Inspection on 07/03/07 for Hilltop

This inspection was carried out on 7th March 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilltop 25/02/09

Hilltop 28/02/06

Hilltop 02/11/05

Hilltop 07/03/05

Hilltop 11/05/04

Hilltop 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hilltop Ridge Walk Ruardean Hill Drybrook Glos GL17 9AY Lead Inspector Mr Nick Jones Unannounced Inspection 7th March 2007 10:00 Hilltop DS0000016468.V328701.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 DS0000016468.V328701.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 DS0000016468.V328701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilltop Address Ridge Walk Ruardean Hill Drybrook Glos GL17 9AY 01594 542026 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.orchard-trust.org.uk The Orchard Trust Mrs Donna Ann Rickards Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Hilltop is a purpose built detached six-bedroom house situated in the Forest of Dean. The home is part of Orchard Trust and has other homes within the area. The home currently provides permanent residential care and respite care for adults with learning and physical disabilities. The home provides an additional respite day care service to service users’ from neighbouring areas. On the ground floor there are five single bedrooms, kitchen, laundry-room, communal dining area and two communal lounges. There are also two bathrooms one is currently being decorated and an additional toilet. On the first floor there is one single bedroom with en-suite facilities and the office. The gardens and the ground floor are fully accessible to wheelchair users. The bathrooms have been adapted to meet the needs of service users with physical disabilities. The home has its own vehicles such as the use of a saloon car and minibus. The respite service is funded by Social Service on a block-funding basis. Prospective service users and others involved in their care are offered information about the home including copies of the Statement of Purpose and Service Users Guide. The weekly fees charged by the home range from £1273 to £1497. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service. The inspection took place during one day on the 7th February and a morning one week later. During the visits various documents were checked including examples of care plans, risk assessments, medication charts, health and safety records, daily records and staffing files. Some staff and service users were spoken with and time was also spent with the acting manager. Some general observation of life in the home took place and the premises were inspected. All staff were helpful and knowledgeable during both days of the inspection. Before the visit survey cards were sent out to staff, visiting health professionals and to relatives of service users, providing written feedback. The Commission had received an anonymous complaint since the previous key inspection. This was investigated by the Commission as a Random Inspection in May 2006. None of the complaints were substantiated, although three recommendations were made, which the home has acted upon. What the service does well: The home works well to support both permanent and respite service users at the home. They work well to support people with a wide variety of support needs. The home provides a person centred approach in all areas of daily living which enables the service users to exercise control over what they do and in the choices they make. The staff team support service users to maintain/ and or develop their skills to be independent. Service users’ files contain, in the main, information that is detailed and up to date which assists staff to support service users appropriately. Staff receive a comprehensive induction and appropriate on-going training including NVQ qualifications. Comments from a person using the service included; “ I like staying here” and “ staff ask me what I like to do”. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 6 A comment card from a health professional working with the home stated they are a ‘professional and welcoming staff group’ 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. The summary of this inspection report can be made available in other formats on request. Hilltop DS0000016468.V328701.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 DS0000016468.V328701.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&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide give people living at the home and people wishing to live/stay there information about the services provided. Good arrangements are in place around referrals and admissions, increasing the likelihood that appropriate admissions will be made. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. Work has taken place across the Trust to produce an updated format for all of the registered services that will then be adapted for each individual service. It is detailed and comprehensive with all relevant information updated. It will be produced in symbol format in due course. It was recommended details should be added about communal areas such as the kitchen that were kept locked at certain times of day and the reasons for this. The home has an appropriate admissions procedure. Service users’ files contained copies of needs assessments and care plans by both social services and the home. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 9 The acting manager described the admissions process for two recent new respite admissions. They included a visit by the acting manager to meet the potential service user in their home to complete the needs assessment and visits to Hilltop. Hilltop DS0000016468.V328701.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place around care planning that promotes consistency and best practice. People’s choices are ascertained and respected as far as possible, helping to empower service users to take control of their lives. Arrangements are in place to assess and manage risks, promoting service users’ safety with minimal restrictions and limitations. EVIDENCE: The care plans of the two permanent service users and two respite service users were viewed in more detail. They contained detailed and clearly written plans that described how staff should support service users in a wide range of assessed needs. This included support needs such as manual handling, personal and health care, support at night, eating and drinking, contact with family, accessing community facilities, use of money, use of the kitchen and Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 11 independent living skills. These plans were regularly reviewed with service users having annual reviews often involving staff from day services and family members. Files also contained details of known likes and dislikes in aspects of life such as activities, food and communication. They also contained details of day care programmes, daily notes, prescribed medicines, accidents or incidents, best interest forms, specialist health assessments, health appointments and risk assessments, which were being regularly reviewed and amended if necessary. The risk assessments related to activities described in care plans. The files contained evidence that clinicians from the local CLDT(Community Learning Disability Team) are often involved in assessing and supporting both service users and the staff team. Some of the files contained old information and would benefit from some archiving. Some personal file entries were not signed and dated to indicate when a plan or assessment took place. Discussions with service users showed they were involved in the process of care planning. Files indicated where a service user had chosen their key worker. Staff were clear that service users were able to make their own decisions as much as possible. Service users were observed to make choices about where they spent time and with whom. Limitations to choices are documented as to why it is in the person’s best interests. Minutes were viewed of monthly house meetings held for service users to discuss issues important to them. One service user stated they liked being able to talk about things. Topics discussed included activities and menus. Respite service users often live at home with relatives or carers and the home aims to support those service users who wish to develop independent living skills. These activities are appropriately risk assessed. Other risk assessments showed the home takes action to minimise risks and hazards in activities such as using the kitchen, going out in a vehicle and personal care. The storage of service users’ files and the position of the medication cabinet were discussed. The possibility of building a wooden, domestic-looking cupboard to box in the medication cabinet in the dining room was discussed. Previous inspections had required the removal of a filing cabinet from the dining room containing some service users’ files. The acting manager asked whether space in the boxing-in of the medication cabinet could be used to store some files. This was considered by the inspector and was agreed after further discussions following the inspection. The home must produce a protocol in addition to their confidentiality policy that describes how files should be securely stored, when they were to be accessed in the dining room and limitations to discussions taking place in communal areas that may be confidential to a service user. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are enabled to access a range of local facilities and activities that promote their independence and community presence. The home is striving to provide an environment that promotes the rights and responsibilities of people living there. Freshly cooked meals are produced which provide a nutritional and balanced diet. EVIDENCE: The two permanent service users have weekly timetables of activities that include attendance at the trust’s day centre, the Barn, which offers a wide range of activities. They also have sessions to go out shopping with staff and to undertake chosen activities at home. Sessions at Artspace and the Triangle social club were also offered. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 13 Service users were being offered a wide range of leisure activities including going swimming, trips to the cinema, cafes, pubs and going for walks. The home also provided activities in the house such as arts and crafts, jigsaw puzzles, video games, karaoke and snooker. Activity sheets in personal files keep a record of activities undertaken both at the home and using community facilities. Social and family relationships are encouraged and supported and most service users have contact with family/friends. Service users were able to use the telephone in the house or their own mobile phones. The home attempts to enable respite service users to spend time at the service when other people they get on well with are also staying. Staff described flexible routines operating in the home; such as the times people went to bed and when people had a drink or snack. This corresponded to care plans and to observations over the two days. People living in the home were seen to move around freely and to treat Hilltop very much as their home even though most service users were respite users. Survey cards from relatives provided further evidence to back up this impression. Staff were seen to be respectful and sensitive to people’s individual needs and wishes. Service users were also seen to be involved in some household routines where possible. Menus and records of food consumed provided evidence that people living in the home were offered a varied, balanced diet including fresh ingredients. Staff described how service users were offered choice around food and drink. Respite service users were asked about their food preferences at the beginning of their respite stays. Likes and dislikes were recorded in personal files. Meetings held monthly for service users to discuss issues at the service recorded food preferences expressed by service users that were incorporated into menus. A meal was observed. People ate together in the dining room in a relaxed atmosphere and appeared to be enjoying their food. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. The support and guidance offered to service users by staff and health professionals ensure personal care and health care is adequately provided. The procedures for the prescribing, storage and administration of medicines ensures the health and welfare of service users is maintained. EVIDENCE: Care plans provided good detail about how people like to be supported with personal care that included clearly written details about moving/ handling and hoisting procedures. Respite service users’ personal care plans were amended during respite stays if staff observed changes in support needs. Staff were seen offering personal care support in a sensitive manner. Staff spoken with described how they met personal care needs in ways that respected people’s preferences, privacy and dignity. Records are kept of health related appointments and recommendations from health professionals such as occupational and physiotherapists are implemented. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 15 They also showed that the prescribed medicines are appropriately reviewed with their GP. Local CLDT (Community Learning Disability Team) clinicians have supported the staff team with a variety of needs of service users. One returned comment card from a CLDT clinician stated the staff group was welcoming and professional. Staff administer medicines and there was a record of the receipt, administration and disposal of prescribed medicines. All were accurate and up to date. Medicines were being stored appropriately. The home has a medication policy. The acting manager described the checks undertaken by two staff on medicines brought by respite service users. Any medicines not in their original containers are not accepted. Staff have, on occasions, made contact with relevant GPs if there were any queries about a person’s medication as they arrive at the home. Staff have received training in the safe handling of medicines. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ lives are improved and protected by staff that are focused on the needs of the individual. The home’s complaints procedure enables it to respond appropriately to concerns brought to their attention. Staff are aware of adult protection and complaints procedures. EVIDENCE: Discussions with staff and service users, and viewing service user’s files showed that the staff team have good information about how best to ascertain the needs and wishes of service users as much as is possible. Speech and Language therapy clinicians from the local CLDT (Community Learning Disability Team) provide support to the home. The acting manager stated relatives/friends and are encouraged to express any thoughts or concerns when visiting the home. The home has received an anonymous complaint since the previous key inspection. This was investigated by the Commission as a Random Inspection in May 2006. None of the complaints were substantiated, although three recommendations were made, which the home has acted upon. Several staff had recently attended training about the protection of vulnerable adults, with other team members due to attend in the near future. Staff spoken with had a good understanding of adult protection issues and their responsibilities in this area. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 17 Records of service users’ finances were sampled and those seen appeared to be in order. Respite service users who are able sign an agreement for each visit to confirm the arrangements for who manages their cash. Some manage their own money and others have cash tins that were kept safely by the home. Balances were checked every day and two cash tins sampled were accurate and up to date. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, homely and comfortable environment is provided, promoting service users’ quality of life. EVIDENCE: All communal areas and all of the occupied bedrooms were checked during the inspection. Hilltop was seen to be homely and comfortable throughout, with service users’ rooms being attractively decorated and personalised. Most of the bedrooms have been fitted with overhead tracking. One bedroom has an ensuite shower. The respite bedrooms have been painted in different colours to offers service users some choice. There was a specialist bathroom with an adapted bath and overhead tracking. It has a music system controlled from the laundry. There was a shower room with shower chair also available to service users. The second ‘quiet’ lounge had been fitted with additional sensory equipment, including ‘soundlab’ lighting, a glitter ball and black-out curtains. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 19 The home was found to be clean and hygienic. Staff have access to disposable gloves, aprons and laundry bags. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 20 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): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support is provided by a skilled, well-trained and supervised staff team, helping to ensure that service users’ needs are met. The manager has a sound understanding of recruitment and selection ensuring service users are protected. One aspect of keeping a record of PoVA First checks must be improved. EVIDENCE: Discussions with staff and the acting manager and viewing records and care practice in the home showed there is a skilled and committed staff team working to meet the needs of service users. Team meeting minutes, service user’s files and discussions with staff showed the staff team work to review how they are able to continue to meet the needs of service users. The home has 50 of the team with an NVQ 2 in health and social care qualification or above. Five staff were undertaking their NVQ 2 or 3 qualifications. Two comment cards returned by CLDT clinicians provided further evidence that the home was well supported by other health professionals. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 21 There was a minimum of three staff on duty at all times, as well as the acting manager during the inspection. This pattern was repeated in duty rotas viewed with several shifts having four staff on duty. One waking night staff works alone at night with a member of staff sleeping in for additional support if required. The Trust has a senior staff on-cal duty rota. Staff at the home would be able to call additional numbers if the allocated person was not responding for any reason. The acting manager stated that she and the deputy manager have communicated to staff that they are happy for staff to call them out of hours in an emergency. Three staff files were viewed and found to contain most of the details as required under Schedule 2 including details of CRB checks. A print out of PoVA First checks was not available in the home but was kept at the Trust’s main office. Discussions took place as to how human resources staff at the main office should forward the PoVA`First e-mail to the manager for the home to print off and retain a copy as evidence. The acting manager stated the one newly recruited member of staff was waiting for their CRB clearance before commencing in post as they were employed as a waking night member of staff. A training matrix was being maintained identifying what training has been undertaken and when planned training is due. New staff were provided with an in-house induction and the LDAF (Learning Disability Award Framework) induction. Staff said that they were attending a range of mandatory training and refresher courses. This included manual handling, safe handling of medicines, adult protection, first aid, fire safety and food hygiene training. Training specific to the needs of people living at the home is provided if needed. Training in specific procedures relating to service users with epilepsy was being provided. There was evidence that staff are being well supervised and there are good communication systems between staff, which enable them to offer flexible support to the service users. Staff were receiving recorded supervision sessions. Staff surveys indicated that team members felt that they worked well together and provided high quality care to clients. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from a dedicated and committed manager and acting manager who promotes good care practices and a person centred service. Service user’s and their relative’s views and preferences inform the aims of the home and staff practice. The home does not have a formal quality assurance system to evidence some of their consultative work with service users and their relatives. Health and safety monitoring is taken seriously in the home to ensure service users live in a safe environment. EVIDENCE: The Registered Manager had been on maternity leave and was returning to work on a gradual basis. She was not present during this inspection. The Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 23 deputy manager has managed the home in her absence. She has worked at the home for many years. The Head of Care has been visiting the home twice a week to support the acting manager and has been in daily phone contact. Monthly Regulation 26 visits were taking place and copies of these were available for inspection at the home. Staff surveys and returned comment cards were positive about the management and support for staff at the home. The acting manager stated she would be attending a course on Equality and Diversity that may be provided for other staff at the home. There was evidence that service users were being consulted to take account of their views. This was found in personal files and service user’s monthly meetings. Changes to activities and menus were seen to have responded to views expressed by service users. The home makes contact with relatives before a respite stay to discuss any issues relevant to the service user. Staff will attend annual reviews, often held at the person’s day centre, along with the service user and their relatives. Some service users have a communication book that passes between the relatives, day centre staff and staff at the home. The notice board in the hallway had cards of appreciation on it from relatives of service users. The acting manager stated a survey was sent out to relatives approximately two years ago. It was suggested this exercise should be repeated and that a satisfaction survey might be devised for some service users. Health and safety aspects of service provision are being maintained and monitored. Records viewed included fire safety checks, fire drills, water temperatures and servicing of equipment. A new Fire Safety risk assessment had been produced in September 2006, in line with recent changes to fire safety legislation. It was recommended that the home contact the Gloucestershire Fire and Rescue Service to confirm arrangements for evacuation in the event of a fire to meet the requirements of the new Evacuation Strategy. Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 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 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Hilltop DS0000016468.V328701.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19(1)Sch 2.7 Requirement When PoVA First information comes through on the email it must always be printed off as evidence and put on the individual personnel file in the home. Timescale for action 30/05/07 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 YA1 Good Practice Recommendations The Statement of Purpose and Service User Guide should describe details of any communal areas of the home that are kept locked, such as the kitchen and laundry, are detailed and the reasons why it is necessary. Care plan entries should be signed and dated. Personal files should be organised to archive old information. A protocol should be produced that describes how personal files would be securely stored and used in the proposed cupboard in the dining room. Surveys of the views of service users and relatives should be undertaken. DS0000016468.V328701.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. YA6 YA6 YA10 YA39 Hilltop 6. YA42 The home should contact the Gloucestershire Fire and Rescue Service to confirm arrangements for evacuation in the event of a fire meet the requirements of the new Evacuation Strategy. 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