Care Home: Hillcrest Avenue (40)

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What the care home does well The needs of service users are fully assessed before they move into the home to ensure that they can be met. A major part of the assessment is making sure a new service user will fit into the household and get on well with the people already living at the home. Service users appear to be very happy with the service provided and were very proud to show their bedrooms and the home in general. All areas of the home were attractively decorated and furnished in a homely style and were clean and freshly aired. Service users are mainly well supported to maintain and develop their skills and leisure interests and to be active members of their local community. The home supports and encourages service users to keep in contact with their family and friends. A very small team of staff support service users. Members of staff spoken with said that they are happy working at the home and some had worked there for a number of years. Staff members and service users were observed to have a relaxed, friendly relationship and there is a homely atmosphere in the home. What has improved since the last inspection? The Statement of Purpose and Service User Guide for the home has been updated and provides comprehensive pictorial and written information. Detailed individual plans using a person centred format are currently in the process of being completed and implemented, together with the staff group undertaking training in relation to person centred care planning. What the care home could do better: Review the staffing level at the home to ensure that there are sufficient staff on duty at all times to meet the needs of service users, and to allow time for the manager to undertake management duties. Ensure that all staff complete the required mandatory training for example First Aid. CARE HOME ADULTS 18-65 Hillcrest Avenue (40) 40 Hillcrest Avenue Chertsey Surrey KT16 9RE Lead Inspector Allocated Inspector - Sandra Crosby Unannounced Inspection 10th December 2007 10:45 Hillcrest Avenue (40) DS0000013495.V347656.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 Hillcrest Avenue (40) DS0000013495.V347656.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. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcrest Avenue (40) Address 40 Hillcrest Avenue Chertsey Surrey KT16 9RE 01932 571978 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) Welmede Housing Association Ltd Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2), Physical disability (3) of places Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate 3 residents with both LD (Learning Disabilities) and PD (Physical Disabilities) within the total persons accommodated The age/age range of the persons to be accommodated will be: OVER 50 YEARS 1st February 2007 Date of last inspection Brief Description of the Service: Hillcrest Avenue is a small home providing accommodation and support for up to five people with learning disabilities. Up to three service users may also have physical disabilities and two service users can be over 65 years of age. The home is run by Welmede Housing Association and the staff are employed by the North Surrey Primary Care Trust (NSPCT). Welmede runs a local network of homes for people with learning disabilities. The property is a bungalow specifically adapted to the needs of service users, situated in a quiet residential avenue on the outskirts of Chertsey. Accommodation is provided in single bedrooms with spacious communal areas and an attractive garden. Car parking is available on the front drive or on the road. The fees at this service are £1,334.00 per week. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) and was carried out under the CSCI “Inspecting for Better Lives” process. The allocated inspector carried out the inspection over five hours. The new manager who took up her appointment in September 2007 assisted with the inspection. The four service users who live at the home were met with and two staff were spoken with. Most areas of the home were seen and a number of records and documents were sampled, including medication records, service users’ individual plans and staff training records. The Annual Quality Assurance Assessment (AQAA) documentation was completed and returned with the requested timescale. Information supplied in this documentation will be referred to in this report. A review of the information held about the service was also carried out before the visit. A number of CSCI survey forms were completed by service users, relatives and healthcare professionals containing comments for example ‘I am satisfied that my relative is happy at the home’, ‘it creates a family atmosphere that my relative likes’ and ‘I cannot see any need for improvement’. The Manager provided a copy of the Hillcrest Staff Meeting and Action that sets out 30 agenda items that need to be addressed and includes a date for completion of said items. The inspector would like to thank the service users and staff for their hospitality, time and assistance. What the service does well: The needs of service users are fully assessed before they move into the home to ensure that they can be met. A major part of the assessment is making sure a new service user will fit into the household and get on well with the people already living at the home. Service users appear to be very happy with the service provided and were very proud to show their bedrooms and the home in general. All areas of the home were attractively decorated and furnished in a homely style and were clean and freshly aired. Service users are mainly well supported to maintain and develop their skills and leisure interests and to be active members of their local community. The Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 6 home supports and encourages service users to keep in contact with their family and friends. A very small team of staff support service users. Members of staff spoken with said that they are happy working at the home and some had worked there for a number of years. Staff members and service users were observed to have a relaxed, friendly relationship and there is a homely atmosphere in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users have been fully assessed before their admission to the home. EVIDENCE: The Manager was able to provide well presented updated pictorial formats of the Statement of Purpose and Service User Guide. Detailed assessment information had been seen at the previous inspection visit dated 01 February 2007 and was said to be detailed in relation to the most recently admitted service user. There have been no new service users since that time. As most prospective service users, would be supported financially by a local authority, a care management assessment would be carried out and a copy of the assessment would be obtained. The home would also carry out an assessment, either at the existing home of the prospective service user or at the service. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 9 Any prospective service user would be invited to visit the home on a number of occasions, usually of increasing length. The prospective service user would be invited to stay for a meal and possibly overnight, if it appeared that the home may be suited to the service user. A focus of the pre-admission assessment would be to ensure that the prospective service user was compatible with the existing service users and to minimise any effects or disruption a new service user may have on them. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 6,7 and 9 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual person centred plans are in the process of being re-formatted and made available to guide staff to the specific support needs of service users. The individual plans include the support required to manage risks to service users. Service users are well supported to make decisions. EVIDENCE: A new format for individual person centred plans is currently being implemented, and one person centred plan was examined, the others are waiting to be updated onto the new system. The individual person centred plans will cover all components as required by regulation. Staff are to undertake training in the system to be used in the near future. The AQAA states that the home encourages service user families to be involved in reviews, assessments and the person centred plans. It was clear that staff had a good knowledge and understanding of the service users’ individual needs, and this is supported by comments in the surveys received. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 11 It was noted and discussed with the Manager that the health needs action notes had not been updated, and cross-referencing in relation to changes in health needs was not evident. To enable service users to be as independent as possible, assessments of risks to service users have been carried out. These included ways of preventing the risks and ways to reduce any risks. The Manager said that individual fire evacuation; bath and vehicle risk assessments had recently been completed. It was observed that service users require assistance in almost all activities of daily living, including making decisions. Staff advised that to enable service users to make decisions, they offer a selection of items, such as clothes to wear, foods or things to buy when out shopping. Staff advised that they take service users known preferences, likes and dislikes into account when supporting them to make decisions. Staff were observed to offer service users a choice of drinks or refreshments and to respect the choices which were made. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 12,13,15,16 and 17 were inspected at this inspection visit. 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 to take part in a range of activities and to be active members of their community, although staffing levels may restrict activities at times. Service users are offered a well balanced diet. EVIDENCE: The AQAA documentation states that service users are provided with a range of activities during the week, others at the weekend together with monthly activities and these include Snoozelum, Bowling, Swimming, Bingo, Arts and Crafts and Get Together Club. At the time of the inspection visit the service users with staff assistance were making chocolate Christmas tree decorations in the kitchen. The service users were pleased with how they turned out. The manager talked about up and coming events on the lead up to Christmas, and also mentioned the service users attending a Pantomine in January. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 13 Staff advised that service users are not able to hold jobs due to the limitations of their disabilities. Currently now there is no ‘floating support worker’ and it was indicated that at times the home may have insufficient staffing levels to meet the needs of the service users. (Pease also refer to the personal and healthcare support standards 18 –21 and the staffing standards 31-36). The manager and staff are striving to achieve more one to one time with service users. The manager stated that service users are actively supported and encouraged to maintain family contacts, by sending cards for special occasions such as birthdays and Christmas. Families are welcomed to visit service users and some service users go out regularly with their families when they visit, and relative surveys returned support this. It was indicated that service users are offered a well-balanced and varied selection of meals, which take their personal needs and preferences into consideration. Service users choose what then want to eat, food pictures have been provided to aid service users in making choices. The menus were seen and the food records were being maintained. It was observed that a support worker asked the service user their choice of flavour of crisps to go with their sandwiches. Staff advised that the main meal of the day is served in the evening and is taken family style as a group with staff. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 18,19 and 20 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way that they prefer and their healthcare needs are mainly well met. Medication is to be more appropriately managed. EVIDENCE: Staff were observed to provide personal support discreetly and in a manner that promoted service users’ independence, privacy and dignity. Service users were encouraged to be independent and staff offered support only if it was needed. From speaking to staff and from records seen, it is clear that service users are supported by a number of healthcare professionals and that their healthcare needs are well met. Service users have received support from healthcare professionals including dentists, opticians, general practitioner (GP), speech and language therapist and hospital specialists. Records seen did not show that changes in respect of one service users’ health needs have been responded to, although the manager said that staff had taken appropriate action. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 15 Medication is supplied by a local pharmacy the manager advised, and is stored appropriately in a central, locked cupboard. Only staff who have received training in this, administer medication. The records seen indicated that they were appropriately signed and up to date. The manager reported that the recording system for the administration of medication is to change in the near future and printed MARS sheets are to be provided by the pharmacy. Sample signatures of staff who are authorised to administer medication were held, along with a signed consent by the service users’ GP, for the administration of homely remedies. These are medications that can be purchased and do not need to be prescribed. These are rarely given the manager advised, as service users are usually seen by their GP if a change in their health is noted. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 22 and 23 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure has been drawn up in a way that is more suited to the needs of service users. Staff are aware of their responsibilities in the safeguarding of service users. EVIDENCE: A complaints procedure is available in written or easy read forms and it was noted that the “Service user’s guide to complaints” has been developed in a more service user-friendly style. It was clear that some service users would have to rely on staff to understand that they were unhappy or dissatisfied in any way, as they may not be able to explain this to staff. From observation at the time of the inspection visit service users appeared generally to be in good spirits. Staff stated that service users are able to communicate their unhappiness in specific individual ways, which are known to staff and are recorded in their individual plans. This would usually be shown by a change in behaviour, which staff would monitor to establish the reason it has developed. Any changes would be recorded and reported to the manager to ensure that appropriate support was provided and that any relevant procedures were followed. The AQAA documentation states that there have been no complaints recorded since the last inspection, and the manager confirmed this. Relatives that have completed and returned survey form indicate that they aware of the home’s complaints procedure. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 17 From speaking to staff it was clear that they are aware of their responsibilities in safeguarding service users. The AQAA documentation states that all staff has undertaken Vulnerable Adults training. Staff stated that they would report any concerns or suspicions of abuse to the manager or person in charge. If needed, staff knew that they could also refer any concerns to an on-call manager or to other agencies outside the home. It has previously been reported in the last inspection report that in the event of an allegation of abuse, the manager stated the home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults. An up to date copy of the procedure is kept in the home, along with the “No Secrets” guidelines and the North Surrey Primary Care Trust adult protection guidelines. These are available for staff to refer to if required. Service users’ monies for day-to-day use are securely held for safekeeping and individual records of these are maintained. Staff advised that these are checked by two staff at the change of each staff shift and to further safeguard service users, two signatures are recorded for each transaction. The amounts of monies held were checked with the records held and these accurately matched. The support worker who had responsibility for the records said that the company audits the records every three months. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 24 and 30 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, safe environment, which is suited to the needs of those living there, and is very clean and hygienic. EVIDENCE: The home is bungalow with a level front door entrance and all areas are fully accessible, even to wheelchair users. The home blends well with other neighbouring properties, being of a similar size and style. The home is attractively decorated in cheerful colours and is bright and airy. It is well furnished and equipped in a homely style to meet service users’ needs. Each service user has their own bedroom and a service user was very willing and happy to show their room. Bedrooms have been made individual with service users’ own belongings, including pictures, ornaments and soft toys. The manager said and it was seen that new fire retardant bed linen has recently been purchased. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 19 It was observed that doors were no longer being wedged open, and the manager reported that action is being taken to needs assess service users in relation to automatic door closures being fitted where appropriate. All areas of the home were seen to be very clean and well presented and appeared hygienic. Liquid hand cleanser and paper towels were provided in all appropriate places to prevent the spread of infection. It was noted that personal protective equipment, including aprons and gloves are provided for staff. A separate laundry room is available, is positioned away from food storage and preparation areas and the laundry equipment has appropriate programmes. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 32,33,34, 35 and 36 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The small team of staff may not always effectively support the service users, although they are appropriately recruited and trained. EVIDENCE: Currently the manager is working as part of the small team providing ‘hands on care’ with no allocated managerial hours. It is indicated that over the past months there have been times when staffing has been insufficient to meet the needs of service users. However, currently there are four service users and the staffing team are able to meet assessed needs, albeit there is often only one member of staff in the home whilst the other member of staff is outside of the home. The manager confirmed that a lone working policy has been completed. It was discussed with the manager that a review of the staffing levels should be undertaken to ensure sufficient staff are available to meet service users’ needs. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 21 Staff advised that they provide support to service users in all aspects of running the home, including shopping, cooking, domestic and laundry tasks. Staff also provide support with transport and a variety of activities. It was reported at the last inspection visit that only one member of staff was present at the home with three service users when the inspector arrived. Another member of staff was on duty but had taken service users to their classes and gone on to do shopping. A number of staff have undertaken and achieved National Vocational Qualifications (NVQ) in care, to level 2 or above and the home has met the recommended target of fifty percent of trained staff. Staff were observed to interact well with service users, listening to what they said and giving time for service users to respond. Staff were open, cheerful and welcoming. Two staff files were seen and indicate that a thorough recruitment procedure is in place and all checks are carried out as required by regulation. Staff training records were seen including a staff training matrix and covered training required by law and training to develop knowledge and skills. These included medication training, food hygiene training, first aid, fire training and the safeguarding of vulnerable adults. The staff training matrix indicated that number of training session were due for example First Aid, Food Hygiene, Health & Safety. The staff team is made up of male and female staff which reflects the service user group. The staff group is of mixed cultural and racial backgrounds and the service users describe themselves as British. Hillcrest Avenue (40) DS0000013495.V347656.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): Standards 37,39 and 42 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Services users mainly benefit from a well run home. The health, safety and welfare of service users are mainly promoted and protected. EVIDENCE: It was evident that the newly appointed manager is experienced in the support and care of service users with learning disabilities, is well qualified and experienced for her role and is now ably supported by staff at the home. The management team have created an open and inclusive atmosphere and provide clear direction and leadership. From the outcomes for service users, it is clear that the service is now being effectively managed, however the staffing level at times at the home may compromise the effective management of the service. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 23 To review the quality of the service provided, quality assurance feedback forms are sent out to all relatives to complete. Service users are supported by their key-workers to also complete forms. The Welmede organisation has systems in place that aim to assess the quality of the services provided. As previously mentioned, responses to CSCI surveys were received in order to obtain independent views of the quality of the service. Comments received include ‘I am satisfied that my relative is happy at the home’, ‘it creates a family atmosphere that my relative likes’ and ‘I cannot see any need for improvement’. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home are carried out appropriately, and to the required frequency, to promote the safety and welfare of all who live and work there, excepting at times when the staffing level at the home may be insufficient to ensure this. The home’s insurance certificate and health and safety at work poster are displayed as required. Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Hillcrest Avenue (40) DS0000013495.V347656.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 YA33 Regulation 18(1)(a) Timescale for action The home has an effective staff 31/03/08 team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. The registered person ensures 31/03/08 that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’ Ensure all staff have completed all mandatory training for example First aid, Health & Safety Requirement 2. YA35 18(1)(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hillcrest Avenue (40) DS0000013495.V347656.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Hillcrest Avenue (40) DS0000013495.V347656.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. 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