Inspection on 23/10/07 for Hilltop

This inspection was carried out on 23rd October 2007.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilltop 10/08/06

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 23rd October 2007 10:00 Hilltop DS0000007271.V353422.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.V353422.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.V353422.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) www.mcch.co.uk MCCH Society Ltd Post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2006 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 and dining 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. The current fees charged by the home are £1219 per week. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 23/10/07 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. The homes manager was not present during the inspection, but spoke with the inspector on the telephone. The home’s senior support worker was present throughout the course of the inspection. The inspector had the opportunity of observing staff interaction with service users, and of the provision of care within the home. The inspection also included an examination of records and other documents, and a tour of the premises. The home completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection, at the request of the CSCI, which formed part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still some issues that must be addressed. In particular, the standard of risk assessments and care plans must be improved. These documents must be comprehensive, and subject to regular review. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 6 It is further required that staff do not take for personal use any medications that have been prescribed to service users, and that medications no longer needed are promptly returned to the pharmacist. 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. The summary of this inspection report can be made available in other formats on request. Hilltop DS0000007271.V353422.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 Hilltop DS0000007271.V353422.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home provides prospective service users with sufficient information to enable them 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 Statement of Purpose and Service User Guide in place. The Statement of Purpose states that the homes objective is to “Provide an empowering environment which provides each client with support, choice and opportunities to enjoy maximum independence.” The Statement includes details of the homes organisational structure and of the aims and objectives of the service. All service users are provided with their own copy of the Service User Guide. However, the Guide needs to be reviewed to be fully in line with National Minimum Standards (NMS). It does not contain all information required by the NMS, for example it does not include a description of the individual accommodation and communal space provided. Further, it also contains some out of date information, for example the details of the registered manager are Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 9 of someone who left the home last year. It is required that the Service User Guide contains accurate and up to date in formation, and that it is in line with NMS. All service users are provided with an individual contract/statement of terms and conditions. These include details of the rights and responsibilities of both parties, and the services and facilities provided by the home. There have been no new admissions to the home since the previous inspection. The home does however have an admissions procedure. This makes clear that service users will be given the opportunity of visiting the home before making a decision as to move in or not. Service users will initially move in on a trial basis. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that service users have control over their daily lives, they were disappointed to note that care planning and risk assessing where of a poor standard, and need to be improved, to help ensure that the home is able to meet all of service user’s needs in a comprehensive and consistent manner. EVIDENCE: Care plans are in place for all service users. Most of these were drawn up four years ago. Reviews consist of a member of the staff team signing the document every six months and writing “No change.” There was no evidence to suggest that the service users have been involved in these reviews, or indeed that a comprehensive review of service users needs actually took place. The home have already identified this as an area that must be improved on, Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 11 and the AQAA supplied by the home prior to this inspection states under the heading What we could do better “We need to ensure that each service user has a yearly review which is arranged by a social worker or care coordinator” and “We need to have in house six monthly reviews to review the care plan goals.” It is a repeat requirement that care plans are subject to regular review, and that service users are given the opportunity of been actively involved in these reviews. Care plans that are in place include information around personal care, health and mobility. However, they do not provide comprehensive information on how the home is able to meet service users needs around equality and diversity issues such as ethnicity and sexuality, and this must be addressed. Risk assessments are in place for all service users, but these are of a variable quality. Where service users have a history of exhibiting challenging behaviours, there are clear guidelines in place on managing this. However, other risk assessments are far from comprehensive. For example, one service user has risk assessments in place around receiving personal care, accessing the kitchen and interacting with other service users. All of these assessments state that there is a high risk in that area. Yet the controls in place to manage these risks merely state “By following safe working practices and providing one to one support.” There is no detailed information about what the safe working practices are that need to be followed. As with the care plans, the home has highlighted in their AQAA that risk assessments are an area in need of improvement, stating “Risk assessments need to be evaluated more stringently.” It is required that clear and comprehensive risk assessments are in place for all service users, which cover all potential areas of risk to the service users and others, and that these assessments include details of how these risks are to be managed and reduced. These risk assessments must be subject to regular review. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. Service users are able to get up and go to bed as they choose. Service users are able to choose whether to have a shower or bath and can choose when and what to have for lunch and choose their own clothes to wear etc. On the day of inspection two service users indicated that they would like to go out, and staff were subsequently seen to arrange this. There was evidence that service users are involved in the day to day running of the home. The home holds regular service user meetings which are minuted. These indicated discussions around menu planning and activities. The home uses pictures to help enable service users to make choices, for example over holiday destinations. Several service users have complex communication needs, and this helps to meet their needs around equalities and diversity issues. A considerable amount of work has been done to the homes physical Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 12 environment since the last inspection, such as new carpets and curtains, and service users were involved in choosing these. The home has a confidentiality policy in place. This makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of issues around confidentiality. Confidential records are stored securely, staff and service users can access their records as appropriate. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are supported to live valued and fulfilling lives, and that they have routine access to the local community. EVIDENCE: No service users are currently involved in any formal employment or educational opportunities. Two service users currently attend day services. These provide various activities and day trips, which service users help to plan. They also provide opportunities for developing and maintaining friendships. Service users have the opportunity of socializing with other homes run by the same organisation, who take it in turns to arrange parties and other social activities. The home recently held a Hawaiian theme party. One service user Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 14 has developed a close friendship with a service user from one of the other homes, and was recently able to go on holiday with them. Service users have routine access to the local community. They regularly access shops, markets, banks, parks and cafes etc. On the day of inspection one service user went to the shops, while another went to the bank, and both had lunch out. Another service user was out at their day services during the course of the inspection. The other service user at home was observed to be offered the opportunity to go out, but made the choice to stay at home. One service user regularly attends church, thus helping to meet their needs with regard to equalities and diversity issues. Since the previous inspection the home has purchased its own seven-seater vehicle, which is unmarked. The vehicles logbook evidenced that service users regularly used it to access the community, including various social and leisure activities. Recent trips have included to Southend, Broxbourne zoo and Hampton Court. Other community based social and leisure activities provided include trips to pubs and restaurants, bowling, the cinema and greyhound racing. All service users are offered a week’s holiday away from the home as part of their basic contract price, which they are able to help choose. This year service users have been to Centre Parks, and a further holiday is planned for Weston Supermare. Service users have access to activities within the home, including television, music, puzzles, and painting. An aroma therapist visits the home weekly to work with service users. Service users are also involved in daily routines, such as keeping bedrooms tidy and watering plants in the garden. The home has a fishpond. Visitors are welcome at the home at any reasonable time, and service users can see visitors in private if they so wish. Service users have access to a telephone they can use. Records are maintained of menus, these evidenced that service users are offered a varied, balanced and nutritious diet. Service users are involved in planning the menu at their weekly meeting, and in buying the food. Menus indicated that service users are regularly offered traditional British food, such as roast dinners and fish and chips, thus helping to meet their needs with regard to equality and diversity issues. There was evidence that fresh produce is regularly used in cooking, and fresh fruit was available on the day of inspection. Service users were observed to help themselves to drinks and snacks. The kitchen was clean and tidy, and food was appropriately stored. Fridge and freezer temperatures are checked daily. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is generally able to meet the health and personal care needs of service users, although it is required that staff do not use any of the service users medication for their own personal use. EVIDENCE: There was evidence that staff support service users to manage their own personal care as much as possible. Service users are able to choose their own clothes to wear, and all were appropriately dressed on the day of inspection. All service users are registered with a GP. Clear records are maintained of medical appointments, including details of any follow up action required. These evidenced that service users have access to health care professionals as appropriate, including chiropodists, psychiatrists, and since the last inspection dentists. At the time of this inspection one service user was in hospital, and Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 16 there was evidence that staff and service users have been to visit them. The home seeks advice from the Continence Advisory Service, and used continence products are disposed of appropriately. The home has a comprehensive medication policy, and all staff undertake training before they administer medications. Medications are stored in a locked cabinet, which is firmly 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 in place, those checked by the inspector were accurate and up to date. A separate chart is maintained by a second member of the staff team who witnesses the administration of medications, to help reduce the risk of an error occurring. In February 2005 one service user was prescribed PARACETAMOL, while another service user was prescribed CO-CODAMOL. These medications are no longer required by the service users. However, they had not been returned to the pharmacist. Instead, staff had put labels on both these medications, stating that they were now for staff use. The senior member of staff on duty confirmed that these were now used for staff’s personal use. Any medications that are prescribed for service users are their personal property, and they then own that medication. When a medication is no longer required, then it must be returned to the pharmacist. It is unacceptable for staff in the home to use service users medication for their own personal use, and a requirement has been made around this. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. 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 that service users are safe, and that appropriate policies and procedures are in place around complaints and adult protection. EVIDENCE: The home has a complaints procedure, a copy of which was on display within the home. The procedure makes appropriate reference to the CSCI, and includes timescales for responding to any complaints received. The procedure has been produced in pictorial form, to make it more accessible to service users, thus helping to meet their needs with regard to equalities and diversity issues. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home also has a complaints logbook, although the senior staff informed the inspector that the home had not received any complaints since the last inspection. The home has a copy of the Local Authorities adult protection procedure, and also its own adult protection procedure. This appeared to be in line with current legislation. All staff have undertaken training in adult protection issues, those spoken to be the inspector demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 18 All service users have their own bank accounts. The home holds money on behalf of service users in a locked safe. Records and receipts are maintained of all transactions involving service users monies. Those checked by the inspector appeared to be satisfactory. However, it was noted that on occasions service users will have a take away for their evening meal, and pay for this out of their own money. This also included paying for the staff on duty to have a take away. The inspector was informed by staff on duty that the organisation that runs the home provides a weekly food budget, and that it is accepted that this will provide for staff to have a meal with the service users. While this is an acceptable practice, staff should not be buying takeaway meals for themselves with service users personal money, and a requirement has been made around this. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 29 and 30. People who use this service experience good outcomes in this area. 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, 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. The home consists of a sitting room, a conservatory, kitchen/dining area, a separate dining room and garden. Service users are able to move freely around communal areas. The garden has appropriate garden furniture, and a BBQ. Both the front and rear garden are well maintained. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 20 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. Bedrooms contained adequate furniture, including chairs, chest of draws and wardrobes. However, the chest of draws in one bedroom was damaged, and must be repaired or replaced. It was also found that the hot water tap on the hand basin in this bedroom was loose, and this must be addressed. Bedding, carpets and curtains in bedrooms were well maintained, and domestic in character. Bedrooms had adequate natural light and ventilation. All bedrooms were centrally heated, and radiators had protective coverings in place. 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, thus helping to meet needs around equality and diversity issues. 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, and staff have undertaken training in infection control. The home has appropriate washing and laundry facilities, and hand washing facilities were situated nearby the laundry room, and throughout the home. The inspector was pleased to note that since the previous inspection COSHH products are now stored securely. A considerable amount of work has been carried out on the homes physical environment since the last inspection. The previous requirement that the hallway carpet be replaced has been met, and new carpets have also been fitted on the stairs and the sitting room. The dining room has been painted, and has new curtains, while the conservatory has had a new blind fitted. New furniture has been purchased for the sitting room, along with a new wide screen television. The bathrooms have had new impermeable floor coverings fitted. There was evidence that service users have been involved in choosing all this. The inspector considers that the homes physical environment has improved as a result of this work, and that it is now a more pleasant and homely environment. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet service users needs, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection, and indicated who was in charge of the home at any given time. Staff have been given a copy of their job description. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities. Staff were seen to interact with service users in a friendly and respectful manner, and demonstrated a good ability to communicate with service users, some of whom have complex communication needs. At times service users made it clear they wished to be left alone, and staff were seen to respect this. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 22 Of the eleven care staff employed at the home, six have successfully achieved an NVQ Level 2 in Care or equivalent qualification, and the other five are currently working towards such a qualification. All staff undertake a structured induction on commencing work at the home, which includes shadowing more experienced members of the staff team. Staff undertake regular training, and recent training has included Communication with Adults with Learning disabilities, COSHH awareness, medication, dementia, infection control and adult protection. The home has various employment related policies in place, including on equal opportunities and a disciplinary procedure. Staff employment records are held centrally by the organisation, with the agreement of the CSCI. The CSCI carries out an annual audit of these records, the last audit found them to be satisfactory. The inspector spoke with a member of staff who said he was employed about a year ago, and that no service users were involved in the process of his recruitment. It is a repeat recommendation that service users who live at the home are given the opportunity of been involved in the recruitment process for any staff recruited to the home. All staff receive regular formal supervision from either the homes manager or senior support worker. Records are kept of supervision, these evidenced that supervision covers performance, training needs and service user issues. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the homes management are suitably qualified and experienced, and that appropriate health and safety checks are in place. EVIDENCE: The home has appointed a new manager since the previous inspection. Although they were not present during the course of the inspection, they spoke with the inspector on the telephone, and said that they would be applying for registration with the CSCI in the near future. The home also has a senior support worker who has responsibility for some of the administrative duties. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 24 Staff and service users informed the inspector that they found the manager to be approachable and accessible. The home has various policies and procedures in place in line with NMS. Those checked by the inspector included medication and adult protection, and these were of a satisfactory standard. Rerecord keeping in the home was of a generally good standard (with the exception of care plans and risk assessments as already mentioned in this report). Confidential records are stored securely. Staff and service users can access their records as appropriate. Staff and service user meetings, and staff supervisions all contribute to the quality assurance within the home. Service users are issued with questionnaires to gain their feedback on the home, completed questionnaires seen by the inspector contained generally positive feedback. Copies of previous inspection reports are available to view in the home. However, the inspector was disappointed to note that the home could only evidence four Regulation 26 visits having taken place in the past twelve months. It is a repeat requirement that monthly unannounced Regulation 26 visits take place, and that a copy of the report of these visits are maintained within the home. Fire extinguishers are situated around the home. These were last serviced in April 2007. The fire alarms are checked by the home on a weekly basis, and regular fire drills are held. Fire alarms were last serviced on the 10/8/07. The home has in date certificates for PAT testing, gas safety and electrical installation. COSHH products were stored securely. The home tests fridge/freezer and hot water temperatures. The home has in date employer’s liability insurance cover in place. Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 25 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 3 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 3 3 3 3 Hilltop DS0000007271.V353422.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement Timescale for action 31/12/07 2. YA39 26 3. YA1 5 4. YA9 13 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, and that care plans are comprehensive, covering all areas of need, including needs around equalities and diversity issues. (Timescale 31/10/06 not met) The registered person must 30/11/07 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. (Timescale 31/10/06 not met) The registered person must 31/12/07 ensure that the homes Service User Guide contains accurate and up to date information, and that it is in line with National Minimum Standards. The registered person must 31/12/07 ensure that clear and comprehensive risk assessments are in place for all service users, covering all areas of potential DS0000007271.V353422.R01.S.doc Version 5.2 Hilltop Page 27 5. YA20 13 6. YA23 13 and 16 7. YA26 23 risk to service users and others. These assessments must be subject to regular review. The registered person must ensure that any medications no longer required by service users is returned promptly to the pharmacist, and that no persons other then the service user it was prescribed for take any medications. The registered person must ensure that when service users use their own personal money to buy themselves take away meals, their personal money is not used to buy take away meals for staff. The registered person must ensure that the broken chest of draws and sink tap in the ground floor bedroom are repaired or replaced. 31/10/07 31/10/07 30/11/07 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 YA34 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.V353422.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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