Inspection on 18/09/06 for Hilton Road

This inspection was carried out on 18th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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 14/11/07

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 18th September 2006 09:30 Hilton Road DS0000037693.V296549.R02.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.V296549.R02.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.V296549.R02.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.V296549.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration apply Date of last inspection 27th February 2006 Brief Description of the Service: Hilton House is a traditional style semi-detached property, which is located in a residential area of Lanesfield, approximately 3 miles from Wolverhampton City centre. The home offers access to local amenities and transport and the premises are in keeping with the local community. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care to a maximum of three adults with a learning disability. The home is owned by Arcare (West Midlands) Limited and the registered manager is Mrs Suman Bala Sharma. The accommodation provided is on two floors comprising lounge, dining room, kitchen, laundry, single rooms (two with en-suite facility) and a bathroom. The home has a small garden to 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. The current fees charged per person range from £389.00 to £575.00 per week. Hilton Road DS0000037693.V296549.R02.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 commenced at 09.30a.m. and lasted five hours. It was carried out by talking with one service user present at the home, the manager, staff on duty, case tracking two service users, observation of some work practices, examination of a number of records and a full tour of the home. 21 key National Minimum Standards for younger adults were assessed during this inspection in addition to Standards 1,5,14,26 and 41 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The purpose of the inspection was to assess ‘Key’ National Minimum Standards and to review the progress made by the home since the last unannounced inspection undertaken on 27th February 2006, when eight requirements and one recommendation was made. The service user, manager and staff were very welcoming and co-operated fully throughout the inspection. Since the last inspection no complaints have been received by the home or referred to the Commission for Social Care Inspection and there has been no referrals made under adult protection procedures. What the service does well: Staff have a good understanding of the individual needs of the people they support and have developed positive working relationships with service users, families and other agencies. The service user present during the inspection reported that she likes living at the home and the staff are nice. The organisation is committed to providing a qualified workforce. The health needs of service users are well met and records seen evidence that individuals are supported to attend NHS Healthcare facilities and their health is closely monitored. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 6 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. Hilton Road DS0000037693.V296549.R02.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 Hilton Road DS0000037693.V296549.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new person to the home. EVIDENCE: A Statement of Purpose and Service User Guide is in place and available to service users and their representatives. There have been no new admissions to the service since 29th July 2005. Appropriate needs assessments were in place and found satisfactory during the inspection undertaken on 23rd August 2005. Signed terms and conditions of residency were available on both the care files and were last reviewed in September 2005. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems provide staff with the necessary information to ensure the assessed needs of service users is met. Service users are appropriately supported with making choices and enabled to take responsible risks. EVIDENCE: Two service users were case tracked and their care files reviewed. Information was detailed and there was evidence that support plans are reviewed at the appropriate timescales. Records available on the file of one service user evidence that a Joint review was held with the day service the individual attends. Review minutes were also available on the file of the other person case tracked and evidence that the service user, family, placing authority and significant others attended the meeting, which was held wt the home. Since the last inspection staff have attended Person Centred Planning (PCP) Awareness training with the local team based at Pond Lane, however PCP’s have yet to be developed with the people accommodated. It was identified Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 10 that the behaviours displayed by one individual are currently challenging the service and although the Intensive support Team from the placing authority are supporting the home, the staff are still awaiting for a behaviour management plan to be developed. Discussions held with managers indicate that the support needs have been discussed with the local psychology team who may offer assistance. Incidents are being recorded however managers are concerned in relation to staff lone working and there not being a management plan yet made available. It was reported that one person accesses an advocacy service provided through his day service. The managers stated that they have requested an advocacy service however this is not forthcoming in the area. Support plans and daily records seen indicate that service users are appropriately supported with making decisions about their lives and the service user present was provided with choices throughout the inspection. The manager was advised to discuss and record people’s likes and dislikes with the people living at the home. Discussions held with the service user present and manager evidence the families play an active role in the lives of their relatives and represent their interests. Service users are also provided with designated key workers. Various risk assessments seen on files evidence that people are enabled to take responsible risks, which are regularly reviewed and updated. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with social opportunities. They are supported to keep in contact with their families and friends and offered a diet respecting their individual preferences and dietary needs. EVIDENCE: Two people living at the home access local authority day service provision five days per week. It was reported that one person attends a work scheme through the day service and receives payment for this. An appropriate day service was sourced for the person admitted to the home last July and the person was supported with a trial visit, which proved unsuccessful. Therefore the person remains at home and is supported on a 1:1 basis throughout the week. A record of activities undertaken is maintained. Discussions held with the person present and records seen evidence that service users are provided with Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 12 opportunities to access their local community on a regular basis with day services and the home. Family links are well established and people are supported to maintain contact through telephone calls and visits. A record of all contact made was available on the files reviewed. The service user present during the inspection reported that her relatives had visited her the day before and taken her out for a meal to celebrate her birthday and purchased a cake. She said that her family visit her a lot and also attend meetings held at the home. It is evident that she very much enjoys the contact with her family. She also reported that she also visits a local home owned by the organisation and made friends with the people living there. Service users may see their visitors in the shared space provided or in the privacy of their own room. A log of all visitors to the home is recorded in the homes diary. Preferred routines were documented on the files reviewed and service users are supported with basic housekeeping tasks as much as possible according to their ability and have unrestricted access to the home. Observations made and discussions held with the service user present and managers evidence that service users rights are respected and upheld and that people may choose when to be alone or in the company of others. A requirement was made at the previous inspection that bedrooms be fitted with a suitable locking device and service users offered a key to their bedroom unless a risk assessment states otherwise. Managers reported that they had discussed this with service users and sent a letter to relatives which were seen on file with the response being that people are not in support of this. However should a new admission take place in the future the home must make this facility available. It was recommended as a result of the previous inspection that food consumed be closely monitored to ensure service users are being provided with varied and balanced diet. A record of all food consumed is maintained by the staff on duty and a menu is available. The service user present reported that she can choose what food she wants to eat and where she wants to eat her meals which was evidenced during the inspection. Discussions held with managers indicate that the home are currently working hard to encourage her to eat a healthy diet for health reasons however this proves difficult at times due to her lack of co-operation. For lunch an appetising and well balanced meal was provided. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The home has an effective system for handling, storing and managing medication which safeguards service users. EVIDENCE: Personal support requirements and preferred routines were documented on the support plans reviewed. The service user present informed the inspector about the support staff provide with maintaining her personal care and appearance and that she regularly attends health appointments which were seen recorded on her file. She reported that a beauty therapist regularly visits the home and she has a manicure, feet and shoulder massage and a chiropodist attends to her foot care. Full medical health checks were undertaken at Pond Lane on 07.09.06 with a general practitioner and professionals from the local team. The home are waiting for Heath Action Plans to be developed. Input from the psychology team is ongoing for the person most recently admitted and placed by Dudley Social Services however it was reported that the home have requested support from the local team who are currently Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 14 looking into the matter and are already familiar with the home. Evidence of health appointments were readily available on the file of the other person case tracked in addition to an Occupational Therapy report for an assessment undertaken on 19.10.05 in relation to the physical environment. Medication procedures appeared satisfactory at the time of the inspection. The home uses the monitored dosage (MDS) system provided by Boots Chemist and staff have received training in this system. Four staff have undertaken accredited distance learning training on the administration and safe handling of medicines and the remainder of the team are booked to undertake the training. A pharmacist employed by Boots Chemist visited the home on 4.07.06 to review the homes medication procedures and two recommendations were made as a result of the visit and a certificate was seen. The home has since met the two recommendations in relation to external medication being stored separately and a designated staff member holding the medication key. Appropriate arrangements are in place for people requiring medication when off site and visiting relatives for the weekend. None of the service users are currently prescribed controlled drugs. Information and side effects in relation to drugs was seen on the service user files reviewed. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are able to express their concerns, and have access to a complaints procedure. Procedures to safeguard service users from potential abuse are in place and the staff team are provided with the necessary training in the local policy and procedure. EVIDENCE: No complaints have been received by the home or referred to the Commission for Social Care Inspection (CSCI) since the last inspection. The complaint procedure is available and managers committed to updating this with details of the local CSCI office and the providers responsibility to investigate all complaints. The service user spoken with had a clear understanding of who to speak to if she was not happy with the service provided. A copy of the local Inter-Agency Adult Protection was available and the deputy manager has been trained as a trainer for adult protection through Wolverhampton City Council and all but one member of staff have received the relevant training as evidenced in certificates seen on personnel files and discussions held with staff present during the inspection. Training has been booked for the outstanding staff member. Managers reported that no service user is subject to physical intervention and the deputy manager has attended training in the Management of Actual and Potential Aggression (MAPA) and the remainder of the team are awaiting dates to attend this training provided by Social Services however the courses are currently over subscribed as evidenced in a letter seen. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 16 Service users are supported to manage their finances, which are held at the Civic office for two people. The family of one service user currently hold the finances on behalf of one individual and managers reported that the person’s finances are readily available. The finances of the people case tracked were checked and were an accurate reflection of the records held. Only the deputy manager and registered manager have access to service users finances. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a clean and comfortable place to live. EVIDENCE: Three requirements were made as a result of the previous inspection that the home must be well maintained, for bedrooms to include furniture as required under NMS 26.2. and that furniture and fittings provided must be of a good quality and fulfil their purpose. A programme of maintenance is in place and identifies the work carried out by the home however it does not provide a schedule for future planning. A full tour of the environment was undertaken accompanied by the registered manager and although the home provides a comfortable place to live, many areas of the home and some soft furnishings appear tired and in need of upgrading. A new dining room suite has been purchased since the last inspection. The service users spoken with said that she would like her bedroom to be redecorated and a new carpet fitted. She has recently replaced the furniture provided by the home with furniture purchased out of her own funds with family support and appears very happy with the purchase. Rooms were found personalised. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 18 The home was found clean and tidy and the staff team have recently undertaken distance learning training in relation to infection control and are awaiting certificates. Cleaning schedules are in place and products hazardous to health are appropriately stored and data sheets available. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, well-trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Discussions held with staff on duty evidence they are knowledgeable and have a good understanding of the individuals whom they support. Staff were observed to be accessible, good communicators and interacted appropriately with the service user present at the home during the inspection. It was reported that staff morale has improved due to the numerous courses that staff have attended, which has boosted their confidence and developed their knowledge base to support the needs of the people accommodated. Managers stated that the delegation of responsibilities is empowering the team and there is greater communication and improved team work. It was reported that out of the six support staff employed, four staff have obtained an NVQ award and remaining staff are currently undertaking the award. The waking night staff member spoken to on arrival at the home confirmed that she had gained her NVQ award in addition to numerous courses attended and receives good support from her managers and considered the needs of the service users well met. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 20 No new staff have been appointed since the last inspection and it was reported that the home has no staff vacancies. Recruitment procedures were reviewed and found satisfactory at the last inspection. Managers considered that staffing may have to be reviewed based on the needs of one person whose behaviours can challenge the service and leave lone working staff vulnerable. As previously stated staff training opportunities have significantly improved and it is evident that the providers are committed to providing a qualified workforce. The deputy manager holds responsibility for staff training and discussions held with her indicate that she takes the role and responsibility seriously and is keen to ensure staff are provided with mandatory and service specific training. A team plan is in place in addition to individual training records that are well presented. Training records and certificates were available on personnel files in addition to evidence of staff supervision. A requirement was made at the previous inspection that all new staff must receive structured induction training to LDAF specification. The deputy manager has since sourced support materials from City and Guilds and two staff are registered on LDAF and commenced work packs. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 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. Aspects of performance are being developed and the premises are managed and maintained in a safe manner to safeguard service users. EVIDENCE: The joint proprietor, Mrs Suman Sharma is the registered manager of the home and has fifteen years experience and has obtained the NVQ level 4 Registered Managers Award. Since the last inspection she has undertaken a number of training courses to include Health and Safety, Infection control, Epilepsy management and challenging behaviour and further courses have been identified and booked. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 22 A requirement was previously made for the homes quality assurance and monitoring systems be developed. A quality assurance file is in place, which contains a number of letters and witness testimonies from professionals and agencies in addition to two completed questionnaires form the relatives of service users. In summary the information available evidenced effective communication and that relatives are satisfied with the overall service provided. Managers have not yet had the opportunity to develop an annual development plan for the home to assist in measuring success and inform future planning and review. The service user spoken with stated that she loves living at the home and that the staff are nice and the food is good. Records reviewed throughout the inspection were found well presented with evidence of regular review. Health and safety procedures appeared satisfactory at the time of this inspection. Risk assessments, accident records, temperature monitoring charts, cleaning schedules, staff training and service certificates were reviewed. A member of staff spoken with confirmed that she has receives mandatory training in safe working practices in addition to health and safety. Only the manager has received moving and handling training however the certificate is now out of date. It was reported that staff do not perform any manual handling tasks however following discussions managers agreed to source the relevant training for the team. It was reported that the fire officer has not visited the home since 10.08.05 and that the requirements made have since been met. The deputy manager also stated that the fire officer has also approved the fire risk assessment and fire plan. An Environmental Health Officer visited the home on 23.08.06 however the report has not yet been received. It was reported that all staff have undertaken a distance learning course in health and safety and are awaiting certificates. A requirement was made at the previous inspection that the health and safety policy must be further developed to include all relevant legislation for safe working practices. Although the deputy manager has obtained information on health and safety legislation this has not been transferred into the policy. Risk assessments for safe working practices to include soiled clothing being carried through the kitchen have been developed as required, however a risk assessment to support staff lone working was not available Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 3 x 3 x 2 x 3 2 x Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 24 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(1)(2) Requirement Timescale for action 09/10/06 2 YA24 3 4 YA39 YA42 5 YA42 A management behaviour plan for the person identified as challenging the service must be developed. 23(2)(b) A planned maintenance and renewal programme must be developed and actioned for the fabric and redecoration of the premises, with records kept. (previous timescale of 30.04.06 not fully met). 24(1)(a)(b)(2)(3) An annual development plan for the home must be developed. 12(1) The health and safety policy must be developed further to include all relevant legislation for safe working practices (previous timescale of 30/04/06 not fully met). 13(4) A risk assessment to support staff lone working must be developed and implemented. 31/10/06 31/10/06 31/10/06 02/10/06 Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA42 Good Practice Recommendations It is recommended that person centred plans be devised with service users/representatives as soon as possible in addition to health action plans. It is recommended that staff attend training in manual handling. Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hilton Road DS0000037693.V296549.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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