Inspection on 10/08/06 for Hilltop

This inspection was carried out on 10th August 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilltop 23/10/07

Hilltop 29/11/05

Hilltop 14/07/05

Hilltop 04/11/04

Hilltop 02/06/04

Hilltop 18/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Hilltop 1 The Drive Walthamstow London E17 3BN Lead Inspector Rob Cole Unannounced Inspection 10th August 2006 10:00 Hilltop DS0000007271.V306742.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 Hilltop DS0000007271.V306742.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. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilltop Address 1 The Drive Walthamstow London E17 3BN 020 8520 5348 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) MCCH Society Limited Ms Sue Farress Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: Hilltop is a residential home providing support and personal care to five adults with learning difficulties. All current service users moved into the home from the former Leytonstone House Hospital in 1991. The home is situated in a residential area of Walthamstow, in the London Borough of Waltham Forest, and is close to shops and other local amenities, including transport networks. All service users have their own bedrooms, and share a communal lounge, conservatory, kitchen/dinning area, and garden and bathroom and toilet facilities. The home is operated by MCCH Society Ltd, and the property is owned by Circle 33 Housing Association. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 10/8/06 and was unannounced. The inspector had the opportunity of speaking with service users, staff, and the homes manager was present for most of the inspection. Overall the inspector believes this to be a well run home, service users informed the inspector that they are happy with the level of care and support provided. There are however some issues that must be addressed, as highlighted within the report. What the service does well: 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. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 6 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 Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 7 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): 1,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that prospective service users are provided with sufficient information to make an informed choice about the home. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Service User Guide and Statement of Purpose in place. Both documents are written in plain English, and the Guide has also been produced in pictorial form. Service users have been provided with a copy of the Guide. The Guide includes details of the homes physical environment and a copy of the homes complaints procedure, and is in line with National Minimum Standards (NMS). However, the Statement of Purpose is not fully in line with NMS, for instance it does not state the age range of service users the home is registered to accommodate. Furthermore, the Statement has not been dated, and there is no indication of when it was last reviewed, or is next due to be reviewed. It is required that the home has a Statement of Purpose in line with NMS and the Care Homes Regulations 2001, that is dated and subject to regular review. The home is registered to provided accommodation to adults between the ages of 18 and 65. However, two of the current service users are over the age of 65. If the home is to continue to provide support to service users outside its Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 8 category of registration, it must apply for a variation of registration to demonstrate how it can meet their assessed needs. Although there have been no recent admissions to the home, there is a policy in place covering admissions. This indicated that prospective service users would be able to visit the home before making any decisions as to move in or not. The policy also stated that the placement would be reviewed after six months. Each service user has a contract/statement of terms and conditions, which include details of rooms to be occupied, duties and responsibilities of each party, fees charged, what they cover and what is extra. These documents have been signed by the homes manager and service users have also signed them. Hilltop DS0000007271.V306742.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): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the inspectors view that service users have control over their daily lives, and that they are involved in the day to day running of the home. However, the home must ensure that service users have regular reviews of their needs and care plans. EVIDENCE: Individual care plans were in place for all service users, these were clear and comprehensive. Plans are drawn up with the involvement of the service user, their keyworker and the homes manager. Plans cover needs associated with mobility, medication and health and social and leisure needs. However, service users do not have regular review meetings to review their needs and care plans, for example for four of the service users their was no evidence of any such review meeting taking place in the past two years. It is required that service users have regular review meetings of their needs, at least every six months. Risk assessments are also in place for all service users. The inspector was pleased to note that these have been updated since the previous inspection, Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 10 and are now comprehensive, covering risks associated with smoking, household tasks and accessing the community. Risks have been clearly identified, and strategies are in place to manage and reduce risks. Through observation and discussion there was evidence that service users have control and choice over their daily lives. On the day of inspection service users were able to get up at a time of their choosing, and had choice over mealtimes and how to spend their time. One service user informed staff that they wished to go out for a walk, and this was arranged. Regular service user meetings are held, where service users have the opportunity of discussing issues of importance to them, including menus and activities. Since the last inspection some of the bedrooms have been decorated, and service users were involved in choosing the new décor. The home has a confidentiality policy in place, which makes clear that on occasions a confidence may have to be broken in the health, safety and welfare interests of service users and others. Confidential records are stored in a locked filing cabinet, which staff and service users can access as appropriate. Staff spoken to demonstrated a good understanding of issues around confidentiality. Hilltop DS0000007271.V306742.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are able to live generally valued and fulfilling lives, although the home must ensure that service users have access to day services and community based social and leisure activities as appropriate. EVIDENCE: No service users are currently involved in any formal educational or employment opportunities. However, there are in house programmes in place to help develop independence and living skills, such as cooking and laundry. Of the five current service users, two have access to day services, and both informed the inspector that they valued this very much. Day services provide a variety of activities, such as day trips and bowling, and service users are involved in planning these activities. Two other service users originally had access to day services when they first moved into the home, but these were cancelled, despite the service users enjoying them. Service users spoken to on the day of inspection informed the inspector that they would wish to have access to day services once again, and it is a repeat requirement that service Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 12 users have access to appropriate day services in line with their assessed needs and stated preferences. Service users have access to the community, for example to shops, banks, parks etc. The inspector was pleased to note that since the previous inspection, service users are now able to visit a place of worship with a frequency of their choice. Service users use public transport. Service users have access to a variety of social and leisure activities in house. Service users have access to television, video, music, puzzles and games. The home has a fishpond which service users help maintain. All service users receive a weekly aromatherapy massage from a visiting masseur. However, the inspector was disappointed to note that service users have only limited access to community based social and leisure activities. For example, the care plan for one service user stated that they should have at least three social outings a week, yet records indicated that in the two weeks prior to inspection the only social outing they had been offered was one trip to the park. It is a repeat requirement that service users are offered appropriate and sufficient community based social and leisure activities in line with their assessed needs and stated preference. All service users are offered at least a weeks annual holiday away from the home as part of their basic contract price. Service users are involved in choosing and planning holidays. Holidays planned for later this year include Blackpool, Centre Parks and Weston Supermare. The home has a visitors policy, and visitors are able to visit at any reasonable hour, and see service users in private. Service users have access to use a telephone in private if they so wish. Service users are able to plan the menu at their weekly meetings. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Fresh fruit was available on the day of inspection, and service users were able to help themselves to drinks and snacks. The kitchen was clean and tidy, and food was stored appropriately. The home keeps daily records of fridge and freezer temperatures. However, these indicated that the fridge temperature was regularly between 10 and 16 degrees centigrade, and indeed, it was 18 degrees centigrade on the day of inspection. In the interests of food hygiene and health and safety it is required that the fridge is maintained at a temperature of between 1 and 8 degrees centigrade. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is generally able to meet the personal and health care needs of service users, although service users must have regular access to dental care. EVIDENCE: Guidelines were in place on providing personal care to service users in care plans. These guidelines indicated that staff encourage service users to do as much of their personal care for themselves as possible. Service users choose their own clothes to wear, and all were appropriately dressed on the day of inspection. All service users have a designated keyworker, and keyworkers spoken to showed a good understanding of service users care plans. All service users are registered with a GP. Records are maintained of medical appointments, including details of any follow up action necessary. Records evidenced that service users have access to a variety of health care professionals, including opticians, psychiatrists and chiropodists. However, records indicated that only one of the current five service users has had access to dental care in the past year, and this must be addressed. The home makes Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 14 use of the Continence Advisory Service, who supply advice and continence products. Used continence products are disposed of appropriately. The home has a clear and comprehensive medication policy, and all staff undertake training before they are able to administer medications. Medications are stored in a locked cabinet, attached to the wall. No service users currently self medicate, or are on any controlled drugs. Records are maintained of medications entering the home and of those that are returned to the pharmacist. Medication Administration Record charts are maintained, since the last inspection these are now up to date and accurate. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home has taken reasonable steps to help ensure the safety and protection of service users. EVIDENCE: The home has a complaints procedure, which was prominently displayed within the home. This includes timescales for responding to any complaints received, along with contact details of the CSCI. The home also had a complaints log, although the manager informed the inspector that the home has not received any complaints since the previous inspection. The home has a copy of the Local Authorities adult protection procedure, and also its own policy and procedure on adult protection. This appeared to be in line with current legislation. Staff in the home have received training in adult protection issues, and those spoken to by the inspector demonstrated a good understanding of their roles and responsibilities with regard to this issue. The home holds money on behalf of service users in a locked safe. Records and receipts are kept of all financial transactions involving service users monies. The inspector checked several sets of finances and records at random, all of which appeared to be satisfactory. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 16 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained both internally and externally, and service users have access to adequate private and communal space. EVIDENCE: The home is situated in the Walthamstow area of the London Borough of Waltham Forest. The home is in keeping with other homes in the area, and is close to shops, transport networks and other local amenities. On the day of inspection, the home was clean and tidy, and generally well maintained both internally and externally. However, the carpets in the hallway and dining area are badly stained, and must be cleaned or replaced. This is a repeat requirement. The home consists of two sitting rooms, a conservatory, kitchen/dinning area and garden, service users are able to move freely around communal areas. The garden has appropriate garden furniture, and a BBQ. Since the previous inspection both the front and rear garden and now well maintained, and discarded furniture has been removed from the garden. The Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 17 home recently had a new kitchen fitted, and service users were involved in choosing it. The home has one shower room/toilet, one bathroom and one toilet on its own. Baths and showers have been adapted to make them accessible to service users. Bathrooms were clean, tidy and free from offensive odour on the day of inspection. All bathrooms are fitted with a working lock, including an emergency override device. All service users have their own bedrooms, including a hand basin. Rooms meet National Minimum Standards on size requirements. Rooms have been decorated to service users personal tastes, for example with family photographs. At the last inspection there was a strong offensive odour in one service users bedroom. The inspector was informed that this was largely due to the soiled carpet in the room and a requirement was set to replace the carpet. The inspector was pleased to note that the carpet has been replaced, and there is no longer a strong offensive odour in the room. Further, at the last inspection one bedroom contained a broken chair and cupboard, and these have both been replaced. Handrails are in place on the stairs, and there are handrails in all toilets. The bath and shower have been adapted to make them accessible to all service users. The garden has a serious of ramps which make all areas of it accessible to service users. On the day of inspection the home was clean and tidy. Protective clothing is available to help prevent the spread of infection. The home has appropriate washing and laundry facilities, and hand washing facilities were situated nearby the laundry room, and throughout the home. However, when the inspector arrived at the home they found the COSHH cupboard to be left unlocked, in an unlocked room, where no staff were present, although it contained several cleaning products and other substances hazardous to health. It is required that all COSHH products are stored securely at all times. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 18 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): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is staffed in sufficient numbers to meet service users needs, and that staff are sufficiently experienced and competent to carry out their duties. EVIDENCE: The home provides 24-hour care and support, including waking night staff and an emergency on-call procedure. The inspector was pleased to note that staffing levels have increased since the last inspection, and there is now an extra 37 hours of staff support a week provided. The home had a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. The home has policies in place on staff recruitment and equal opportunities. The inspector spoke to the most recent member of the staff team to start working in the home, they informed the inspector that no service users had been involved in their recruitment to the home. It is recommended that service users who live at the home are given the opportunity of been involved in all staff recruitment to the home. All staff are provided with a copy of their job description and the General Social Care Council codes of conduct. Through observation and discussion there was Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 19 evidence that staff have a good understanding of their roles and responsibilities, and have built up good relations with service users. Staff were observed to interact with service users in a friendly and professional manner, and demonstrated a good ability to communicate with service users, some of whom have complex communication needs. Staff employment records are stored centrally by the organisation, with the agreement of the CSCI. An audit of staffing records has been carried out earlier this year, separate from this inspection. The audit found that staffing records were satisfactory. All staff receive regular formal supervision from the homes manager or deputy manager. Records are kept of supervision, and staff are given their own copy. Records evidenced that supervision covers performance, service user issues and training needs. Regular staff meetings are held, all staff are able to contribute to the agenda. Minutes are maintained of these meetings, these evidenced discussions on domestic duties, service users and health and safety within the home. All staff undertake an induction on programme commencing work at the home, this includes health and safety and service user issues. Staff have access to on going training opportunities, recent staff training has included medication, supervision skills, adult protection and multi sensory concepts. Three of the eleven care staff at the home have achieved a relevant care qualification, and two more staff are currently working towards such a qualification. It is required that at least 50 of care staff working at the home achieve NVQ Level 2 in Care or an equivalent care qualification. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 20 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): 37,38,39,40,41,42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is generally well run, and that the manager is sufficiently experienced to carry out their duties. EVIDENCE: The home has a registered manager in place, who has seventeen years experience of working with adults with learning difficulties they informed the inspector that they are currently working towards the Registered Managers Award. Staff and service users informed the inspector that they found the manager to be approachable and accessible, and on the day of inspection staff were observed to interact with the manager in a relaxed manner. Record keeping within the home was of a generally good standard. Confidential records were stored securely, and staff and service users could access their records as appropriate. Policies appeared to be in line with National Minimum Standards, those checked by the inspector included adult protection and complaints, and were found to be satisfactory. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 21 Service user meetings, staff meetings and staff supervisions all contribute to quality assurance within the home. Copies of previous inspection reports were available to view in the home. However, the home could only evidence that two Regulation 26 visits have taken place in the past twelve months. It is required that monthly unannounced Regulation 26 visits are carried out, and that a report of these visits is forwarded to the CSCI, and a copy retained in the home. The home has various health and safety policies in place, including on COSHH and fire safety. Staff undertake health and safety training, for example first aid and food hygiene. Fire extinguishers were situated around the home, and last serviced on the 10/10/05. Fire exits were clearly signed and free from obstruction. Fire alarms are checked weekly, and were last serviced on the 2/6/06. The home holds regular fire drills. Hot water temperatures are checked weekly, and the home had in date certificates on PAT testing and electrical installation. However, the home could not evidence that it has had a gas safety check within the past twelve months, and this must be addressed. The home had in date employer’s liability insurance cover. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 2 2 X 3 2 4 3 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 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 3 3 2 3 Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA13 Regulation 16 Requirement The registered person must ensure that all service users have access to appropriate day services in line with their assessed needs and stated preference. (Timescale 31/03/06 not met) The registered person must ensure that all service users have access to appropriate and sufficient community based social and leisure activities in line with their assessed needs and stated preference. (Timescale 31/03/06 not met) The registered person must ensure that the stained carpet in the hall and dining area is appropriately cleaned or replaced. (Timescale 31/03/06 not met) The registered person must ensure that the homes Statement of Purpose is in line with NMS, and is dated and subject to regular review. The registered person must ensure that the home is appropriately registered to provide support to all service DS0000007271.V306742.R01.S.doc Timescale for action 31/10/06 2. YA14 16 31/10/06 3. YA24 23 31/10/06 4. YA1 4 and 6 31/10/06 5. YA3 12 31/10/06 Hilltop Version 5.2 Page 24 6. YA6 15 7. YA17 13 8. YA19 13 9. 10. YA30 YA32 13 and 23 18 11. YA39 26 12. YA42 13 and 23 users accommodated at the home, including any service users over the age of sixty-five. The registered person must ensure that regular review meetings are held at least once every six months to review the care and support needs of individual service users. The registered person must ensure that all fridges used for the storage of food in the home are maintained at a temperature of between 1 and 8 degrees centigrade. The registered person must ensure that service users have access to all health care as appropriate, including dental care. The registered person must ensure that all COSHH products are stored securely. The registered person must ensure that at least 50 of the care staff employed at the home has a NVQ Level 2 in Care or an equivalent care qualification. The registered person must ensure that monthly unannounced Regulation 26 visits are carried out, and that a copy of the report of those inspections is sent to the CSCI, and a copy retained in the home. The registered person must ensure that the home has a landlord’s gas safety check carried out at least once every twelve months. 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 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 YA8 Good Practice Recommendations It is recommended that service users are offered the opportunity of participating in the recruitment of all staff to the home. Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Hilltop DS0000007271.V306742.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!