026817.V345959.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, 25, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hillcrest House provides a homely, comfortable and safe environment for service users to live in. EVIDENCE: Hillcrest House, formerly two cottages, has been carefully extended and converted and blends in well with the local community. It faces the main road leading through the village of Stallbridge and is within easy walking distance of the village and all the local amenities such as shops, library, pubs and restaurants. The home is on a main bus route, providing access to the larger towns of Gillingham and Yeovil. It has a large rear garden with far reaching views of the surrounding countryside. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 19 There are seven single bedrooms, some on the ground floor and others on the first floor. None of the bedrooms offer en-suite accommodation, however there are sufficient communal bathrooms, showers and toilets which service users share. There are two communal lounges on the ground floor, a dining area, kitchen, utility room, toilet and shower room and office space which is also used as the staff sleep-in room. One of the people who lives in the home kindly agreed to show me around their home. I did view all of the communal areas, along with three of the service user’s rooms. All areas of the home were clean and tidy and furnishings and fittings are of a good quality. The house is tastefully decorated and there are many photographs of service users displayed, which help to personalise the home. Each service user is expected to help keep their home clean and tidy, with each person’s responsibilities clearly reflected in their care plan. One individual told me it was their day to clean the kitchen area as there is a weekly rota for this. Each person’s bedroom has been decorated and furnished to make it personal to them. There were lots or personal effects, pictures and photographs which added to this. One individual told me they wished to change the colour scheme in their room and staff were helping them with these plans. There have been some improvements to the home since the last inspection. New carpets have been fitted in all of the communal areas, the patio in the garden has been repaired and vegetable garden has been developed. These are all positive developments and have enhanced the homely feel of Hillcrest House. However, the bathroom on the first floor would benefit from updating, the access to the ground floor shower room is not practical as it is through a small corridor, which leads to the back door and utility room and this area should be re-designed and redecorated. The home is maintained by Western Challenge Housing Association and any faults or repairs are reported directly to them and recorded within the home’s own maintenance log. Hillcrest House DS0000026817.V345959.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): 31, 32, 33, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clarity of staff roles and responsibilities along with staff training and supervision helps to provide a consistent approach to the support of staff and service users. EVIDENCE: There remains a core of well-established staff with varying abilities who are skilled and experienced to meet the needs of those living in the home. Staff members I spoke with said that the staff team continues to be very open, honest and supportive. Each commented on how nice it is to work in the home. They felt well supported by the management team and were able to discuss issues in an open and honest way. Staff were observed interacting well with service users and those spoken with demonstrated a good understanding of the support needs of each person who lives in the home. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 21 The service users I spoke with said they like the staff and felt they are supported well by them to live the life they wanted. They said they are always listened to and the staff do act on what they say. Staff spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. The staff team meets regularly. Clear records are kept of each meeting and these show that a wide variety of topics are discussed and that attendance is generally very good. There is a strong commitment by the home to provide staff with a variety of training opportunities, which are provided either by the organisation or external training providers. The records I examined showed that staff have had training in First Aid, Manual Handling, Adult Protection, Food Hygiene, Health and Safety, Medication Administration and Fire Safety. Regular formal supervision is provided for all staff. Although I did not examine the supervision files, the home does maintain a list of supervision dates which shows that staff are provided with supervision sessions each month. Staff are also appraised on an annual basis, described by the home as a ‘Performance Review’. Staff I spoke with find supervision and the appraisal process helpful and supportive. The quality of staff support in the home is commended. Staff are supported to gain a National Vocational Qualification, known as an ‘NVQ’. At present, seven staff either hold or are working towards NVQ Level 2 or 3, and the Deputy Manager is working towards NVQ Level 4. This means the home has approximately 60 of its staff team who either hold or are working towards this qualification. Hillcrest House DS0000026817.V345959.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, 38, 39, 40, 41, 42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and service users benefit from the ethos, leadership and management approach of the home. Service users views are central to the monitoring and review of the service provided by the home. Each person’s rights and best interests are promoted by the home’s record keeping and the organisations’ policies and procedures. The health, safety and welfare of people living in the home is promoted and protected. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager, Mrs.Leach, has completed both NVQ Level 4 in Care and the Registered Managers Award. She also undertakes periodic training to maintain her knowledge and update her skills and level of competence. Mrs. Leach is currently supporting another of the organisations’ services, on a short-term basis. Adequate arrangements have been made to manage Hillcrest House in her absence with the Deputy Manager and an additional ‘Acting’ Deputy assuming responsibility. The management approach remains open and positive, with a clear sense of direction and leadership. The ethos of the service is person centred with the views of service users actively being sought as part of this process through the ‘Service Users’ Meetings’, the review processes used within the home and the use of surveys as part of the home’s Quality Review process, which was last carried out in June 2007. Staff spoken with said their views are always listened to, and that they are well supported by the manager and other members of the management team. There are efficient management systems and structures in place to ensure the home runs effectively. The quality of record keeping in the home is good, with all records required during my visit easy to access and stored securely when not in use. Mencap have comprehensive policies and procedures to support the home, which are designed to ensure it complies with the law and remains aware of good practice guidelines. Full details of each policy were provided by the Manager as part of the AQAA she completed for us as part of this Key Inspection process. The registered provider’s representative makes regular visits to the home, and produces a comprehensive report of their findings. The views of both service users and members of staff are always included in these reports. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included fire drills, fire alarm system checks, fire fighting equipment checks, water temperature checks, details of hazardous products used within the home, the safety of gas appliances and portable electrical appliance testing. All of these records were in order and checks were up to date. There are a number of general Risk Assessments in place to ensure the welfare of service users and staff. These have all been recently reviewed. Hillcrest House DS0000026817.V345959.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 3 2 3 3 3 4 3 5 3 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 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 3 36 4 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 3 Hillcrest House DS0000026817.V345959.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. 2. 3. 4. Refer to Standard YA6 YA18 YA27 YA27 Good Practice Recommendations The home should consider developing an accessible ‘Person Centred Plan’ for each person who lives in the home. The home should consider developing ‘Health Action Plans’ for each person who lives in the home. It is recommended that the back porch be refurbished and the access to the rear shower room improved. The home should consider upgrading the bathroom on the first floor. Hillcrest House DS0000026817.V345959.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 House DS0000026817.V345959.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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