Inspection on 20/09/06 for Hillside Resource Centre

This inspection was carried out on 20th 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillside Resource Centre 23/10/07

Hillside Resource Centre 07/11/05

Hillside Resource Centre 10/05/05

Hillside Resource Centre 23/11/04

Hillside Resource Centre 19/04/04

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Insight - Eastchurch

Southfields

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Dovedale Court

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

CARE HOME ADULTS 18-65 Hillside Resource Centre Portesbery Road Camberley Surrey GU15 3SZ Lead Inspector Helen Dickens Key Unannounced Inspection 20th September 2006 10:15 Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillside Resource Centre Address Portesbery Road Camberley Surrey GU15 3SZ 01932 794614 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) Tina.Lawton@surreycc.gov.uk Surrey County Council - Adult & Community Care Mrs Julie Denise Wadham-Coxon Care Home 22 Category(ies) of Learning disability (21), Learning disability over registration, with number 65 years of age (1) of places Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Accommodation and services may be provided to named persons aged 65 years and over with the prior written agreement of the CSCI. Up to 8 residents accommodated may also have a dual diagnosis of mental health and learning disability. Respite care may be provided to a maximum of 2 persons at any one time. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. 7th November 2005 Date of last inspection Brief Description of the Service: Hillside is owned and managed by Surrey County Council (SCC) Adults and Community Care Services. It is registered for 22 people with learning disabilities. The property is located in a pleasant residential area and is in close proximity to Camberley town centre. The residents live in three self-contained units within the home and all have their own single rooms. The home has fully equipped kitchens, dining rooms, living rooms and adequate numbers of bathrooms and toilets. The home has its own transport. The current cost is £608 per person per week. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to June 2007. The inspection was carried out by Helen Dickens, Lead Inspector for the service. The Registered Manager, Julie Wadham-Coxon, represented the establishment. A partial tour of the premises took place. The inspector interviewed 3 residents and spoke with several others during the day. Two members of staff were also spoken to at length. A number of files and records were examined including resident’s care plans and health action plans, and a number of health and safety certificates were sampled. This was another busy day at Hillside and the Inspector would like to thank the residents, staff and the Registered Manager, for their time, assistance and hospitality throughout. What the service does well: What has improved since the last inspection? The Requirements made at the last inspection have been met and these will be discussed later in the report. The manager’s registration with CSCI was completed. Care plans have all been transferred into the person centred planning format and those viewed on the day of the inspection were put together in an extremely resident friendly format. Residents now also have individual health actions plans, which are set out in a similarly accessible format. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 6 Since the last inspection the residents and staff have continued to run their café at the local college of further education. The manager gained outside funding for this project and it continues to be very successful in a number of ways, particularly the improved quality of life for those residents who are taking part. The registered manager has put in a further bid for Hillside to have its own day centre in the town as some current day placements are no longer meeting resident’s needs. A number of improvements to the premises have been completed including new hand washing facilities in the kitchen, a complete refurbishment for Rawlinsons lounge, new cupboards in the dried food store, and new blinds and decoration in Buckles lounge. One bathroom has also been totally refurbished and new flooring put down in one resident’s bedroom. 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 Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective resident’s individual needs and aspirations are thoroughly assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessments at this home are thorough and showed detailed background information on residents. Those sampled had clearly been used as a basis for each resident’s care plan and subsequently up-dated as resident’s needs had changed. Original assessments for residents who have been in the home for a long time (some for 20 years or more) have been archived, as later assessments are now more relevant. Discussions with the registered manager regarding a recent resident who had stayed for a short time at the home, showed that residents needs are fully taken into account both before moving in and in the early stages of admission. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 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 and 9 Resident’s changing needs and goals are reflected in their care plans, and residents are assisted to make decisions about their daily lives. Residents are consulted about all aspects of life in the home and are supported to take risks as part of an independent lifestyle. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans (Person Centred Plans) are excellent at this home. They are set out in very user-friendly formats using words, pictures, symbols, and photographs of relevant people and places. All personal, health and social needs were clearly documented together with goals and action plans. Of the six plans sampled, all had been reviewed in a timely fashion and had evidence of resident’s involvement, usually the resident’s signature or mark on each section of the plan. Residents are encouraged to make decisions and choices with support from staff. The information relevant to residents has been translated into resident friendly formats to enable them to participate and make informed decisions. For example the complaints procedure, and their care plans and health action Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 10 plans. The registered manager outlined how they had worked with several residents who needed hospital treatment but had initially refused. Once the relevant information on the procedure was translated into a format which could be explained and demonstrated to the resident, and they then had a better understanding of what was involved, they usually decided to go ahead and have the treatment or procedure. Though no residents manage their own money totally independently, many residents can deal with some aspects of their finances, such as their banking and personal shopping, with assistance from staff. Throughout the home there are examples of residents participating in all aspects of daily life. In the kitchens, straightforward and pictorial instructions on the use of kitchen equipment such as the colour coded chopping boards (with pictures of what each board is used for) are displayed. On the day of the inspection several residents used the downstairs kitchen to choose and put together their own snack lunches and drinks. Kitchen rotas (in pictures and words) set out what residents had already agreed about the jobs they helped with, such as filling the dishwasher, brushing the kitchen floor, and making up their own pack lunches for college. An improvement since the last inspection has been the goals from resident’s person centred plans being displayed in the bedrooms of those residents who find it helpful to have these as a reminder. Residents are also invited to join staff meetings, take part in the recruitment of new staff by sitting on the interview panel, and have input into up-dating the statement of purpose. The tenancy agreement is currently being revised and the registered manager said she would be involving residents as soon as the first draft of the friendlier format is available. Residents are encouraged to take responsible risks, and safety guidelines are set out for various resident activities including going out into the community, e.g. shopping and leisure activities, and activities in the home such as moving and handling and independent living skills such as kitchen activities. Residents have been supported to do a basic food handling and hygiene course where this is one of their interests, and a number have passed using a resident friendly teaching and course evaluation method. Risk assessments also exist relating to accessing the building as there are difficulties for residents on the approach to the home which is on a hill, with cars parked on, and completely blocking, the footpath. A sharp bend in the road adds to the difficulties. This is discussed further under health and safety. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 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): 11,12,13,14,15,16 and 17 Residents have ample opportunities for personal development and for work, training and social activities. Family and friendship links are encouraged and resident’s rights respected. Residents are offered a healthy diet and enjoy their mealtimes. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home encourages personal development for residents and the adult education timetable for residents was sampled during the inspection. It included arts and crafts lessons, healthy lunchtime cookery, keep fit and dance, needlecraft, and computer lessons. Residents have done a variety of courses on improving life skills and certificates for these were noted on some resident’s files. On the afternoon of the inspection a number of residents were preparing to go out for their ‘cook and eat’ class where they make their own meal and can then eat the food. The registered manager and staff at Hillside have also set up and developed a café at the local adult education college which has received very positive comments both from the residents working there and from people who use the café. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 12 The residents in this home are encouraged to continue their education and to take part in appropriate work. As mentioned earlier, a number of residents were supported to do the food handling and hygiene course and six have gone on to work at the café. This is counted as training rather than paid work and residents, under supervision, make drinks, homemade sandwiches and cakes, and deal with the payments for these items. The home have also linked with Brooklands College and one resident has now achieved the London Chamber of Commerce ‘Skills for Working Life (catering)’ award. One other resident is in paid employment, and two others have signed up with employability to help find them work. One resident is currently on work experience. Some residents no longer wish to attend their day centre where they have been going for many years and the manager has put in a bid to North West Surrey Valuing People Group to set up a Hillside day centre in the town. Residents at this home play a full part in local community life. Some have done the ‘ what’s on in your community’ course at the local college and there is much evidence from activity plans that residents use local facilities including banks, shops, the theatre and the local college-in fact virtually all residents attend at least one session at the local adult education college. The residents from Hillside, as mentioned above, run the café at the adult education college providing an excellent service to other college users and to staff. Access to the local community is hampered by double-parked cars on either side of the hill which mean residents have to walk on the road or use Hillside’s own transport. A record of all educational and leisure activities including trips out and holidays is kept for each resident. In-house and personal activities included personal shopping and banking, swimming, food shopping, evening activities including walks and drives, and health and beauty sessions. The home has a number of ad hoc entertainment events and the residents meeting agenda showed that they were now planning their social calendar for Christmas. Family and friendship links are encouraged and care plans and assessments showed how resident’s relatives had been involved. Relatives are invited to some of the social events at the home and visiting is open and flexible. From the range of activities residents participate in, there are many opportunities to meet people who are not from Hillside, and who do not necessarily have the same disability. Personal relationships can be developed and staff ensure appropriate support is given in the form of information, counselling and practical help. Daily routines at this home promote independence. Residents were seen arranging their own lunchtime snacks and most residents also prepare breakfast independently. Some residents have keys to their rooms, others prefer keypads, and yet others do not wish for either. Staff were observed to be respectful to residents and to interact well with them. Residents were Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 13 observed to turn to staff for assistance. Resident’s rights are respected and there were a number of examples such as all those whose photographs were being used either in Surrey County Council publications, or in the home’s own newsletter, had been given a friendly format consent form to sign and this was kept on their file. Meals are flexible and residents at Hillside encouraged to be independent. As already mentioned, residents helped themselves to drinks and snacks and could make light meals. Menus were drawn up with resident’s input and agreement and staff promoted healthy food choices. For example there were large bowls of fruit in the kitchen areas and plenty of fresh vegetables and salads in the fridges. One member of staff said residents were encouraged to choose the non-sugary breakfast cereals. Residents were knowledgeable on food matters as some had done the food handling and hygiene course, and many were doing or had done some form of cookery classes. On the evening of the inspection those residents who were not going out to their ‘cook and eat’ class were having homemade pasta bake with bacon and cheese sauce, and a freshly prepared fruit salad. Staff are knowledgeable on residents food and nutritional needs and special needs are documented on residents files. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Residents receive personal care in the way they prefer and require. Their health needs are identified in their health action plans and are well met. The administration of medication is well organised at this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal Care needs are clearly identified on residents care plans and protocols are on file regarding support residents need with personal care, toilet arrangements, and any aids and equipment required. A monthly report on each client summarises changes/successes/ill health over the previous month and in addition ad hoc notes are kept on behavioural issues, health concerns, and any other relevant events. Specialist advice is taken as necessary and in the six files sampled there were a variety of reports and advice from occupational and physiotherapists, behavioural and mental health specialists, and community nurses. There is a key worker system in place, which ensures continuity for residents. Documentation setting out personal care needs is in a friendly format, which makes it easier for residents to participate in planning their own care. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 15 There is an excellent record of resident’s health needs in the new health action plans. These contain a good record of their past medical history, healthcare contacts such as GP and specialist nurses, and health appointments – e.g. for the flu jab. These plans also cover care of ears, nails, and eyes etc together with an action plan and goals for each area of health. These plans are all in words and pictures which make them very accessible to residents. Specialist reports for example speech and language therapy are also documented. Medication is well organised at this home. No residents are entirely selfmedicating but some keep their medicines in a locked cabinet in their rooms and staff go along to administer the medication within the residents room. Medication is recorded on resident’s plans and on medication administration records (MARS) – on the day of the inspection there were no unexplained gaps on the MAR sheets sampled. There are currently no controlled drugs at this home. All staff administering medication have been trained to do so and one person has overall responsibility for ordering stocks and managing the system. The recommendation to chase up the community pharmacist with regard to visiting and advising the home has been carried out though the visit will not take place until later this month due to staff shortages at the pharmacy. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents views are listened to and their concerns taken seriously. Residents at this home are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s monthly meetings always begin with one staff member asking if anyone has any complaints or problems. These meetings are well organised and the outcomes documented in a format which is accessible to residents. There is also a resident friendly complaints procedure and residents would also have the option of raising issues either with their key worker or directly with the manager. There have been no complaints since the last inspection. Staff at this home are trained in the Surrey multi-agency procedures for the protection of vulnerable adults and are knowledgeable on safeguarding adults issues. An issue raised since the last inspection was dealt with correctly by the home and the home should be commended for the sensitive way this matter was handled. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 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 and 30 The home’s premises are safe, and the interior of the building is accessible, well maintained, and adapted to make it as homely as possible. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hillside is a large 1970’s building which has been adapted to provide three smaller units of accommodation. Though the building may look institutional from the outside, the facilities and care residents receive is not. The two units for more independent residents have smaller domestic type kitchens and throughout the building, staff have worked hard to provide homely and comfortable surroundings. Bedrooms were very personalised and the home was clean and hygienic throughout. The home offers access to local amenities and where there are challenges, e.g. the home is literally on a hillside, specialist advice has been sought to ensure residents can move as safely as possible outdoors. The safety issues regarding the outside access are discussed later under health and safety. The home is generally decorated to a good standard and improvements been made since the last inspection including new hand washing facilities in the kitchen, a complete refurbishment for Rawlinsons lounge, new cupboards in Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 18 the dried food store, and new blinds and decoration in Buckles lounge. One bathroom has also been totally refurbished and new flooring put down in one resident’s bedroom. Residents spoken to liked their rooms and were pleased to show the inspector around during the tour of the building; bedrooms were noted to be very personalised. Some decorative issues were raised with the registered manager including one kitchen which will soon need refurbishment; one shower room with inadequate ventilation has peeling paint and mould; and a toilet where the door would clash with the door at the top of the stairs if they were opened at the same time. This toilet needs to be reviewed as it is not as fragrant as the other toilet areas (possibly due to inadequate ventilation) and the paintwork needs to be redone. It was also noted that the garden is not being well kept in some areas (it needed weeding and the bushes cutting back, and an allotment area is now disused and needs to be tidied). Some minor matters were also highlighted on the day of the inspection including moving the training flip chart from the resident’s lounge; moving the two perching stools from the corridor, especially as one was in front of the fire extinguisher; moving the wheelchair which was being stored in the stairwell; and reviewing whether a pull cord was needed in one shower room in addition to an emergency bell near the toilet. The registered manager agreed to remedy these matters. The home does appear to be short of storage space and this will need to be reviewed. This home is clean and hygienic throughout. There are no offensive odours and the toilet areas are fragrant. There are suitable laundry facilities including a sluicing programme on the washing machines. Bathrooms and shower rooms inspected were all clean and tidy. Policies and procedures relating to infection control are in place to protect service users. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 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): 32,34,35 and 36 Residents are supported by competent and qualified staff and protected by the home’s recruitment practices. Resident’s needs are met by well-trained staff who are regularly supervised. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff at this home are well trained and good records are kept regarding training courses attended and staff development needs. Staff were approachable and residents were seen to turn to them for advice and assistance. Staff are knowledgeable about the needs of this client group and have completed LDAF accredited induction and other training. Currently 50 of staff are trained to NVQ2 or above (Standard 32.6) and this target will be exceeded by next month when further staff receive their NVQ awards. Recruitment at this home is a shared responsibility with social services head office and original records were kept there. However, of those staff files sampled all had the necessary written information including an application form, two written references, and the necessary CRB and POVA checks. The registered manager was asked to ensure that when prospective employees give their dates for previous employment, they should state the month as well as the year when they left each job and started each new one. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 20 Staff training is documented on a central record which was sampled during the inspection, and which is regularly up-dated; staff files contain their training certificates for courses attended. New staff have a structured LDAF accredited induction training. The registered manager gave examples of how the training and development of staff is linked to the needs of residents and this information, together with the other elements listed in Standard 35 are currently being put together into a training and development plan for the home (35.2). Staff at this home are regularly supervised and all staff files sampled showed they have exceeded the target (Standard 36.4) of having at least six sessions per year of formal and documented supervision. A chart setting out the supervisors and supervisees was also examined during the inspection. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 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 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): 37,38,39 and 42 Residents benefit from a well run home; their views are taken into account; and health and safety arrangements are generally good. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager at Hillside has gained the Registered Managers Award and NVQ4. She ensures that the aims and objectives of the home are achieved and the budget well managed. She also ensures that the home complies with the Care Standards Act and Regulations. In addition she is very pro-active regarding improving the quality of life of residents and puts in outside ‘bids’ for money and other resources which would be otherwise unavailable to residents. One such successful bid enabled Hillside to take over the running of the café at the local adult education college and residents who are part of this project comment very positively on their involvement. There is currently another bid to start a Hillside ‘day centre’ Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 22 which will better meet the needs of Hillside residents than some of the current placements available. The manager communicates a clear sense of direction to the team and the commitment and enthusiasm of the staff at Hillside is very noticeable. The processes for managing the home are open and transparent, and innovation and creativity encouraged. Quality assurance arrangements at this home consist of a number of ways of gaining feedback from residents and others involved in the home. For example, there are very well run monthly resident’s meetings where the same member of staff organises the meetings and gathers issues (from staff and residents) for the agenda. She then Chairs the meetings and provides resident-friendly feedback in words, pictures and photographs on the issues discussed and any actions and outcomes. These meeting notes were sampled for 2006 and each one began by asking residents if they had any complaints of problems. From the resident’s files sampled, the manager can demonstrate year on year development for each resident and regular reviews give other professionals and friends and relatives the opportunity to participate both in individual resident’s care and on wider issues to do with the home. The home also has monthly Regulation 26 visits from a senior social services manager, regular staff meetings, and staff supervision sessions which give staff the opportunity to have input into the running of the home. The home currently does not seek views from residents and other stakeholders using any form of questionnaire though this is something they will be doing in the near future. The inspector outlined the importance of internal quality assurance systems and a recommendation will be made to review current arrangements in order to meet Standard 39 in full. Health and safety arrangements are generally good at this home and a number of documents and certificates were sampled including the legionella testing certificate, professional indemnity and employers liability insurance cover, and the CSCI certificate which was displayed in the entrance to the home. The recent electrical appliance certificate, and confirmation of the correct installation of the new bath (commissioning certificate) were seen. Fire extinguisher testing was done in December 05 and routine servicing of the lift in February 06. The hazardous substances cupboard was secure. On the day of the inspection a regular member of staff was overheard to be giving a new agency member of staff information about what to do it the fire alarm goes off and was arranging to do a tour of the building. It was noted that the chef’s knives kept in each kitchen are stored in locked cases so that only staff, or residents under supervision, would be given access. Some minor safety matters needed more attention for example the perching stools being ‘stored’ in the corridor, one blocking the fire extinguisher, and a Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 23 risk assessment needs to be carried out regarding the toilet and landing doors which may knock into each other if opened at the same time. In addition, no further action seems to have been taken regarding the access road to this home. On the day of the inspection the entire pavement was blocked by parked cars and this forces pedestrians to walk on the remaining narrow roadway. The road is on a hill and there is a sharp bend. These arrangements continue to impede the independence of residents who would otherwise be able to walk into town on their own. The few residents who do use it are being placed at a higher level of risk than is necessary due to not having a safe walkway or pavement available. The manager has carried out a risk assessment but a requirement will also be made in this regard. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 3 3 X X 2 X Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23(2)(l) Requirement The registered person must review the adequacy of storage arrangements within the home as discussed in the report and with particular regard to the perching stools; the wheelchair; and the training flipchart. The registered person must review the following and take remedial action in a timely fashion: • The small kitchen which will soon need to be refurbished; • The shower room with inadequate ventilation and peeling paint and mould; • The toilet where the door clashes with the door at the top of the stairs; • This toilet needs appears to have inadequate ventilation and the paintwork needs to be redone; • The garden is not well kept in some areas. DS0000034532.V312744.R01.S.doc Timescale for action 27/09/06 2. YA24 23(2)(b) 27/09/06 Hillside Resource Centre Version 5.2 Page 26 3. YA42 13(4)(a)(b)(c) The registered person must 27/09/06 review the following health and safety matters and take remedial action as necessary; • The shower room which has a fixed emergency button but no pull cord • The access road to the building which compromises resident’s safety and restricts their independence. 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 YA42 Good Practice Recommendations The registered person should ensure arrangements are in place regarding the storage of opened food items in the fridges and cupboards, as perishable foods should be covered/resealed and date labelled once opened. Hillside Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Resource Centre DS0000034532.V312744.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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