Inspection on 17/02/06 for Hilldales

This inspection was carried out on 17th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilldales 07/09/06

Similar services:

Clouds House

Closereach

Westcliffe House

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Hilldales Hilldales 11 - 13 Oxford Park Ilfracombe Devon EX34 9JS Lead Inspector Dee McEvoy Announced Inspection 17th February 2006 10:00 Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 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 Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 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 Older People and 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. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hilldales Address Hilldales 11 - 13 Oxford Park Ilfracombe Devon EX34 9JS 01271 865893 01271 879357 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) Dr Htay Kywe Mrs Thida Oo Ms Lesley Jean Mason Care Home 56 Category(ies) of Past or present alcohol dependence (56), Past or registration, with number present alcohol dependence over 65 years of of places age (56), Mental disorder, excluding learning disability or dementia (56), Mental Disorder, excluding learning disability or dementia - over 65 years of age (56) Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The adjoining corridor to be completed by December 2005. Date of last inspection 10 August 2005 Brief Description of the Service: Hilldales is a care home providing services for 56 men and women experiencing past or present alcohol dependence and/or mental health problems. The home provides accommodation and support for residents within a mixed age category. Since the last inspection a new provider has been registered with CSCI. The home consists of two large detached terrace houses, which have been connected by an adjoining corridor. Previously registered as two separate homes, Hilldales and Northview, the home is now registered as one under the name of Hilldales. Hilldales is an older style property, which is situated within easy access of Ilfracombe community resources. Accommodation is single occupancy and there are several communal areas around the home, including a pool and library area. The home has a mini bus and offers transport to residents for hospital appointments and other trips. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was the second inspection of the current year and took the inspector just over five hours to complete. National Minimum Standards, which have been met at the previous inspection on 10 August 2005, were not inspected on this occasion. This inspection focussed on key National Minimum Standards, which had not been inspected at the previous inspection or those, which were the subject of previous requirements and/or recommendations. Several residents were seen or met around the home during the inspection and six were spoken with in depth about life at the home. Comment cards were received from 18 residents in respect of the service. The inspector also spoke with seven members of staff, the newly registered provider and manager. CSCI received comment cards from two relatives and four comment cards from health and social care professionals. The inspector toured the premises and inspected a number of records including residents’ care plans, and records relating to training, quality assurance and health and safety. The registered manager had completed a pre inspection questionnaire. On the day of the inspection a central heating boiler in part of the home was ‘out of commission’ due to safety concerns. The provider had obtained portable heaters for communal areas in that part of the home. Residents spoken to were happy with the temporary arrangements and none complained that they were cold or uncomfortable. Action had been taken by the provider to ensure that a new system was installed and a date had been confirmed to start the work as soon as possible. What the service does well: Residents spoken with and those responding with comment cards liked living at the home and felt safe and well cared for, comments included, “I couldn’t wish for a better place to live” and “The staff are wonderful. I love it here”. All residents spoken with were positive about the staff and found them approachable and caring, comments included, “The staff are easy to talk to”, “Staff always have time for a chat” and “They are all very kind people.” Health needs are particularly well monitored and met by the home. Relatives and health and social care professionals responding were happy with the standard of overall care, one relative wrote, “We can’t fault the care”, another, “They all work very hard. My son is well looked after.” A health professional described the care given as “Excellent”. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 6 Residents were generally positive about the quality and variety of food provided. Residents are involved in the development of menus to ensure individual preferences are taken into account. The home is well managed. The new provider and manager have established a good working relationship to ensure a smooth transition. Residents, staff relatives and professionals were happy with the management of the home, which is open and positive. 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. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 The admissions procedure ensures that there is a proper assessment prior to people moving into the home. EVIDENCE: Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 9 The content of initial assessments had improved considerable since the last inspection. Comprehensive assessments are undertaken by referring professionals and the home completes a full assessment prior to admission to ensure that individual needs can be met. One recently admitted resident told the inspector, “Staff are friendly and sympathic. I feel settled and my needs are met.” Health and social care professionals recognised Hilldales as a ‘useful resource’ meeting the needs of chronic alcoholics and others with associated problems, such as poor physical and mental health and homelessness. The home operates a key worker system, which provides continuity of care and staff spoken with were aware of the individual needs and preferences of the residents’. Residents spoken with could identify their key worker, one told the inspector, “Staff have time to talk and listen.” Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 & 9 The staff have a good understanding of the health and personal care needs of residents, which are clearly documented in care plans and risk assessments. Opportunities for residents to make personal decisions are given whenever possible and residents are encouraged to participate in various aspects of life at the home. EVIDENCE: Residents’ care is very well planned and residents spoken with confirmed they are involved in developing and reviewing their care plans. Care plans seen provided staff with a good description of residents’ needs and how they should be met, including clear goals and desired outcomes. For example, health needs are clearly documented and the relevant health professionals are involved. One health professional described palliative care at the home as “Excellent”. Four Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 11 visiting professionals were happy with the overall care provided at the home. Detailed personal statements provide information about residents’ interests, preferences and family relationships ensuring that emotional, social and psychological needs are understood and met. Residents spoken with and those responding with comment cards felt well cared for. Residents are encouraged to participate in the day-to-day running of the home. Since the last inspection regular residents’ meetings have been established to ensure that residents have an opportunity to influence key decisions at the home, for example the development of the activities programme and meal planning. Residents spoken with felt their opinion was listened to and staff would act on their ideas. One resident gave the example of the activities now provided at the home. Five residents responding with comment cards said they would be like to be more involved in decision making within the home. The manager is to continue to explore ways of extending all residents opportunities for consultation and to contribute to the development of the services provided. Risk assessments seen in resident’s files had been completed and provided comprehensive information, describing what was to be done to manage/reduce risks identified. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14 & 17 Residents benefit from organised activities, which provide stimulation, variety and interest, and opportunities to develop independent living skills. Residents generally enjoy meals, which are nutritious and appealing, taking into account, the likes and dislikes of individuals. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 13 EVIDENCE: A majority of residents benefit from or enjoy the lifestyle of the home. Residents spoken with and the majority of those responding with comment cards were happy living at the home and all felt that staff respected them and their privacy. Residents have a good deal of independence and freedom around the home and good access to the local community facilities. Residents spoken with recognised the support available to promote independence and choice, for example one resident is currently working on a small patio garden and tools and materials have been made available to pursue this; another is assisted to keep their room clean and tidy, and another is supported to undertake chosen chores around the home. One resident said, “I like to be busy and help out”. It appeared that the allocated chores made some residents feel ‘useful’. Since the last inspection three residents have been helped to enrol on college courses, although none are currently continuing. Since the last inspection a variety of activities have been developed with a great deal of input from the residents. Residents spoken with and the majority of those responding with comment cards felt that the home provided suitable activities. One resident told the inspector, “There is something going on every day.” A popular event is the ‘pampering’ day, which provides the residents with a weekly hairdressing service, shaving, pedicure and manicures, and some hand massage. Residents described the pampering as “great” and “really enjoyable”. One male resident said, “I didn’t think I would enjoy it but it is great!” Other in-house activities include film and music evenings, live music is provided by one or two of the residents, pool and dart competitions and quiz nights. A resident told the inspector, “Some activities are so popular, like film and music night, that you can’t get a seat!” Residents will be involved in organising a summer activities programme, which will include outings to local beaches and places of interest. Residents spoken with and the majority of those responding with comment cards were happy with the food provided. Menus available showed that three good meals are provided daily and residents also have free access to hot drinks and snacks, including homemade cakes. Some residents have drinkmaking facilities in their own rooms. Three residents told the inspector that alternatives were available, one said, “The kitchen staff are very good and fresh fruit and salads are always available.” Other residents described the food as “lovely” and “very good”. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 The systems for the safekeeping and administration of medications are generally good, however some recording practices compromise safety. EVIDENCE: Medication is securely stored at the home and staff spoken with administering medication had received training in the safe management of medicines from the local pharmacist. A recent community pharmacist audit reported satisfactory standards at the home. Residents are supported to manage their own medication where appropriate and risk assessments have been completed for this. Where medication is hand written on Medication Administration Record (MAR) charts two signatures have been obtained to ensure accuracy, with the exception of one chart. The District Nursing Team responding with a comment cards were satisfied with the overall standard of care and had no concerns regarding residents’ health care. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 15 A comment card was received from a Macmillan Nurse who praised the staff for the care and support provided to residents with cancer and terminal illness, the nurse wrote, “The staff cope excellently, with skilled care and compassion”. Staff were credited for enabling residents to die “in their home” and not having to be admitted to hospital. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The safeguards to ensure residents’ personal monies are correctly managed are not entirely robust. EVIDENCE: Residents are assisted to manage their finances where necessary. Many residents have been assisted to set up bank accounts. The inspector looked at records and storage of residents’ monies at the home. Evidence of good practice included individually kept accounts, cash balances and receipts for various items purchased. Individual computer records are held for each resident with up to date information about monies held by the home. All monies held by the home on behalf of residents are securely kept. However, it was noted that individual personal allowances were not kept separately; money is ‘pooled’, which could lead to inaccuracies. This was discussed with the manager, who must ensure that residents’ monies are kept separately. Following the inspection the manager contacted CSCI to confirm that all personal monies were now held separately. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 These standards were not inspected on this occasion; relevant key standards were met at the previous inspection. EVIDENCE: Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 35 Residents are supported by caring, committed and generally well trained staff, however there is a risk that the complex needs of residents will not be consistently met if some staff have not had training related to the type of care the home offers. EVIDENCE: Training records showed that regular updates in mandatory training are provided; staff are also encouraged and supported to achieve NVQ 2 and above. The pre-inspection questionnaire showed that 50 of staff had achieved NVQ 2 or above and their skills had been developed to a nationally recognised standard. Staff spoken with felt well supported and had a good knowledge of residents’ needs. It was identified that some staff would welcome further specific training on issues relating to alcohol use and mental health. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 19 NVQ training, which reflects the Drug and Alcohol National Occupational Standards {DANOS}, would be beneficial for staff dealing with residents with complex needs. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39 & 42 Residents benefit from the ethos and management of the home, which is open and inclusive. Residents are involved in the running of the home, with evidence that their views are sought and acted on. However, formal review of the quality of care is less well addressed. One health and safety issue needs to be addressed to ensure the residents and staff are protected from hazards. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 21 EVIDENCE: The newly registered provider spends as much time as possible at the home working with the manager to ensure a smooth transition and the continued high standard of care. Residents and staff were positive about the changes and felt that the new owner was approachable and listened to their opinions and ideas. The manager was praised by several residents and staff members for her openness and friendly approach, one resident said, “She is always there and prepared to listen.” Regular staff meetings are held and staff are encouraged to express opinions about the care of residents and the running of the home. The home operates a variety of quality assurance systems, including a robust complaints and recruitment procedure and staff training and supervision. Residents and staff said that regular meetings were held and minutes were seen. Residents complete questionnaires twice a year exploring their views on the service provided and other relevant services such as social services and care management. The home also conducts general surveys about menus and activities. Although results are collated and changes are implemented where needed, for example with the menus or activities, no formal report on the quality of the service is produced and made available to residents and other interested parties such as CSCI. The manager was encouraged to ensure that future quality assurance included health and social care professionals. All professionals responding with comment cards were happy with the care provided at the home and this should be reflected. A range of servicing and maintenance records were seen at this inspection, including gas and electrical certificates; all were satisfactory with the exception of one. A central heating boiler in part of the building was out of service for safety reasons. The provider was taking steps to address this. Risk assessments are completed and reviewed to ensure that safe working practices are maintained for example in the kitchen or when using the mini bus. Fire safety is generally well managed and a visit from Devon Fire and Rescue Service found satisfactory standards. However, it was noted that emergency lighting had not been checked for some months. Once identified, a senior member of staff immediately addressed this. Staff receive regular fire safety training and the inspector discussed whether residents would benefit from similar training. All windows have been fitted with restrictors to prevent harm to residents. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 22 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 Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT Standard No Score 37 X 38 3 39 2 40 X 41 X 42 2 43 X 3 X 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hilldales Score X X 2 3 DS0000064816.V283055.R01.S.doc Version 5.1 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement The registered person shall supply a report to the Commission in respect of any review of the quality of care provided at the care home, and also make a copy available to residents. Timescale for action 17/07/06 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. Refer to Standard YA20 YA23 YA35 Good Practice Recommendations It is recommended that 2 signatures are used when transcribing medicines on to MAR sheets. It is recommended that all personal monies held by the home on behalf of the residents be kep seperately. Staff training is recommended on the issues of mental health and consideration should be given to accessing NVQ training which reflects the Drug and Alcohol National Occupational Standards {DANOS}. It is recommended that emergency lighting be checked DS0000064816.V283055.R01.S.doc Version 5.1 Page 24 4. Hilldales YA42 monthly as per guidelines. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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. Extracts may not be used or reproduced without the express permission of CSCI. Hilldales DS0000064816.V283055.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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