Inspection on 26/09/06 for Hillside House

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillside House 17/12/07

Hillside House 28/12/05

Hillside House 17/09/05

Hillside House 01/02/05

Hillside House 07/09/04

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 Hillside House 1/2 Hillside Cotham Hill Bristol BS6 6JP Lead Inspector Andrew Pollard Key Unannounced Inspection 26 September 2006 09:30 th Hillside House DS0000020335.V294662.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 Hillside House DS0000020335.V294662.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 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. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hillside House Address 1/2 Hillside Cotham Hill Bristol BS6 6JP 0117 9735784 0117 9709301 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Ramani Thirunamam Care Home 22 Category(ies) of Learning disability (22) registration, with number of places Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing Notice dated 15/11/2001 applies Manager must be a RN on Parts 5 or 14 of the NMC register Date of last inspection 10th January 2006 Brief Description of the Service: Hillside House is operated by Aspects and Milestones Trust and has twenty-two nursing beds, which are registered for adults with learning difficulties. The house is a converted Edwardian property providing single and double rooms on three floors, with communal space in five areas. There are 17 permanent residents and there will be no further admissions to reduce the number of people who share a room. There is no lift in the home and residents must therefore be independently mobile. Hillside House is situated in a busy suburban position and can be readily accessed by car or public transport. There is a shopping centre, local shops and coffee shops within walking distance of the home. Hillside House also has a mini bus, which is used regularly by residents. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used in the production of this report; observation, pre-inspection questionnaire, discussion with staff, resident surveys, relative comment cards, tour of the home and sampling policies, records, care plans. The building is large and old and would not be suitable as it is for people with physical disability and the frail elderly. Plans are in place to improve and update the environment and creating new types of dwellings and making better use of the buildings This report has been written using all available evidence including a visit to the home. What the service does well: Hillside is a well run home offering a good standard of care and quality of life. The inspector’s overall impression was that the residents are happy, settled and secure and the staff have a good rapport with the residents. Consultations with the residents gave a positive view of life and the staff in the home, 90 said staff treated them well, making comments such as ”I like it at Hillside and don’t want to move anywhere else”. A large number of staff have known the residents for many years and have an in depth knowledge and understanding of their needs which has contributed to the wellbeing of the residents who have the potential to be challenging and have complex needs. Staff continue to be highly supportive of residents, which enables them to lead active and interesting lifestyles using a person centred approach allowing residents develop their own daily routines. The manager supports staff to work more effectively. There are good systems in place for supervision and support. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 the following standard(s): 1,2,5 The outcome in this quality area is good Prospective residents would be given all relevant information in written or verbal form about the home. Residents have written contract and term and conditions of residency. EVIDENCE: The majority of these standards were not assessed. There is a stable and settled group at Hillside House and the home has received no new admissions. All residents are issued with a statement of terms and conditions and these were seen at the time of the visit. They state the house rules and fees payable. Where able residents have signed contracts. Each person has a financial information sheet detailing their benefits rent, contributions to use of a vehicle and banking arrangements. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6,7,8,9 The outcome in this quality area is good. Care plans are well written and enable staff to provide a consistent and individualised care. Residents are involved with the personal care planning process The homes philosophy promotes resident’s individual development, selfdirection and empowerment. Residents are supported to take risks, which means they lead active and interesting lifestyles. EVIDENCE: The staff have reviewed the format of the care plans which provide detailed information and input from the individual residents about their wishes identified in the “Person Centred Planning” process which is now well established in the home. One meeting was held in a resident’s mother’s house in Cheshire as she was unable to travel and the resident felt it to be important for her to be present. No residents have any particular cultural needs. Each file contains personal information; individual support and health care needs, daily routines, care plans and risk assessments. The information seen was well written and provided evidence that the home provides a holistic service which takes into account social, mental health and physical needs Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 10 Risk assessments have been reviewed and are updated at least annually and relate to individual needs. Residents are encouraged to take risks as part of independent lifestyles. Some people go into the community on their own within certain guidelines; some have paid employment. The home manages the diverse needs of residents well and ensures that those who are able are supported to take calculated risks and develop their independence. Fifteen residents consulted stated they “always or usually” were free to make day-to-day choices, including comments such as “I choose to go out when I want or stay in if I rather” Some relative comments included, “Our daughter feels secure and happy we are more than happy” and “ I cant praise the staff enough for all the things they do for him”. Hillside House operates a “key working” system whereby each resident has a named nurse and support worker who play a more central role in co-ordinating the care they receive. This provides meaningful staff support to residents, which is particularly important to those who have complex needs. Aspects and Milestones have a confidentiality policy, which is discussed as part of the initial induction process. This was confirmed through records and in previous discussion with staff, all of who displayed a good understanding of their responsibilities in this respect. All records of a personal nature are kept in locked cabinets Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12,13,14,15,16,17 The outcome in this quality area is excellent. Residents have the opportunity to lead active lifestyles, be part of the local community and to maintain links outside of the home that are important to them. The recreational and occupational arrangements in the home are well organised and varied. The menus are varied and offer choice and a balanced diet. EVIDENCE: Residents continue to be supported to have active lifestyles. Each person has a weekly plan, which is tailored to his or her individual preferences. These range from paid employment to regular attendance to college courses and activity resource centres. The recently introduced “Workmates” scheme has been a big success where residents can work for £10 per day for two days carrying out handyman tasks for the Trust. A team of care worker, gardener, chef and a nurse supports the residents. The two residents spoken to at the site visit very much enjoyed the Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 12 work and it was felt their involvement had a very beneficial effect on they’re general well being. Residents attend three activity resource centres, eight people attend adult education courses and individuals attend “Art and Power” workshop, horse riding and work on a farm. The home is to be to be commended for the support they provide in this respect. In addition to this residents pursue hobbies and activities of personal interests during their leisure time. One resident stated, “I let it known to people what I want or don’t want to do” Hillside House is located near the heart of Bristol and is close to many local facilities and places of interest. Residents regularly go out on their own or supported to by staff. The manager recognises the importance of residents being part of the community and is aware of issues that may lead to discrimination. The League of Friends holds events in the home and raises money to support projects in the home, recently donating £3,500 toward the cost of a new vehicle. Residents are supported to maintain friendships and links with their family most of whom take an active interest in the home. Some residents go to stay with relatives either for the day or overnight often facilitated by staff. One person is being taken to the Isle of Weight, as their relative is too infirm to travel. One relative who was ill in hospital said, “My son was brought to see me and had very good support from the staff they did everything possible”. Some residents have established friendships outside of the home including people they have met at day placements, from the home next door and ex residents living in the community. All residents have been on holiday this year most recently to Butlins and regular day trips take place. Residents are encouraged, with varying degrees of support, to take responsibility for the upkeep of their rooms and of the communal areas. One relative felt that more effort should be made to keep the bedroom tidy. The home has two dining rooms and residents can eat where they choose. Some residents are able to prepare snacks and beverages. The menus offer choice for all meals and the residents select their choices the day before. The menu was varied and offered a balanced diet. There are no special cultural diets required. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18,19,20 The outcome in this quality area is adequate. The staff provide appropriate personal and nursing care in a sensitive manner to maintains residents dignity, health and well-being. Proper arrangements are in place for residents to access primary and secondary healthcare services. The nursing staff properly manages and administer medication. EVIDENCE: Files contained individual support plans, which cover all aspects of personal care needs. Those seen were written to a good standard and gave detail of individual preferences. They ranged from skin care, to bathing and to assistance with personal hygiene. They also included information as to gender preferences. One relative stated that she would like to “see more attention hair and nail care”. Records show that residents are supported to have regular health check ups and to visit the opticians and dentists. It was suggested that the manager consider the introduction of the “OK Health Check” to help develop health action plans. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 14 The Consultant Psychiatrist actively supports four residents with mental health needs and will see any resident if required. The manager also has access to the forensic support services if need be. All residents are registered with Dr Granier who the manager considers to be very supportive. Most resident attend the local surgery but in the main require staff support when doing so. It was noted that residents benefit from annual reviews of their medication by their GP. One person is undergoing a closely monitored drug reduction programme. The GP stated in a comment card “ It is an excellent care home. Staff have an in depth knowledge of the residents. I am very impressed with the management”. One resident who suffered a stroke and had significant care needs previously has made a full recovery. Two residents have problematic epilepsy and require additional medication periodically. Some bottles of medication had “As directed” labels rather than the actual direction for use and did not state the maximum dosage to be given in 24 hours. The staff lead by the nursing team have effective strategies for diffusing and de-escalating potentially challenging situations as a number of residents have significant overlying mental health needs and in the past have presented difficult management problems. It is testament to staff skills that very minimal amounts of “As Required Medication” is administered. The home now operates a monitored dosage system. The manager has developed a local policy for the new medication system and this works in conjunction with the general policy issued by Aspects and Milestones. This was clearly written. All records held in relation to the receipt, administration and disposal of medication were found to be accurate and well maintained. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22,23 The outcome in this quality area is good. There are robust and comprehensive policies in place to manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of POVA matters so residents can expect to be protected from abuse. EVIDENCE: All staff have received their protection of vulnerable adults training. The manager is making enquiries with the training department about the frequency of future updates. The home has an updated vulnerable adults policy published by Bristol City Council, which includes the contact number of the Adult Protection Co-ordinators, left in a prominent position for easy access. There have been no allegations of abuse. The Trust has a whistle blowing procedure in place called “do the right thing” which is kept in the polices and procedures file. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 16 The complaint procedure is prominently displayed in both hallways. The contact information for the area office of CSCI is included. There is a complaints procedure using symbols that may be accessible to some residents. A number of residents would require staff or others to advocate on their behalf. The complaints record that showed no complaints have been received this year. Seventeen residents stated in surveys that they “knew who to speak to if they were not happy ”fourteen stated that “staff listen to and act on what they say”, two said “usually” and one said “sometimes”. Some relatives said they were unaware of the complaint policy. In the past there have been instances between residents, whose relationship is volatile and raised the potential of assaults. The staff have acted appropriately and reviewed risk assessments and care plans to resolve this. Three residents financial records were looked at. All benefits, including disability living allowances, are paid into residents’ bank accounts. Fees are then taken out via direct debit. All residents are entitled to a set weekly personal allowance. Records held in relation to this were found to be accurate with bank statements tallying with running records. Some residents are able to get their own money, others require support with this and to budget their money. Each person has a ledger sheet and wallet for their allowance held in safekeeping. The financial arrangements are fully recorded within the care plans including agreed arrangements for paying for use of the home’s mini bus. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 24,25,27,28,29,30 The outcome in this quality area is poor Overall the premises are shabby and have rundown appearance meaning that residents do not benefit from a homely and comfortable environment. Bathrooms are generally adequate. The shower room is unsuitable for its purpose. Bedrooms show high levels of individualisation. Shared spaces are suitable for their purpose. The home is generally clean and tidy. EVIDENCE: Hillside House is a listed premise and requires high maintenance. Aspects and Milestones set out plans to the commission four years ago to refurbish and upgrade the premises and convert some of it to supported living. Plans were submitted to the Local Authority for the conversion, which have been refused planning permission. However an appeal has been lodged and the Trust is hopeful that progress can be made by the end of the year. The house is not ideally suited to the needs of its occupants and requires significant refurbishment to bring it up to nationally recognised minimum standards. The stairwells and hallways are dark, poorly decorated and Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 18 institutional in appearance. Some of the paintwork is chipped and jaded in appearance and some if the carpets are faded and stained. Two of the bedrooms on the top floor are susceptible to flooding during heavy rain. In addition to the above the bathrooms and toilets are institutional in appearance and not homely. The shower room is in a general storeroom and unsuitable for residents use. Only one person is using it due to their inability and or reluctance to use a bath. This resident has previously suffered a stroke and has to step up into the shower cubical and hold onto a Zimmer frame for support. There is a significant risk of injury to the resident or staff should the resident have another cardiovascular incident or loose their balance. The manager is aware that the shower should no longer be used. The one hoist in the home is currently out of operation awaiting repair. A requirement was previously made that refurbishment of premises commence by April 06; no significant improvements have been made. Some decorating has been carried out by the “workmates” which have been of benefit to the residents but the overall standard of décor remains poor. Depending upon the Response from the Trust to this report a further random inspection may be necessary to draw up a list of detailed requirements for improvements on a room-by-room basis. The home is well established within the local community and is close to local amenities and shops, which are used regularly by residents. The garden is private and well maintained and residents have unlimited access to this. It should also be noted that staff have made strenuous efforts to make the premises homely and comfortable within the limitation imposed by the Trust. All areas of the home were found to be cleaned to a good standard and there are infection control procedures in place. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 The outcome in this quality area is adequate. The home is adequately staffed with appropriately trained and experienced staff. Staff have the resources and skills to meet residents’ complex needs. The staff are well supervised. There is a robust recruitment procedure in place that protects vulnerable adults. EVIDENCE: The staff spoken with displayed a clear awareness of their roles and responsibilities. Copies of job descriptions are within personal files and clearly stated what is expected. There is a low staff turnover in the home and the consistency of staff presence is important to the wellbeing of the residents and maintaining the strategies of care that prevent challenging incidents and tensions in the home. Bank and some agency staff have been used recently to cover gaps in the rota. The manager considers that the staff work well as a team and supported one another. Fifteen residents in surveys stated that “staff treat them well”, one usually and one sometimes. Ten relatives felt there were sufficient staff and seven felt there were not. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 20 One person commenting that “The staff are committed to the wellbeing and welfare of people in their care” and “staff seem to understand the complex emotional and intellectual needs of some of the resident”. Staffing rotas indicated that there are generally sufficient numbers on duty to meet the needs of residents and in general the requirements of the staffing notice which is a condition of registration and must be complied with. The Trust has cut the number of Registered Nurses (RN) working in the home contrary to the advice of the manager. At present there are not always two RN’s on duty from 7.30-13.30 on Saturdays and Sundays as required in the staffing notice. There is a current proposal to remove the RN night cover, this would constitute a breach of the conditions of registration unless there is a successful application to de-register the nursing care status of the home, and no formal application has been made to date. Aspect and Milestones would need to apply to the CSCI formally about this and demonstrate, through independent (including a medical/nursing) reassessments, that nursing care is no longer required. The home employs a cook, part time admin support and gardener and fulltime housekeepers. Nursing staff should not be diverted from their role to cover gaps in the catering rota as is happening on occasions. The Trust has a robust recruitment procedure in place that protects vulnerable adults. All personal files are now held on the premises, which included completed application forms, two references and criminal records checks. There was also evidence that pin numbers had been checked for the RN’s. Some files had yet to be fully completed for recently employed staff whose records were in the personnel department. All new staff completes a Trust induction programme including the Learning Disabilities Award Framework. All staff receive statutory training of first aid, fire, manual handling and food hygiene and protection of vulnerable adults. The manager has drawn up a schedule of those staff requiring updates. Staff continue to attend external courses. Opportunity was also taken to see individual training profiles, which show further training. Two staff recently completed a one- year person centred planning and empowerment course and are delivering the learning to the staff. Three carers have NVQ level3 qualifications and two have level2 and two are on programmes. All staff receive formal supervision and appraisal at regular intervals of which written records are made, some of which were seen. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 21 Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42,43 The outcome in this quality area is good. There are various methods and systems in place to obtain residents views. Residents’ benefit from a well run home. There are appropriate arrangements in place to service and repair plant and equipment. The home has good Health and Safety arrangements. EVIDENCE: All staff previously consulted with spoke positively about the manager and said that he was firm but fair. He has been working at the home for a number of years and has demonstrated an ability to change his work practices during this time. He displayed a good knowledge of his responsibilities as a registered manager and works positively to meet all requirements where he has the power to do so. The manager is involved with a new peer audit review where exchanges between home managers are done to conduct a quality audit. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 23 There have been two formal residents meetings this year which are well attended and records indicate resident participation. Four staff meetings have taken place this year of which records were seen. Ms Stevenson carries out visits to the home and writes Regulation 26 reports, however none have been submitted since June. From consultation with relatives all responses said, “Staff were welcoming” a large majority said they were “kept informed and consulted with about the care of residents”. Nineteen of twenty response said they “were satisfied with the care in the home”, one person said not always. Resident’s comments were all-positive and have been referred to in the body of the report. The kitchen was recently inspected by environmental health and the standards Were considered good. The laundry is in poor condition but adequately equipped. Only one resident is willing or able to manage their own laundry. Annual Health and Safety Audits are carried out by the Trust. The gas safety inspection was taking place during the inspection. The electrical installation safety certificate was in date. The fire alarm system had been inspected and all required tests and drills have taken place. The next fire safety training is booked for December. Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 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 X 4 X 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 1 25 2 26 X 27 1 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 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 2 3 x 3 X 3 X X 3 2 Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 25 N/A 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 2. 3. 4. Standard YA27 YA33 YA24 YA43 Regulation 13.4 (a) (c) 18.1 (a) 23(2) 26 Requirement Desist in the use of the basement shower. Repair the bath hoist. All aspect of the staffing notice and conditions of registration must be met in full. Submit plans for the rapid refurbishment of premises. Ensure required reports are submitted to the Commission monthly Timescale for action 27/09/06 27/09/06 15/10/06 30/10/06 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. 2 Refer to Standard YA19 YA27 YA20 Good Practice Recommendations Introduction of the “OK Health Check” to help develop health action plans. Install a walk-in/sit down shower. Ensure bottles of “As required” medication state actual direction for use and the maximum dosage to be given in 24 hours. DS0000020335.V294662.R01.S.doc Version 5.1 Page 26 Hillside House Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Hillside House DS0000020335.V294662.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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