Inspection on 14/11/07 for Hilton Road

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hilton Road 03/11/08

Hilton Road 18/09/06

Hilton Road 23/08/05

Hilton Road 27/02/05

Hilton Road 14/10/04

Hilton Road 27/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Hilton Road Hilton House 92 Hilton Road Lanesfield Wolverhampton West Midlands WV14 6DR Lead Inspector Rebecca Harrison Key Unannounced Inspection 14th November 2007 11:30 Hilton Road DS0000037693.V351202.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 Hilton Road DS0000037693.V351202.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. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilton Road Address 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) Hilton House 92 Hilton Road Lanesfield Wolverhampton West Midlands WV14 6DR 01902 820069 01902 651616 Arcare (West Midlands) Limited Mrs Suman Bala Sharma Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last key inspection 18th September 2006 Brief Description of the Service: Hilton House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and care for a maximum of three adults with a learning disability. The registered provider is Arcare Limited. Mr Raj Kishan Sharma is the responsible individual and the registered manager is Mrs Suman Bala Sharma. The property is semi-detached situated in a residential area of Lanesfield; approximately 3 miles from Wolverhampton City centre and is accessible to local amenities, transport and relevant support services. Accommodation is provided over two floors. People are provided with single bedrooms and shared areas include a lounge, dining room and kitchen. A small paved garden is provided at the rear of the property. The homes philosophy is to Maintain a high standard of care, respecting individuality, privacy, residents dignity and independence at all times. First and foremost a happy and secure environment within the home. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged range from £389.00 to £575.00 per week. This fee information was not available in the Service User Guide as required; therefore the reader may wish to obtain more up to date information direct from the service provider. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 14th November 2007 by one inspector over six hours. A random unannounced inspection was also undertaken on 12th February 2007 to review the requirements made at the previous key inspection. Four of the five requirements had not been met and a letter detailing the outcome was sent to the provider. A range of evidence was used to make judgements about this service to include discussions with all three people who receive a service, staff on duty, the registered manager and a tour of the home. The inspector also looked at a number of records and observed aspects of care provided for two people using the service. Before the inspection we received surveys from three people and some of their comments have been included in the report. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to Hilton House for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The deputy manager completed this and some comments have been included within this inspection report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review all 5 requirements that were made as a result of the previous key inspection undertaken in September 2006. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: People using the service appear happy living at Hilton House and lead active lifestyles. Staff are provided with excellent training opportunities and have attended training in safe working practices and training specific to the needs of the people they support. All of the staff hold a recognised care award known as a National Vocational Qualification, which exceeds National Minimum Standards. The team are very good with monitoring peoples health needs and making referrals to the appropriate health and social care professionals as required. Some of the comments that we received include: Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 6 ‘I love it here and the staff are alright’ ‘My relatives medical needs are addressed regularly and promptly and health is monitored meticulously. Staff are always welcoming and it is always a pleasure for me to visit Hilton. Thanks to all of the carers for their hard work and love shown towards the residents’ ‘We treat the residents very well and respond to their every need as best we can’ ‘My relative led a very sheltered life with her parents and this home was a breath of fresh air’ What has improved since the last inspection? What they could do better: It is acknowledged that the provider has made some improvements to the environment however more investment is required to provide people with a more comfortable and homely place to live. Rooms still appear tired and cold in appearance and some furniture and fittings are not fit for purpose. The plaster damage to the first floor bathroom, as identified at the previous inspection, has yet to be repaired and must be attended to as a matter of priority. Quality assurance systems require further development to assess performance and evaluate outcomes for people using the service. Discussions held with service users and observations made indicate that people could be provided with greater opportunities to develop their independence for example, by helping prepare their own meals, cleaning etc based on a risk assessment. Staff should develop a greater understanding of empowering the people they support. Some of the comments that we received about how the home could improve include: Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 7 ‘Provide a variety of food so that residents don’t eat the same kind of food all of the time’ ‘May be keep them more happy’ 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. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 8 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 Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service User Guide in place however both documents require updating to ensure people are provided with accurate information about the service. EVIDENCE: A Statement of Purpose and Service User Guide are available in a standard format. The Statement of Purpose was last reviewed and updated in August 2005 and the Service User Guide requires updating to reflect the changes in the Care Homes Regulations, amended September 2006. Managers committed to undertaking this at the earliest opportunity to ensure people have up to date information about the service. There have been no new admissions to the service for two years therefore key standard 2 was not assessed on this occasion. We received a survey from a relative stating: ‘We found this home after visiting several others. This was most suitable for my relatives needs. We had several visits to view the home and spoke to several staff but even on out first visit we knew this was the best place for my relative’. Hilton Road DS0000037693.V351202.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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are provided with information to ensure service users’ assessed needs are met. The people who use the service are supported to make decisions and enabled to take responsible risks. EVIDENCE: The self assessment completed by the provider states: ‘The home strives to empower service users care by valuing diversity, making advocacy available, actively listening to build a supportive relationship, offering choices and using person centred approaches’ Care documentation held on behalf of two people using the service was examined. Basic support plans were available with evidence of review. The deputy manager stated that staff are currently revising one persons support plan in conjunction with other staff working at the home to ensure consistency across the team. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 11 Staff spoken with had a good understanding of the needs of the people they support and considered they are provided with sufficient information to effectively support people. Both files seen evidenced that individuals had been formally reviewed with significant others. Reviews are being held for one individual on a monthly basis due to events in his life. It was reported that a person centred plan is being drawn up with an advocate to support the person through change. Both service users spoken with confirmed that they attend their reviews, which was also evidenced in the minutes of meetings seen on file. A behaviour management plan developed in conjunction with the Intensive Support Team was available for one individual as required by the previous key inspection. The plan was comprehensive and evidenced that staff have met regularly with psychology and explored issues to include factors that influence and reduce behaviours and how best staff can support the individual concerned. It was reported that the person’s behaviours have signicantly reduced and the person has since been discharged from psychology services but that staff can seek advice if required. One person receives a service from an independent advocate who represents his best interests at monthly reviews. Families also represent service users as evidenced in discussions with a visiting relative. Assessments to support individuals with risk taking were available on the two files examined to include personal care, mobility, medication, finances, health, activities and the community. Managers were advised to update these in conjunction with support plans. Hilton Road DS0000037693.V351202.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): 12,13,15,16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service have a community presence and are encouraged to keep in contact with their family and friends but may benefit from a more balanced and varied diet. EVIDENCE: Two people access external day provision five days per week and discussions held with them indicate they enjoy attending these services. The other person receives funding for six hours a day after declining to attend a day service. The person told the inspector that she prefers to stay at home with staff and go out visiting friends, shopping and having meals out. She reported that a relative regularly visits her. Records seen and discussions held with the people using the service indicate that routines are flexible and that people are given choice. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 13 Staff spoken with had a good understanding of people’s rights and responsibilities. Discussions indicate that the team advocate in the best interests of the people they support. Daily records evidence that people are part of the local community and are provided with good opportunities to develop friendships and maintain contact with families. A relative visited the home during the inspection and was very complimentary about the service and it was evident that the staff have developed positive working relationships with him. People’s specific dietary requirements were documented on records seen. The home has a basic seven-day menu in place and a record of meals eaten was available. These suggest that people could be offered a more balanced and varied diet for example records for one person mainly consisted of soup and sandwiches. We received a survey that considered the home could improve by providing ‘A variety of food so that residents don’t eat the same kind of food all of the time’. Managers reported that people are encouraged to eat healthily and that the menu is basic but alternatives are provided. All three service users spoken with said that they like the food that staff cook for them. One person reported he does cookery at college and enjoys this. Managers were advised to look at providing opportunities for people to develop their skills for example by taking an active part in meal preparation and cooking based on a risk assessment. Hilton Road DS0000037693.V351202.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 health and personal care that people receive is based on their individual needs and advice is sought from healthcare professionals to ensure their health needs are monitored and met. The home has a satisfactory system of handling, storing and managing medication, which safeguards the people who use the service. EVIDENCE: People’s preferences concerning their personal care support needs were available on the two files seen. Records evidence that the healthcare needs of service users is paramount and the team are proactive in referring individuals to health and social care professionals as required. Annual health checks are undertaken by the community nurse and general practitioner, outcomes recorded and recommendations followed up. A survey received in preparation for this inspection stated: ‘My relatives medical needs are addressed regularly and promptly, her health is monitored meticulously’. One person was recently admitted to accident and emergency and although a full account of the Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 15 circumstances were held on file the home failed to notify us, as required under Regulation 37. On the morning of the inspection two people attended an appointment at their surgery. Outcomes of appointments were well documented. Medication procedures were discussed with the deputy manager who demonstrated a clear understanding of how medication is managed within the service. It was reported that all staff have attended accredited training via the distance-learning route provided through the local college, as confirmed by a member of staff on duty. Staff have also received training on the monitored dosage system, which is currently used within the home. Managers were advised that staff competency to administer medicines should be regularly assessed and the outcome documented. There have been no errors concerning medication reported to us since the last key inspection. Staff have access to useful literature on common health conditions to include dementia, depression, sleep, continence and side effects of medicines. Hilton Road DS0000037693.V351202.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 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Procedures to safeguard service users from potential abuse are in place but require further development. Staff are provided with the necessary training in adult protection to ensure they have the knowledge and an awareness of the referral process to safeguard the people using the service. EVIDENCE: The home has a complaints procedure in place and discussions held with the people who use the service and a visiting relative evidenced that they had an understanding of whom to approach if they were not happy with the service. The procedure is not in an easy read format however the deputy manager stated that staff have discussed this with the people they support. No complaints were found recorded in the complaints log as stated in the providers self-assessment forwarded to us. We have not received any concerns or complaints in relation to this service since the last key inspection. The home has received one compliment from a relative in March 2007, which stated: ‘I am very pleased about the care that X is receiving at Hilton House...’ All staff have received training in Adult Protection, Recognising and Reporting Abuse provided by the Council. The deputy manager confirmed that the home has obtained the new safeguarding adults policy and procedure and a DVD. It Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 17 was also stated that staff have attended personal safety training in addition to dealing with violent incidents. Financial procedures were discussed with managers and recording systems examined. Although staff considered that procedures safeguard the people who use the service, a policy must be developed for the management of finances to ensure staff are clear about service users expenditure to include meals out, transport costs etc. Hilton Road DS0000037693.V351202.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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although improving, parts of the home still require investment in order to provide people with a safe, comfortable and homely place to live. EVIDENCE: A full tour of inside and outside of the home was undertaken. Since the last inspection the house has been painted externally and a ramp fitted to the front of the property to aid access for one person with mobility difficulties. The lounge suite has been replaced and new curtains fitted in the lounge and one bedroom, which service users helped to choose. Service users were happy to show the inspector their bedrooms and indicated that they are pleased with their rooms, which were personalised. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 19 Some furniture and fittings require repair or replacement. For example one person is unable to access their wardrobe because the handles are missing. The chest of drawers in one bedroom has been replaced however the replacement is not of a good quality or robust. The first floor bathroom has plaster damage to one wall; the toilet seat was found broken. The bathroom suite remains odd in colour and a shower facility is not provided. Overall this room does not present a pleasant or safe environment for people to bathe. The self assessment (AQAA) submitted to us states: ‘The rooms and furniture could be of a more robust nature to reduce deliberate breakages by service users; but they could be very expensive’. The house was generally found clean during this unannounced inspection. It was reported that staff clean the home and service users help out. Staff have received training in the control of infection. Paper towels are still required in communal areas such as the kitchen, laundry, toilets and bathrooms as identified at the previous inspection. Products hazardous to health are appropriately stored and data sheets available. Hilton Road DS0000037693.V351202.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 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a trained, committed staff team who have a good understanding of their individual needs. EVIDENCE: Staff spoken with had a good understanding of their roles and responsibilities and appeared committed to their work. Staff were observed interacting positively with the people using the service. It was reported that all four support staff hold a recognised care award known as a National Vocational Qualification at level 2 and three staff have since started NVQ level 3. The deputy manager has NVQ level 4. This exceeds National Minimum Standards. The team consists of a registered manager, deputy manager and four support staff. The staff rota was examined and failed to evidence the registered managers hours. It also identified that the deputy manager has worked seven days a week since March 2007 in addition to being the registered manager of a sister home. Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 21 The usual staffing is one member of staff supporting three service users. The person who does not access day services receives additional funding for six hours a day Monday to Friday. A staff member spoken with considered staffing is sufficient to meet the individual needs of the people accommodated. It was stated that no new staff had been employed for the last two years providing consistency for the people using the service. The homes recruitment procedures were therefore not examined on this occasion. Training was discussed with managers and a member of staff on duty. Feedback indicates that people are provided with excellent training opportunities in safe working practices and specific to the needs of the people using the service for example person centred planning awareness, epilepsy and dementia care. It was reported that the home have applied for staff to attend training in the Mental Capacity Act and Disability Awareness. Staff are to attend training in lone working and funding has been approved for LDAF. The deputy manager is responsible for training and continues to be committed to providing a qualified and trained workforce. In addition to individual training records seen, a team training matrix has been developed which clearly indicates specific training courses attended however the deputy manager was advised to state dates attended rather than just ticks. The deputy manager stated that staff are very positive and motivated and have gained lots of confidence through the numerous courses they have attended. She reported that staff work well as a team are very committed to their work. Hilton Road DS0000037693.V351202.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): 37,39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management approach of the home creates an open and positive atmosphere from which the service users benefit. Quality assurance systems require further development to assess performance and evaluate outcomes for people using the service. Staff receive training in safe working practices however not all aspects of the home are maintained in a safe manner, potentially placing people at risk. EVIDENCE: Mrs Sharma is the Registered Manager of the home and is closely supported by her deputy. A new Area Manager has recently been appointed. Managers Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 23 discussed the changes they intend to make across all three services in terms of registered managers. Mrs Sharma committed to contacting our Regional Registration Team within seven days regarding proposed changes and requesting applications for new managers. Managers were informed there must be clear evidence of who is actually managing each of the services. Mrs Sharma has obtained NVQ 4 Registered Managers Award. It was reported that since the last inspection she has undertaken training to include IOSH Managing Safely, Dementia Care, Dealing with violent incidents and diabetes awareness. The manager has yet to distribute surveys to people using the service, their relatives and stakeholders to gain their views about the service. Reports required under Regulation 26 were not available. The provider has recently appointed a new area manager and discussions with her following the inspection indicate that she will take on the responsibility of overseeing all of the providers younger adult services and undertaking Regulation 26 visits. The service has produced a basic annual development plan as required by the previous inspection. People using the service are regularly reviewed by the home in conjunction with significant others and any actions addressed. The AQAA submitted to us stated that the team aims to develop person centred plans with the individuals they support. Records examined evidence that health and safety checks are carried out at the required frequency. Not all records were available to evidence that equipment had been serviced at the required timescale or that the required action had been taken. However following the inspection some of this information was faxed through to our offices, which appeared satisfactory. Risk assessments have recently been reviewed and updated however a falls risk assessment needs to be developed for an individual currently prone to falls in addition to a risk assessment for radiators which the deputy manager committed to do. It was reported that the Environmental Health and Fire Department have not visited the service since the last inspection. The registered manager holds the IOSH certificate in Managing Safely and all staff have attended a distance learning training course in health and safety in addition to manual handling training as recommended by the previous inspection. Managers are working towards developing the health and safety policy as required by the previous inspection. The plaster damage to the first floor bathroom must be attended to as a matter of priority. Hilton Road DS0000037693.V351202.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 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 x 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 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 4 3 x 3 x 2 x x 2 x Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23(2) Requirement The home’s premises must be suitable for its stated purpose, safe and well maintained to ensure service users are not placed at risk. Timescale for action 01/01/08 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 YA26 Good Practice Recommendations Furniture and fittings should be sufficient, safe and suitable to meet individual needs of people accommodated. (As required by the previous inspection) A policy for the management of finances should be developed at the earliest opportunity to ensure staff are fully informed of the procedures for dealing with peoples finances. Repair to the plaster damage in the first floor bathroom needs to be actioned as a matter of urgency for the safety of service users. Managerial arrangements should be reviewed and discussed with CSCI Central Registration Team at the earliest opportunity. DS0000037693.V351202.R01.S.doc Version 5.2 Page 26 2. YA23 3. 4. YA24 YA37 Hilton Road 5. YA42 (As recommended at the previous inspection) The health and safety policy should be finalised as soon as possible to ensure the employee and employer are aware of their responsibilities to ensure safety of service users and staff. (As required by the previous inspection) Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI Hilton Road DS0000037693.V351202.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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