Inspection on 18/03/08 for Hylton Bank (28)

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Excellent service.

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

Other inspections for this house

Hylton Bank (28) 15/12/08

Hylton Bank (28) 03/10/06

Hylton Bank (28) 17/01/06

Hylton Bank (28) 23/06/05

Hylton Bank (28) 01/02/05

Hylton Bank (28) 13/10/04

Hylton Bank (28) 24/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Hylton Bank (28) South Hylton Sunderland SR4 0LL Lead Inspector Sam Doku Key Unannounced Inspection 18th March 2008 10:00 Hylton Bank (28) DS0000015740.V357109.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 Hylton Bank (28) DS0000015740.V357109.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. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hylton Bank (28) Address South Hylton Sunderland SR4 0LL 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) 0191 534 1185 0191 534 2137 Northumberland, Tyne & Wear NHS Trust Mrs Christine Turnbull Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 9 The maximum number of service users who can be accommodated is: 9 3rd October 2006 Date of last inspection Brief Description of the Service: 28 Hylton Bank is a care home for nine people who have a learning disability and who have autism or behaviours associated with an ASD (Autistic Spectrum Disorder). Cheviot Housing Association owns the building and Northumberland, Tyne and Wear NHS Trust lease the property and delivers the care. The service accommodates male and female service users between the ages of 18 and 55 years. At present there are 9 men and women living at the home all who have varying abilities. All have difficulty in understanding their environment or communicating their needs. Consequently all of the people living at Hylton Bank have the potential of exhibiting challenging behaviours. There are 9 bedrooms and each service user occupies a single room, which complies with the National Minimum Standards. One of the rooms is detached and considered as a separate bungalow and has its own lounge, kitchen and other facilities to promote independent living. The design of the house with a North and South side gives the appearance of two separate houses, each accommodating 4 people. An area, which includes the activity room, the laundry and staff sleep over room, connects the 2 sides. Service users have access to all parts of the house with the exception of other peoples bedrooms unless invited. It is the aim of the home to develop activities, including daily life skills that are designed to reduce anxiety while creating personal security for the individual. The rate of charges in the home is between £194.60 and £522.36 per week. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The inspection was unannounced and started on 18 March 2008 and completed on a final visit on the 25 March 2008. Before the visit the inspector looked at: Information we have received since the last key inspection visit on October 2006; How the home dealt with any complaints & concerns since the last visit; • Any changes to how the home is run; • The provider’s view of how well they care for people, as highlighted in the details provided in the Annual Quality Assurance Assessment (AQUAA); • The views of the residents who use the service and their relatives. During the visits the inspector: • talked to the residents, the senior support workers and care staff; • looked at information about the residents and how well their needs are met; • looked at other records which must be kept; • checked that staff had the knowledge, skills & training to meet the needs of the residents; • looked around the building to make sure it was safe & secure; • checked what improvements had been made since the last visit; • the inspector told the provider what he found. All of these activities contributed to the inspection findings. What the service does well: There are good arrangements in place for admitting new residents into the home. There are pre-admission visits to the home, and also specific training needs for the staff are provided, which relates to the prospective resident before and after the admission. The home is good at involving other agencies in the planning of the care of the residents. This is particularly the case when specific challenging behaviour needs are identified. The home provides contracts to the residents and this is in pictorial format, which is helpful to the residents. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 6 The home delivers high quality service that meets the residents’ individual needs. The staff provide an environment that enables the residents to make choices, however limited these may be in some specific cases. The current staff team are highly motivated and positive about their role and the care they provide. The person-centred care plans and care practices allow the residents to experience fulfilling lifestyles. The residents are supported to engage in social and recreational activities of their choosing. Educational and employment opportunities are sought for individuals who have expressed the wish for such activities. The staff play active role in preparing and supporting the residents to engage in these activities and also to maintain their independence and community involvement. The home is good at recording incidents in the home and reporting it promptly to the appropriate agencies. The home has two cars, which enable the service users to access community facilities. Service users are also encouraged to use public transport, and in doing so it provides them with the opportunity to engage with the general public. The staff receive good management support to enable them to continue to support the residents. This has created high moral amongst the staff team at all levels. Each service user has their own room and are furnished and equipped with personal items, which provide a sense of personal space for each person. What has improved since the last inspection? What they could do better: The statement of purpose and service user guide should be updated to reflect the new management structure of the home. There is little understanding of the Mental Capacity Act 2005 amongst care staff. Staff at all levels need to have the appropriate training to ensure that Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 7 the residents’ rights are not infringed upon. All the current staff must have Awareness in Autism training. Staff induction must be reviewed to ensure that it is in line with the Skill for Care induction training standards. It was noted that all aspects of the induction was carried out in one day. There were no records of the six weeks follow up training for the staff whose records were examined. The home’s fire risk assessment must be reviewed annually as recommended by the fire authority. 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. Hylton Bank (28) DS0000015740.V357109.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 Hylton Bank (28) DS0000015740.V357109.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, 2, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good admissions policy involving assessment of needs, which identifies care needs of the individual including considerations for their aspirations. This promotes the resident’s welfare and wellbeing. EVIDENCE: At the time of the inspection visit, an admission to the home took place. The inspector reviewed the admission process and found the arrangements to good. This involved a planned introductory visit to the home. Detailed assessments were carried out and this formed the basis of his transition plan, which sets out support systems for the first six weeks of his residency. The plan also sets out who is responsible for what. The residents support plans set out each person’s care needs and how those needs are to be met. There is evidence in the service user’s files indicating their involvement in the writing of the support plans. This ensured their right to be involved in matters relating to their future care arrangements. Each resident has a contract and this is in a pictorial format, which makes it easier for the them to understand the content of the contracts. Hylton Bank (28) DS0000015740.V357109.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care needs of the residents are constantly being re-assessed and reviewed to reflect their current care needs. This promotes their wellbeing and welfare. There are good systems in place, which ensures that the residents are consulted on the day-to-day management of the home. The staff support people who require it to help them make decisions for themselves and to be involved in the management of their care. The residents are supported to take reasonable risks. This enables them to make independent decisions while at the same time protecting them from harm. EVIDENCE: Over the years, the home has developed and maintained a person-centred approach to the care regime in the home. This provides the residents with the Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 11 opportunity to make decisions about their life and how they are to be cared for. This is reflected in the care plans and the daily report records, which provided evidence of the steps taken to involve the residents or their representatives in the planning of their care and future plans. The files also provide further evidence of the involvement of the residents in the day-to-day management of the home. The residents have input into the planning of menus, social and recreational activities. This promotes their independence and sense of control and wellbeing. The residents are supported to be involved in the drawing up of their care plans. Staff gave examples of how the residents are able to contribute to their own care. One family commented on how the staff often consulted them on issues that affect the wellbeing of their son. Previous inspection reports have highlighted the emphasis on risk assessment to promote the safety and welfare of the residents. The comments are repeated here indicating the consistency with which staff adhere to safety policies. Risk assessments have been carried out for all the residents relating to aspects of their care, which require careful monitoring or management. This enables each person to lead fulfilling lifestyle and enjoy the protection of the staff team. Some of the risk assessments include going out independently, travelling, household activities, using public transport and road safety. These risk assessments are designed to protect the residents from harm while at the same time promoting their independence and right to take reasonable risks. The risk assessments continue to be regularly reviewed to ensure that they remain effective in safeguarding the safety and welfare of the residents. Hylton Bank (28) DS0000015740.V357109.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): 11, 12, 13,14, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is commitment amongst all the staff to promote the residents involvement in community activities. This enhances the residents’ sense of belonging. EVIDENCE: Each resident has a programme of activities, which sets out the arrangements for ensuring their involvement in community activities. Records show that the residents are supported to remain part of the local community and to engage in community activities. Residents are supported to take part in social, recreational and educational activities. These activities include regular visits to local pubs, theatre, cinema, shopping, attending discos, opportunities to attend college courses and other community facilities. There are also arrangements Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 13 for the residents to engage in indoor activities such as board games, video films and watching TV and to visit friends and families. Staff continue to involve the residents in the drawing up of the weekly menus and also take part in the weekly shopping for the home. The residents are offered choice of meals and continue to be encouraged by staff to maintain some level of independence regarding meals. The care plans show that the service users dietary needs are met. Service users are frequently offered the opportunity to go out for meals. This is part of the home’s policy in ensuring that the residents are part of the wider community. The staff support the residents to eat healthy and balanced diet. Hylton Bank (28) DS0000015740.V357109.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 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to actively promote the emotional and physical health of the service users through the GP and other healthcare professionals. There are suitable arrangements in place for the safe handling of medication in the home. This promotes the health and welfare of the residents. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 15 EVIDENCE: The arrangements for meeting the personal and healthcare needs of the resident remain good. Residents care plans, risk assessments and other care records show that individual care needs continue to be clearly identified and care programmes have been put in place to meet them. The care staff ensure that the care provided matches what has been agreed in the care plans. Where there are changes, the care plans are altered to take account of the changes to the individual’s needs. The residents’ reactions, their views and that of relatives and advocates are taken into account when reviewing their care. There are good arrangements in place for the healthcare needs of all the residents. All the residents have their own GPs and they are supported to attend appointments with their doctors when required. There are other arrangements for the residents to attend specialist out-patient appoints and other healthcare professionals. These visits are recorded in the individual life plans and in daily report books to show that they have been receiving the care that they are entitled to. The home had taken appropriate action to review the drugs administrative system following a series of medication errors. Each unit now has its own drug storage system and the person in charge of the respective unit manages the medicines. This re-organisation has drastically reduced the amount of errors reported to the Commission in recent months. The drugs administration system was inspected and there were no discrepancies noted. Staff who have responsibility for administering medicines have had suitable training in safe handling of medication. Detailed written policies on medicines were also available for inspection. Hylton Bank (28) DS0000015740.V357109.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. The provider’s complaints and safeguarding adults procedures are efficient and are implemented in the home in ways that protects the residents from abuse. This ensured their safety and wellbeing. There is a general lack of understanding of the Mental Capacity Act 2005 amongst the staff. This does not fully safeguard their rights. EVIDENCE: Recent events leading to a major safeguarding alert was handled extremely well by the TRUST and the other professional agencies involved. The correct procedures were followed and thorough investigations from the various agencies were carried out. Anxious relatives were kept informed about progress and how the investigations were going. One family commented on the professionalism of the agencies involved. Shortly before the inspection visit, an incident happened in the home, which was considered an infringement on the rights of a resident. The home took immediate action to suspend the staff member involved while they carried out their investigation in the person’s behaviour. There are detailed protection of vulnerable adults policies and procedures in the home and the staff who were spoken with demonstrated good knowledge Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 17 of how to protect the service users from any form of abuse. All the staff have received training and have good knowledge and understanding of the procedures. Such training and understanding has empowered the staff in “whistle blowing” on bad practices in the home. The home has a written complaint procedure, which is part of the Northumberland, Tyne and Wear NHS Trust complaint procedure. Summary of the complaint procedure is included in the Statement of Purpose/Service User Guide and copies are retained on his file. The Trust also has a “Whistle Blowing” policy and copies of these procedures are available in the home. The staff who were spoken with confirmed that they have received training in the City of Sunderland Local Authority’s MAPPVA (Multi Agency Panel for the Protection of Vulnerable Adults) procedures and on whistle blowing policies. Hylton Bank (28) DS0000015740.V357109.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, 25, 26, 28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, homely, clean and meets the service users needs. This ensured that they live in a safe and welcoming environment. EVIDENCE: The positive comments made in the last inspection report have been maintained. These comments are repeated here indicating the commitment by the home to maintain a safe and homely environment for the residents to live in. The home is designed to meet the needs of people with a wide range of physical disabilities. The corridors and doorways are wide enough to allow easy access and comfortable movement of people. The generous room sizes allow the residents to furnish their rooms with personal items while leaving sufficient spaces for movement within their rooms. The two lounges are Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 19 suitably furnished and decorated. This provided a pleasant environment, which enhanced the self-esteem of the residents. Good standard of hygiene is maintained to avoid any cross contamination. On the day of the inspection the home was clean and maintained to a good standard. Antibacterial hand washing facilities were available in the toilets and bathrooms. The kitchen, lounge and bedroom were all noted to be clean and in good order. The laundry machine has programme facilities to meet disinfecting standards, thus ensuring good control of infection practices and protection of the service users from cross contamination. There are policies and procedures in place regarding safe handling and disposal of clinical waste, dealing spillage, the provision of protective clothing and hand washing. This also protects him from infection and accidents. The staff are currently re-decorating the relaxation room as one resident has been identified as someone who would particularly benefit from the facility. Hylton Bank (28) DS0000015740.V357109.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): 31, 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are supported by a staff that are appropriately trained to undertake their duties. This promotes the residents’ safety and welfare. The recent changes in the staffing structure has had no known detrimental effect on the residents. The new team has positively enhanced the life experience of the residents. The residents enjoy good staff to service user ratio, enabling them to enjoy personalised care and attention. EVIDENCE: In the past twelve months there has been a number of changes in the home, including the change of manager and a number of care staff. These changes were necessary to promote the welfare of the residents. The new staff team have positively improved on the quality of life experience for the residents. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 21 Examination of past rotas indicate that the recent staffing arrangements provided sufficient staffing complements to meet the needs of the residents. The home adheres to proper employment policies in recruiting staff. Staff who were spoken with confirmed that they had completed job application forms and were interviewed before they were appointed. All the staff said they had provided suitable references and also had enhanced CRB check before their appointment was confirmed. The Trust has a comprehensive induction plan for all newly appointed staff. However, the initial induction programme shows that every area of the induction was completed in a single day. The inspector could not trace any of the six weeks induction training documentation that the TRUST expects all new staff to complete. Staff receive regular supervision but between June and November last year the frequency was reduced due to the lack of sufficient senior staff to undertake such duties. However, the acting manager indicated that the programme of staff supervision is now back on track. Staff training included moving and handling, first aid, fire safety training, food hygiene, challenging behaviour management, protection of vulnerable adults awareness training. However, there little understanding or awareness amongst staff of Mental Capacity Act 2005. Staff must receive such training to ensure that they understand the role as carers in relation to the Act. Hylton Bank (28) DS0000015740.V357109.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, 40 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run and managed in a way that promotes the health, safety and welfare of the residents. EVIDENCE: There is currently no registered manager in the home. The home is currently managed by an acting manager who has been seconded from another establishment. She has NVQ Level 4 in both Care and Management. She is supported by two senior support workers who also have substantial experience in the care of people with learning disabilities. Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 23 Staff were keen to talk about the management arrangements of the past, and the situation as it exists now. Staff are very happy with the current arrangements and feel that they now have the support they needed to provide higher standard of care. Staff stated that the acting manager runs the service for the benefit of the residents and has positive relations with the staff and the service users. The Trust has produced detailed Health and Safety policies and copies of these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The manager stated that all staff have had training in food hygiene, fire precaution and first aid. Records relating to fire instructions have been maintained. However, the fire risk assessment has not been reviewed since April 2006. This must be done to ensure that all the fire safety measures are place to ensure the welfare of the residents. Records show that all portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. There is evidence of regular servicing of fire equipment, gas and electrical appliances. Hylton Bank (28) DS0000015740.V357109.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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 3 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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(4) Requirement Timescale for action 01/05/08 2 YA31 YA32 3 YA32 The home’s fire risk assessment must be reviewed annually to ensure that all fires risk areas have been considered and where necessary precautionary measures put in place. 13(6) Staff must receive appropriate training in Autism awareness and also the Mental Capacity Act to further promote the safety and welfare of the residents. 18(1)(c)(i) Staff induction training must be reviewed so that it is line with the Skill for Care induction standards. 30/06/08 30/06/08 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 YA1 Good Practice Recommendations The statement of purpose should be reviewed to take account of the changes in the management structure of the home. DS0000015740.V357109.R01.S.doc Version 5.2 Page 26 Hylton Bank (28) Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 Hylton Bank (28) DS0000015740.V357109.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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