Inspection on 25/05/05 for Hillcrest House

This inspection was carried out on 25th May 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hillcrest House 13/11/07

Hillcrest House 14/03/07

Hillcrest House 15/03/06

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 DT10 2LR Lead Inspector Sophie Barton Unannounced 25 May 2005 10:00 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 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 Stationary 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 D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Hillcrest House Address Church Hill, Stalbridge, Sturminster Newton, Dorset, DT10 2LR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01963 363861 01963 363496 Royal Mencap Society Ms Vanessa Leach CRH PC - Care Home Only 7 Category(ies) of LD Learning Disibility - 7 registration, with number of places Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 01 March 2005 Brief Description of the Service: Hillcrest House is situated close to the centre of Stalbridge in Dorset, and is registered to accommodate up to 7 adults who are learning disabled. The service is operated by Mencap Homes Foundation and service users have licence agreements with the property’s landlord Western Challenge Housing Association. The property is within easy walking distance of the village centre and is on the main bus route. The house, formerly two cottages, has been carefully extended and converted and does not stand out from it’s neighbours in any way. The interior is domestic in scale. There are 7 private bedrooms located on the 1st & 2nd floors, and service users share a lounge, dining room and kitchen. The home has just reduced the number of service users it accommodates from eight to seven, following alterations to the interior of the property, making two bedrooms into a bedroom and private sitting area for one of the service users. Service users at Hillcrest House live as independently as possible within the physical constraints of the house. The aims and philosophy of the service seek to promote the independence of service users by providing the degree of support necessary to achieve their chosen daily lifestyles, and also by providing opportunities for service users to develop skills that will support independence. The home is staffed 24 hours of the day. The staff group and manager are experienced and skilled in supporting people who have a learning disability, and who also have sensory disabilities and autistic spectrum disorder. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out between the hours of 10am and 5pm on the 25th May 2005. The manager, Vanessa Leach, was present throughout the day. The Inspector spoke to three service users individually, spoke to a group of service users informally over a cup of tea, observed staff and service user interaction, and spoke privately with one member of staff. Full discussions were also had with the manager. Comment cards were also sent to service users and relatives, requesting feedback on the care provided by the home. At the time of writing this report the Commission has received five replies from service users and two from relatives. Three care files of service users were examined in detail (which entailed looking at care and support plans, risk assessments, and daily case and medical records). Other records such as the fire log, complaints, health and safety, medication and staff records were also examined. Twenty-eight standards were assessed in full, and sixteen of the nineteen key standards were assessed. What the service does well: The Inspector considers that this home provides a very good service to the service users, and has exceeded the National Minimum Standards in a number of areas. The home is run in a flexible way, with service users’ interests and rights at the centre of all practice. The staffing hours provided are arranged around individual needs and wishes, and aim to ensure the service users are enabled to be as independent as possible (with accessing the community, learning independent living skills, undertaking domestic tasks, shopping, cooking). Service users are encouraged to pursue their own hobbies, and provided with information on a range of different options (adult education, holidays abroad, internet, musical shows, community centres). Service users are fully involved in decision making about staff selection, about prospective service users, and communal budgets for the home. Effective admissions procedures are followed to ensure that service users admitted to the home are suitable and that their needs can be met. Staff have been very proactive in supporting service users with friendships and relationships. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4 Service users benefit from effective admission procedures and practices, confirming that the home can competently meet the needs of the service user being admitted. Prospective service users are encouraged to make their own informed opinion about whether they want to move into the home. EVIDENCE: A service user last moved into Hillcrest over a year ago. This service user’s needs had been assessed through Care Management and the home had obtained a copy of the assessment. The Registered Manager and staff team also met with the service user to confirm that the assessment was accurate and that the service user’s needs could be met within the home. Through discussions with the Manager she demonstrated that she was clear about the range of needs the home can meet, and was able to clearly articulate that many referrals for a place in the home are turned down because the needs fall outside the home’s criteria. Of most importance is that the existing service users confirmed that they are then consulted about whether they believe the prospective service user is compatible and that their opinions are listened to and acted upon. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 9 The newest service user informed the Inspector that she visited and stayed over in the home prior to making a decision to move there, met with service users, staff and went out in the local area. The home went through a care plan with her about how they intended to meet her needs. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. The home’s care practices and care planning systems allow for full consultation and participation from service users. Service user’s right to make their own decisions is fully promoted and encouraged, ensuring that service users take control of their own lives and lead lives that they choose. The care planning practices do not provide adequate information for staff on how they are to support service users reaching their goals. EVIDENCE: Two Care and Support Plans were examined in detail by the Inspector. The areas covered were detailed and holistic, and written in a very person centred way. The service users confirmed that the care plans are developed in consultation with themselves and that they keep their own copy of the plan. The plans detail how service users are to be encouraged to be as independent as possible with staff providing guidance. The care plan clearly details any potential risks and is cross-referenced to risk assessments. The risk assessments highlight potential risks, and set out the clear decisionmaking and action to be taken to reduce the risks. Of most importance is that the assessments seen, balance the right for service users to take acceptable Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 11 risks and live an “ordinary” life by promoting independence. For instance the staff were currently providing training to one service user in using public transport and safely walking to college so that he can learn to be independent in this area. Very few limitations are placed on service users, and where they are these have followed a detailed risk assessment weighing up the risks and benefits. The Plans conclude with a list of goals for each service user. This area was limited in detail and there was no indication of how the home was to support the service user to reach these goals. Service users participate regularly in house meetings and the minutes seen showed that the staff support service users to make decisions about how the home is run (domestic tasks, activities money, communal furniture and budgets, holidays, staff recruitment and selection). Service users have been supported to set up their own bank accounts and enabled to be as independent with their money as possible, being supported to collect their own money rather than staff doing it for them. On the day of the inspection the Inspector saw service users cleaning, doing their own laundry, putting away their shopping, making their own snacks, and sitting down with staff adding up their receipts and money spent. To aid independence staff use a variety of tools, i.e. photos and symbols on shopping lists, and money stickers. Service users have also been helped to have some self-catering facilities in their bedrooms. Service users have been referred to the Advocacy Service for support as necessary. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, and 16. The staff ensure that service users are given every opportunity to lead ordinary and meaningful lives, with links with the community being commendable enriching service users’ social, educational and leisure opportunities. Service users’ rights are respected and the home’s practices promote independence and individual choice. EVIDENCE: On the day of the unannounced inspection the Inspector observed service users taking responsibility for answering the home’s phone, answering the door and deciding on whether people could visit the home or not. Service users decided independently when to have lunch, what and where to eat. Staff bring their own lunch and eat it with service users if they are invited to do so. Service users are responsible for entertaining guests. One service user informed the Inspector that his girlfriend comes to stay, and that other friends are also able to visit for drinks or dinner. Service user’s mail is not opened by Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 13 staff, but service users are aware that they can ask any staff for support with their mail if needed. Service users keep their own correspondence. One service user stated that when they find the main house too busy they are able to spend time in their room or in the gardens. One lounge is also a bit quieter than the other lounge. The daily recording evidenced that service users take part in a range of activities. Day activities are arranged for each individual, with some service users going to college, Day Centres, and adult education classes. The staff have referred service users to specialist agencies to support them with day activities (i.e. Community Support Team Social Services, and Stepping Stones). Over a period of a week one service user went shopping to Poole, did some gardening, had family for tea, went to the pub most evenings and did shopping and cooking in his leisure time. In the same period another service user went out for lunch three times, to Yeovil shopping twice, to Sherborne, and visited relations in Poole. One service user told the Inspector how she goes to college, adult literacy classes and sewing classes. Through staff supporting service users to use the website “Friends Reunited” and “Genes United” two service users have made recent contact with family, and the staff are supporting them emotionally with this and practically. At least two service users go to church regularly. Some of the service users had a recent holiday in Weymouth. Staff have also helped a service user arrange a trip to London, and Barcelona, and one service user has been helped to arrange a holiday in Cornwall with his girlfriend. Of the comment cards received from service users, four stated that the home provides suitable activities and two stated that the home ‘sometimes’ does. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The health needs of service users are well met with evidence of good multi disciplinary working taking place. The home’s practice of promoting service user’s independence in managing their own health is commendable, ensuring service users take control of their lives. Medication systems continue to need to be improved slightly to ensure safe recording systems are practices. EVIDENCE: Daily recording showed that service users are encouraged to be as independent as possible with their health needs. Examples of diary entries were “X to be reminded to phone doctors for test results today”, “X to make dentist appointment. She would like staff support to attend”. Each service user has been assessed in relation to administering their own medication, and at least 2 service users self-administer. The medication records were examined and these were accurate and met regulations, although two staff were not signing the hand written changes to the medication administration records. The staff have been liaising closely with other health professionals (Occupational Therapist, Community Nurse) in relation to one service user’s needs, to ensure she receives appropriate support. The care files seen Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 15 evidenced that service users have had regular appointments at the dentist and optician. The notes made by staff of service users’ visits to medical professionals are detailed and informative, ensuring that health needs are monitored effectively. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a good complaints system, and service users’ right to raise concern is promoted and valued by the organisation. In practice the management need to improve its systems in adult protection, in particular referring to other agencies and following good practice recommendations so that service users are better protected from potential harm. EVIDENCE: In discussion with service users they confirmed that the staff listen to them and that they can approach staff with any concerns. They also stated that they have a pre-written stamped postcard which if they post will go to the Mencap Office and someone will come and see them to discuss their concerns / worries. The house meeting minutes also evidenced that this is a forum where service users can also raise concerns and complaints. The care and support plans are reviewed with service users regularly and these also have a section informing service users of their rights to complain, and who they can complain to (which includes detail of the Commission). Six out of six replies from the service user comment cards confirmed that if they were unhappy with their care they know who to speak to. The two replies from relatives also confirmed that they are aware of the complaints process. The list of staff training provided to the Inspector evidenced that staff have undertaken in house training in Adult Protection, and following discussion with the Manager she confirmed that she is aware of the No Secret procedures. The Inspector noted that a service user raised concerns about a member of staff’s conduct. This was not referred to the appropriate agencies and there Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 17 was no evidence that consideration was given to a referral to the Protection Of Vulnerable Adults register. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 28, and 30. Some improvement is needed to the home’s fixtures as at present service users are not provided with a well-maintained environment. Service users are however living in a homely domesticated environment which is kept clean and hygienic. EVIDENCE: On the day of the unannounced inspection the home was found to be clean, tidy and free from offensive smells. There are clear systems in place for using colour coded mops etc for different areas in the house to prevent any contamination. The laundry area is readily cleanable and is away from the kitchen area. There is ample communal space with comfortable seating for all service users and guests and the garden is welcoming. There is no designated private area for guests, but the office or one of the lounges can be used for private meetings. The kitchen is domestic in size. One service user stated that he considers his sink to be broken and in need of renewal. One service user has had a new sink but is awaiting a new carpet. Holes in a service users ceiling have yet to be repaired. New flooring in the bathrooms have however been provided and the housing association has been asked to replace the kitchen units. The home has now included furniture replacement and decoration in the homes development plan. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) and 36. 32, 33, 34, 35 The home provides flexible and sufficient staffing hours, providing a personcentred service which supports the service users individual assessed needs at all times. There is a well-trained and competent staff team, with the staff having the collective skills and qualities to meet the needs of service users, again ensuring a good quality and effective service. The staff recruitment records were insufficiently maintained, potentially placing service users at risk. Service users benefit from a well supported and supervised staff team. EVIDENCE: The Inspector examined one weeks rota which was worked in May 2005. This evidenced that 222 staff hours were provided. The Department of Health recommends that the home provides at least 200, therefore the home sufficiently meets these recommendations. The Manager stated that the rota is flexible, and the staff hours are provided in consultation with service users, and when they would like and need the support. Following this consultation and a review, the main staffing input is during the day, with only one member of staff on in the evening. Staff and service users stated that this was appropriate. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 20 Over 50 of the staff team have at least a NVQ 2 qualification in care. All new staff have undertaken Mencap’s induction and foundation training, which meets TOPSS and the Learning Disability Award Framework standards and timescales, and includes anti-oppressive practice. There is a designated training budget and staff appraisals address training and development needs. Discussions with staff members evidenced that they have a good understanding of service users specialist needs (autism, visual impairment, communication difficulties) and that they link with other professionals in order to increase their own knowledge and skill base. For instance one member of staff confirmed how she had received some input from the Blind Club, had attended an Autism Conference, and also received input from a Community Nurse re: supporting sexuality issues for service users who have a learning disability. Two service users confirmed that staff were “lovely”, “all nice”, and all of the comment card replies from service users stated that they feel well cared for and that staff treat them well. There are two male volunteers that provide some support to service users, all other staff are female. Two new staff have recently been appointed. The Inspector noted that there were shortfalls in the recruitment processes. For instance a reference was not obtained from a most recent employer, and only one written reference received. The manager confirmed that two references had been obtained but that the copy had been sent to Head Office and not kept in the home. Criminal Record Bureau and POVA checks had been made appropriately, and a record kept of previous employment and experience and confirmation of identity sought. Clarification of gaps in employment had not been recorded, but only known verbally. Staff files evidenced that staff had received regular supervision. Supervision sessions are recorded well, and these records showed that a number of sufficient areas are discussed. The manager confirmed that all staff have had an annual performance review, and staff files also showed evidence of this. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, and 42 The new manager is competent, has a clear vision for the home, with the service users benefiting from a positive and inclusive atmosphere. Record keeping practices and procedures are effective, and promote service users’ rights to independence and confidentiality. Health and safety within the home is maintained to a satisfactory standard, with service users benefiting from a safe environment. EVIDENCE: The Commission has recently interviewed the new manager and registered her as ‘fit’ to run the care home. Ms Leach was previously the Deputy Manager and has a good understanding of the service users needs. The service users and staff spoken with confirmed that the management approach is open and inclusive. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 22 The records kept on service user’s needs and care are well maintained and accurate. Old information is archived appropriately. Service users keep the majority of their own records (care plan, assessments, reviews, financial correspondence) and have been provided with appropriate storage for this. The Inspector examined the fire, accident and incident and health and safety logs. These were all kept up to date with regular checks taken of water temperatures, and fire safety equipment. It is advised that a fire drill is carried out in the late evening / early morning so that staff and service users are trained in evacuating at night. The Manager confirmed that all staff have undertaken the statutory training in emergency first aid, manual handling, and food hygiene, and the staff training record also evidenced this. The Inspector was also shown safe working practice risk assessments, and observed staff appropriately assessing the ability of a service user in using garden equipment. Hillcrest House D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 4 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 4 4 x Standard No 31 32 33 34 35 36 Score x 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hillcrest House Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 2 x D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23 Requirement The kitchen cupboards and flooring must be of sound construction and be resonable decorated. Previous timescale of March 2005 not met. Timescale for action 31.08.05 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 6 Good Practice Recommendations There should be a more detailed record made of how the home is to support the service user in meeting their goals and aspirations as highlighted in their individual care plans. A second person should countersign any handwritten entry/changes to the medciation administration record. The record made of any concerns or complaints about the conduct of a member of staff should evidence that a referral to the POVA register has been considered, and that all necessary agencies have been notified. The system for obtaining all recruitment records and checks should be more robust to ensure that all necessary records are maintained in the home. At least one of the annual fire drills / evacuations should take place in the late evening / early morning. D55 S26817 Hillcrest V216292 250505 Stage 4.doc Version 1.20 Page 25 2. 3. 20 23 4. 5. 34 42 Hillcrest House Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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. 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