Inspection on 07/11/05 for Hillside Resource Centre

This inspection was carried out on 7th November 2005.

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

The inspector found 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 Resource Centre 23/10/07

Hillside Resource Centre 20/09/06

Hillside Resource Centre 10/05/05

Hillside Resource Centre 23/11/04

Hillside Resource Centre 19/04/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Hillside Resource Centre Portesbery Road Camberley Surrey GU15 3SZ Lead Inspector Helen Dickens Unannounced Inspection 7th November 2005 10:15 Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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.V263599.R01.S.doc Version 5.0 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. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillside Resource Centre Address Portesbery Road Camberley Surrey GU15 3SZ 01276 27720 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) Surrey County Council - Adult & Community Care To Be Confirmed 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.V263599.R01.S.doc Version 5.0 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. 10th May 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 in a pleasant residential area close to Camberley town centre. Residents live in three self-contained units within the home, and all have their own single rooms. The home has fully equipped kitchens, dining areas, living rooms and adequate numbers of bathrooms and toilets. The home has its own transport. Parking is available on the driveway and beside the home. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. The Manager, Julie Wadham-Coxon, represented the establishment. A partial tour of the premises took place. The inspector met most of the residents and spoke with 6 of them in more depth. Three members of staff were also spoken to at length and a number of files and records examined as part of the inspection process. A visit was made to the new café project at the local further education centre, which is being managed and run by Hillside’s residents and staff. This was a particularly busy day at Hillside and the Inspector would like to thank the residents, staff and the Manager, for their time, assistance and hospitality. This report looks at fewer Standards than the previous one, as most of the ‘key standards’ were examined at the May 2005 inspection. What the service does well: What has improved since the last inspection? The Requirements made at the last inspection have largely been met and these will be discussed later in the report. The manager’s registration with CSCI is due to be finalised within the next seven days. All staff have had CRB checks and a record is being kept in this regard. Care plans continue to be transferred into the person centred planning format and those viewed on the day of the inspection were put together in a very Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 6 resident friendly way. This work is ongoing and will be completed by April 2007 when the special funding for the project runs out. Since the last inspection the residents and staff have opened their café at the local college of further education. The manager gained outside funding for this project and it is proving to be very successful in a number of ways, particularly the improved quality of life for those residents who are taking part. The café project is discussed later in the report. According to residents, a number of social events since the last inspection, such as the ‘Grease barbecue’ (mentioned later in the report) and the Halloween celebrations, have provided a great deal of pleasure. A second kitchen area has been opened on one of the units which gives residents more space and flexibility around mealtimes. 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.V263599.R01.S.doc Version 5.0 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) Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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): 4 Resident’s at Hillside are given good opportunities to ‘test drive’ the home in advance and therefore plenty of time to decide whether this home will meet their needs. EVIDENCE: Prospective residents can make short visits to Hillside whilst in the process of choosing a suitable home. The home has two ‘short term break’ beds and temporary residents who come for these breaks can use the opportunity to see if their lifestyle and care needs can be met at Hillside. There was evidence of flexibility with regard to permanent residents and one was spending four days per week at the home, going home for the other three days. There was evidence from resident’s files that those who had moved in as ‘permanent’ residents continued their assessment regarding the suitability of Hillside, had their needs kept under review, and alternative placements explored as Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 9 necessary. Resident’s views were listened to, documented and taken into account. During discussion regarding this Standard, the Manager highlighted that she needed to familiarise herself with Standard 4.5 regarding meeting the admission criteria for emergency admissions. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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 Resident’s assessed and changing needs, and personal goals are reflected in their care plans. EVIDENCE: Care plans examined were thorough and comprehensive and detailed resident’s needs and goals. This Standard was assessed at the previous inspection and it was noted that not all care plans were in a resident-friendly format. Since then, specialist funding has been obtained to transfer all care plans into person centred plans. The project started in June and staff have been on an awayday to show them how to do this; one member of staff was taking the lead to support the team. Those plans already transferred into the new format were very well done – residents will find them easier to follow and be able to take a greater part in compiling and reviewing them. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 11 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): 12,14,15,16 and 17 Residents are actively encouraged to take part in fulfilling leisure and educational opportunities. Their rights and privacy are respected. They have a healthy diet and are encouraged to play a full part in the planning and preparation of meals. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 12 EVIDENCE: Care plans examined showed residents leisure and educational needs are wellcatered for, including participating in activities and interests which began before moving to Hillside. The manager and staff are commended for securing funding for Hillside to run the café at the local college of further education. Residents there are working as ‘trainees’ and gaining skills in food handling and hygiene, catering, public service and communication skills, as well as building self-confidence. They serve freshly made sandwiches to order and home-made cakes and biscuits; the café was half full by 12.30 and customers were obviously enjoying both their food and the ambience. One resident told me how much she enjoyed working at the café. She was now in charge of the cake making and knew the recipes for the six different cakes and biscuits off by heart. Later during the visit she brought out a cake which she had just finished icing. A respite resident was taking the money from customers and said how much he was enjoying his new job. One resident has already been offered a paid job as a result of the experience gained on this project – others are being considered for work on the school meals service. In addition to the four residents on duty, two members of staff support the residents and help as necessary. This is an unusual departure for staff who are employed in a care home and, despite the rather hectic nature of the activity over the lunch period, were doing so with patience, enthusiasm and great humour. Leisure opportunities at Hillside are well organised and residents have their own programmes to follow. In addition, in house entertainment is particularly well-done at this home. A ‘Grease Barbecue’ saw the home being transformed into a 1960’s film set with the residents playing their favourite characters from the film Grease. Signs and music reinforced the authentic atmosphere. Residents were talking about this, unprompted, months after the event, one saying she had won a prize for her portrayal of one of the main characters. The photograph album gave residents the opportunity to be reminded of their part in the event. A ‘stars in their eyes’ special is being planned for Christmas where all residents get the opportunity to be their favourite celebrity. One resident said they sometimes got a bit bored at Hillside, and would like to do more dancing. This was passed on to the manager who said they were already looking at ballroom dancing opportunities for this particular resident. Residents at Hillside are well supported in building and maintaining friendships as well as intimate relationships where that is their wish. There was evidence on this from both observing residents together, and from looking at their care Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 13 plans. The home also has a policy on personal relationships which guides staff on relevant issues such as residents rights, positives images, and education. Residents were observed to be treated respectfully throughout the inspection and daily routines and activities were designed to promote the independence of residents. Several residents have had key-pads fitted to their bedroom doors which means they can lock their doors when they choose, but do not have the worry of keeping and using a key. One resident demonstrated how she used this and though it took two attempts, it enabled her to be independent and keep her room private when she wanted it to be. Residents were offered healthy diets and encouraged to play a significant part in the planning and preparation of food. Many residents had done a food handling course and there were many aids in the kitchens to assist residents. A chart in one kitchen had pictures depicting the foods which could be put on the various colour-coded chopping boards for example raw fish, raw meat, and dairy products. Some residents cooked their own meals, others assisted staff to do so. One unit had now had a second kitchen to allow more flexibility over the mealtime period. Advice had been sought from a dietician where appropriate, and this was documented on resident’s files. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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): 19 and 20 Resident’s health needs are met at Hillside. The home’s policies and procedures for the administration of medication protect residents. EVIDENCE: There was evidence on resident’s files that health needs of residents had been appropriately identified and met. Residents have routine appointments with opticians, dentists and chiropodists, and there was also evidence of specialist intervention such as the physiotherapist, dietician and biomechanical assessments. There was also evidence that sexual health and awareness was being considered as part of resident’s overall health needs. The administration of medication is well organised at Hillside and the staff member who has responsibility for medication is both knowledgeable and confident on the subject. The lunchtime medication ‘round’ was observed. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 15 At a previous inspection there was concern that the SCC policy of having all policies available on the intranet only, could mean they were not easily accessible to staff. At this inspection two policies were tested out for accessibility and the medicines policy was one of these. The local policy was available in the medicines room and gave staff clear guidance on the system and actions involved in administering medication. There is a separate policy for respite client’s medication and this was also readily available. The policy on medication errors needs a small addition about the need to report these to CSCI. The inspector also noted that the previous community pharmacist’s inspection was last year and homes are entitled to two visits per year; this should be followed up as soon as possible and a new appointment made. If there has been a more recent visit then the pharmacist’s inspection report should be located and placed on file. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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 12, 13, 15, 16 and 17 (Adults 1865) 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): 22 and 23 Resident’s complaints and suggestions are taken seriously at Hillside and systems are in place to protect vulnerable adults. EVIDENCE: There have been no complaints since the last inspection and issues raised by residents are taken seriously by staff. One resident told the inspector that she could hear ‘banging’ in the night, often as she was going off to sleep, and this would then keep her awake for ages. This was reported to the manager and she said she would ask the night staff to find out what this was so that it could be remedied. Resident-friendly copies of the complaints procedure were on view and a book with tear out pages available publicly for residents and visitors to make comments or complaints. The second policy to be tested for accessibility was the protection of vulnerable adults (POVA) policy. At the last inspection this was only available on the intranet on the computer but the service manager had said that a paper copy would be made available in the home. A paper copy has now been obtained and is available in the staff room. The manager was knowledgeable on POVA issues and discussed an ongoing issue at a day placement involving one of the residents and another council area. Hillside staff were following the local SCC policy which ensures that vulnerable people are protected. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 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 The home’s premises are safe, accessible and well maintained, and adapted to make the interior as homely as possible. 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 Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 18 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 safely outdoors. Respite and emergency admissions are catered for within existing units – there is no separate area for short term breaks. This has the advantage of integrating potential future residents, and at the same time gives existing residents the opportunity to meet and spend time with new people. The home has been redecorated to a good standard throughout and none of the residents spoken to raised any concerns about their rooms or the general environment. A new kitchen area has been added to one of the independent units to allow more room and flexibility of mealtimes for residents. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 19 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): 35 Resident’s individual and joint needs are met by appropriately trained staff. EVIDENCE: Hillside has allocated one member of staff with special responsibility for coordinating training at Hillside. The training and development plan is based on resident’s needs and staff competencies as identified and discussed in individual supervision. The annual appraisal has a special section for staff training. There is also an overall SCC Adults and Community Care training plan. Staff said there was no lack of training available and as well as the induction training, which includes Learning Disability Award Framework training up to level 2, disability equalities training, and anti-racism training are also compulsory for all staff. Staff have done SCIP training which involves learning how to manage challenging behaviours. Specialist training in certain health Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 20 conditions has been commissioned from the NHS such as recent training on bipolar disorder, and dementia. All staff have had epilepsy training as a significant number of residents at Hillside have epilepsy. The member of staff responsible for co-ordinating the training was both knowledgeable on the subject and had kept good records of training activities and opportunities. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 21 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): 37,38 and 42 Residents at Hillside benefit from a well run home, where the management style is open, positive and inclusive. EVIDENCE: Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 22 The manager at Hillside has now completed her registration with CSCI and just completed her Registered Managers Award and NVQ4. The manager 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. 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. The home is generally safe and well maintained and resident’s safety is a priority. On the day of the inspection there was plenty of evidence of appropriate risk assessments being carried out, the COSHH cupboard was locked, and the Council’s own health and safety officer had recently been to Hillside to carry out a health and safety inspection. A great deal of effort is put into residents food handling and hygiene skills, and some residents have a certificated course on this subject. However, some issues were picked up including a bed which was being temporarily stored in the fire escape stairwell. The water temperatures are being monitored but some outlets are often as low as 37C; all outlets accessible to residents should be regulated as close to 43C as possible. In areas where water needs to be hotter, such as kitchens and the laundry, risk assessments must be carried out. The home did not have an up-to-date legionella certificate available on the day of the inspection and this needs to be followed up. Roller towels have been installed throughout the home but one of the towels in a toilet area had come adrift and needed repairing. Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT 37 3 38 3 39 X 40 X 41 X 42 2 43 x Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 X X X X X 4 X 4 3 3 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 x Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 24 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 YA6 Regulation 15(2)(a) Requirement Timescale for action 01/06/06 2. YA42 13(4)(a) (b)(c) 3. YA42 13(4)(a) (b)(c) 13(4)(a) (b)(c) 4. YA42 The home must continue with the up-dating of care plans into a format which residents can appreciate and understand. The project is funded until June 06 by which time all new care plans will need to have been completed. The recommendations made by 07/12/06 the environmental health department of the local council should be carried out in a timely manner. Beds and drawers temporarily 08/11/05 stored in the corridor and stairwell should be removed as soon as possible. The water outlet temperatures 14/11/06 should be controlled to around 43C in areas accessible to residents. In areas where water is required to be hotter, (e.g. the kitchen and laundry) a risk assessment should be carried out. An up-to-date certificate regarding legionella safety should be available for inspection. DS0000034532.V263599.R01.S.doc Version 5.0 Hillside Resource Centre Page 25 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 YA20 Good Practice Recommendations The home should include CSCI on the list of agencies to inform in the event of a medication error. The community pharmacists visit appears to be overdue and should be chased up as set out in the report. The towel in one of the new roller towel holders needs to be replaced/repaired. 2. YA42 Hillside Resource Centre DS0000034532.V263599.R01.S.doc Version 5.0 Page 26 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.V263599.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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