Inspection on 28/11/07 for Forest Hill Care Home

This inspection was carried out on 28th November 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Forest Hill Care Home 14/09/09

Forest Hill Care Home 30/09/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Forest Hill Care Home Forest Hill Park Worksop Nottinghamshire S81 0NZ Lead Inspector Jayne Hilton Unannounced Inspection 28th November 2007 08:00 X10015.doc Version 1.40 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 Forest Hill Care Home DS0000069212.V354793.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 Older People. 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. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Hill Care Home Address Forest Hill Park Worksop Nottinghamshire S81 0NZ 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) 01909 530531 01909 532239 foresthill@barchester.net Barchester Healthcare Homes Ltd Mrs Josephine Mary Tuddenham Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64), Terminally ill (4) of places Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: The category of persons to be accommodated shall be the elderly with general health care needs including a maximum of beds for Adults 50 years Palliative Care. This service was newly registered with Date of last inspection Barchester Healthcare Homes on 23rd January 2007. Brief Description of the Service: The home was previously part of Westminster Healthcare Ltd, as part of a reorganisation, the home transferred to an existing operations company called Barchester Healthcare Homes Ltd in January 2007. Forest Hill Care Home is a large, modern purpose built home on two floors. It provides 24 hour nursing care for up to 64 older people care. The home is situated in a quiet residential area north of Worksop town centre and close to Bassetlaw District Hospital. It has two units, one on each of the two floors, which can be accessed by a lift. There is ample communal space on each floor and all bedrooms are single with en-suite facilities. Landscaped garden, with seating, is available at the front and rear of the building and there is a car park to the rear. The building is wheelchair accessible, with wide corridors and doorways, and level access on each floor. The current weekly fees were not provided at the inspection and although there is a section about fees, these, were not detailed in the service user guide. The Statement of Purpose and Service User Guide and are available in the main entrance area of the home and service users have a copy in their bedroom. Copies of previous inspection reports are available on request. 1. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This service was newly registered with Barchester Healthcare Homes on 23rd January 2007. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 7.5 daytime hours and was unannounced. The main method of inspection used was called ‘case tracking.’ This involves selecting three service users and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Not all service users who were “case tracked” were able to help by giving an opinion about the care provided. Six members of staff, seven service users, three relatives and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to service users. A visiting healthcare professional was also spoken with. Prior to completing this visit the inspector assessed the homes service history including complaints and adult protection referrals. The Annual Quality Assurance assessment completed by the manager was also used in assessing evidence of the quality of service. Two relatives surveys were received prior to the report being written, with two staff surveys returned also. A review of the registration certificate was also carried out at the inspection and a recommendation made to remove the TI [Terminally ill] category was agreed by the manager. What the service does well: Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 6 A kind and caring ethos was prevalent throughout the home and a comfortable rapport was evident between service users and staff. Service users spoken with were very happy with life within the home and care received. They stated that staff, were kind, caring and respectful. Staff spoken with, were extremely compassionate with regards to service users needs and ensuring a quality of life is maintained and service users are given the utmost respect. The lifestyle within the home offers the opportunity for service users to live a life of their choice and expectations ensuring a quality life is experienced. People who use the service are able to make complaints and are confident these are dealt with appropriately and advocacy services are actively promoted. The home is generally run in the best interests of service users, by a competent staff team supported by a dedicated and focused manager. The service is proactive in its staffing recruitment and training. Service users live in a well-maintained, safe, clean, pleasant and hygienic environment. The environment was observed, to be, well maintained and the home is decorated to a good standard. What has improved since the last inspection? What they could do better: Improve the system for care planning to encompass the whole person needs and respecting equality and diversity. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 7 Ensure all events of accidents and/or falls are monitored and appropriate care plans and risk assessments implemented. Ensure all service users nutritional needs are appropriately assessed and monitored and action taken when they are identified to be at risk. Ensure service users with epilepsy have a care plan and risk assessment in place. Ensure all safeguarding issues are reported under safeguarding adult protocols and to the Commission for Social Care Inspection [CSCI] as required under Regulation 37. Ensure all records are completed as required by regulation. Improve the training provision for staff in respect of supporting people with a learning disability, communication needs and epilepsy and in meeting their diversity needs. Improve the training and systems for reporting issues so safeguards are in place to protect the people who use the service. Improved monitoring for storage temperatures of medication and completion of medication records. Ensure that where risk assessments are in place for the use of bedrails, the service user and / or their representative always agree these. Where service users do not wish to hold or are not able to hold a key to their bedroom door or lockable facility an agreed risk assessment must be in place for this purpose. Ensure life history information and the social and leisure interests of service users are always obtained. Improved mapping of individual social profiles and the activities that are provided would further enhance the service users lifestyle and choices. Research, innovation and use of communication aids, symbols and pictures should be developed to ensure all service users needs are addressed and catered for. Ensure evidence of surveys and any feedback from these is kept in the home for inspection. Six requirements and fourteen good practice recommendations have been made. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 8 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. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have the information they need about the home, but further development of the assessment and care plan documentation is needed to ensure service users needs, will be fully met. The home does not currently provide an intermediate care service EVIDENCE: The Statement of Purpose, Service User Guide and copies of previous inspection reports are available in the home, but not everyone spoken with were aware of these. Therefore it is recommended that extra information about how to accessing inspection reports be posted around the home. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 11 Service users needs are assessed prior to moving into the home, however one of the service users ‘case tracked’ had many gaps in information about the persons needs, despite being at the home for six months. Service users and relatives spoken with confirmed that the care provided was of a good standard in their opinion. It is recommended that Person Centred Planning formats be introduced for all service users, particularly those that are under 65 years of age. The home has an Equality and Diversity policy in place but there was no evidence that training is provided in the topic. Staff spoken with demonstrated some knowledge about individual service users needs, but information pertaining to specific needs of those with cultural, religious, disability or communication needs, was not fully documented within the care plans. For example one service user is supported to attend church, [relatives and staff confirmed this] but there was no record that the person had attended church in the care plan. Staff said that one person, who has ethnicity needs, is supported with skin and hair care, but there was no assessment or care plan in place for this need or any evidence documented that staff had provided this. Any dietary preferences of two people with cultural needs were not identified in the care documentation, a relative said that they bring in their traditional foods for their family member. The specific communication needs of one service user are not being fully supported due to a lack of knowledge and training in this area and there was no evidence that support from external agencies had been sought. Further development of the diversity needs of service users within the assessment and care plan process should be explored. Also service users and /or their representatives had not signed their involvement or agreement to the assessment or care plan. A relative praised the home admission process, stating that they were impressed by the time spent with them showing them around the home and listening to their needs and that their relative had settled in very well, they felt due to the commitment of the staff team. Another said that Polish staff had supported his mother who is also Polish. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal, social and healthcare needs are not being fully being met, however they are treated with respect and their privacy upheld. EVIDENCE: The care plans and risk assessments viewed were generally well written, kept up to date and reviewed regularly, however one persons documentation was very sparse or not fully completed for example there was no risk assessment for risk of pressure areas, despite pressure relieving equipment being in place. Service users said that staff respect service users preferences and privacy and observation of practice on the day of inspection confirmed this. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 13 Suitable aids and equipment is provided and independence is promoted and staff undertake training in pressure are care, continence management, diabetes etc. No service users currently have pressure areas. A healthcare professional spoken with praised the staff teams, stating that in her opinion the home is excellent and manages the care of some people with complex needs very well, that training is very good and that staff seek advice for anything they feel may be a problem. Events of accidents and/or falls are not always well monitored, one person was noted to have had three accidents, which, none, had not been documented in the accident records [See Standard 37 and 38] and no care plans had been implemented in respect. One person was noted to have a fracture undetected for five days. Body mapping tools were noted to be in use in the home, but not in this person’s case. Nutrition, weights and any nursing interventions were generally recorded, however where Integrated Pathways of Care are used for end stage of life care, these were not always fully completed and one person had noted weight loss, which had not been recorded on the persons nutritional profile neither had any action been taken to monitor dietary intake. [See also Standard 15] Service users and relatives spoken with confirmed that they felt their personal, social and healthcare needs were met and that staff, assist access to healthcare professionals as required. One person with epilepsy did not have a care plan or risk assessment in place for the management and monitoring of seizures. Where service users cannot verbally express pain, information from relatives should be obtained about how the service user may have expressed discomfort or pain prior to moving into the home. There is an efficient medication policy in place and staff undertake training and the manager on a regular basis also undertakes audits. A recent pharmacy audit identified some areas for improvement, such as needing to circle codes when medication not given and dating eye drops and creams upon opening. There was one entry noted for one service user, not to be signed or coded on the day of the inspection, but eye drops were noted to be dated upon opening. Although fridge temperatures were monitored the general storage temperatures of medication were not and this is therefore recommended. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 14 Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most service users find the lifestyle experienced in the home matches their expectations and preferences and receive a wholesome and balanced diet. Further improvement of activities provided on a one to one basis to service users, the use of communication aids and improved menu options would ensure all service users needs are fully met. EVIDENCE: The home employs three activities co-ordinators who arrange a wide programme of activities and fundraising events. They record participation of individuals within the care planning process. Life history information, social and leisure interests of service users are generally obtained but this was not fully completed for one person case tracked, with communication difficulties. Care plans viewed on the ground floor were more detailed regarding individual preferences, likes /dislikes and for personal care choices such as Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 16 hairbrush/comb sponge or flannel and this should be followed by staff on the first floor. The use of communication aids, symbols and pictures should be developed to ensure all service users needs are addressed and catered for. Trips out are arranged regularly but places are limited due to the wheelchair capacity of the minibus and one, service users relative said his mother would like to go out on the minibus more often. [The activities staff said they do try to operate a fair system for this within varying limitations] Documentation of one to one time spent with service users who remain in bed or in their rooms did not provide evidence of what activity had been tried or participated with and this is an area that should be improved. Service users are supported to maintain relationships with relatives and the local community. Relatives reported that they are always made welcome, offered drinks and can eat meals with their relatives. Staff reported that plans were being made for relatives to eat Christmas dinner at the home should they wish to. Menus were devised over a four- weekly cycle and appear nutritious and varied and offer a second option choice. Individual breakfast trays were seen prepared with service users preferences catered for. A full English breakfast and fruit is on offer as well as the usual cereals, porridge, toast and preserves. Soft diets were served in an appetising way and service users reported that they were satisfied with the food and that drinks were offered regularly. Where a person had been refusing food on occasions, this was recorded but there was no evidence that alternative favourite foods or supplements had been offered, neither was there any information what the persons dietary preferences actually were and given that the person could not vocalise their preferences alternative communication aids had not however been tried. [See Standard 8] Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 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 relatives are confident that their complaints will be listened to, taken seriously and acted upon. Training is provided for staff to protect service users from abuse, however, some incidents and accidents have not been reported appropriately by staff, which suggests service users health and welfare is not always fully promoted and protected. EVIDENCE: A complaints policy is in place which is displayed in the home and in the service user guide, however not all service users and relatives spoken with were aware of the policy. The policy displayed in the home was not easily viewed as placed high up and in small print. It is recommended that a larger print version be placed in amore accessible position such as above the visitor’s book and on service user information boards around the home. Six complaints were documented and were dealt with promptly and appropriately. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 18 Service users have risk assessments in place for the use of bedrails, but these were not always agreed by the service user and /or their representative. Not all service users had a key to their own room or a key to their lockable facility and there was no documentation within the care plans in respect of this. Care should be taken that service users rights to privacy and property are upheld and that they are not discriminated against. Therefore where service users do not wish to hold or are not able to hold a key to their bedroom door or lockable facility an agreed risk assessment must be in place for this purpose. The manager did not have an up to date local agreed protocol for dealing with safeguarding issues, although previous protocols were seen. Staff undertake training in safeguarding and those spoken with all said they knew about the whistle blowing policy and would report poor practice and anything that concerned them about the way a service user was treated. However there was evidence of an incident, involving a visitor to the home, which had been highlighted in documentation, but which had not been reported under safeguarding adult protocols or to the Commission for Social Care Inspection [CSCI] as required under Regulation 37. The manager stated the incident had not been reported to her, therefore the notification and referral not made. The manager agreed to make the necessary alert to the lead agency [Adult Social Care and Health] without further delay. Also, although notifications were regularly made to CSCI when a service user died the home was in breach of the regulation 37 for not notifying the Commission for events which affected the health and welfare of service users residing in the home. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is maintained to a very high standard and the premises are clean throughout, this provides service users with a safe and extremely pleasant environment to live in. EVIDENCE: The home is a purpose built, two storey building, set in its own grounds with well-maintained gardens. A new rear garden with paved access, seating and raised flowerbeds was constructed last year. The home is fully accessible throughout and has a large lift between floors. A tour of the building showed that the layout was spacious with wide corridors and doorways. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 20 Bedrooms and communal areas had a homely atmosphere and were clean and tidy with no unpleasant odours. Relatives confirmed that this was always the same when they visited. All bedrooms are single with an en-suite toilet and washbasin. All rooms seen were of a good size and were well furnished and decorated. Service users said that they were very happy with the accommodation and the home’s general facilities. A relative reported that the payphone was currently out of order and the mobile telephone used has a bad reception, probably due to lack of charging and agreed to discuss this with the manager. Staff were observed on the day to use the communal lounges for their breaks handovers etc and a relative commented that staff meetings were held in these rooms also. The relative added that an alternative quiet room was offered on an occasion, but there should be a staff room provided for this purpose. Infection control policies are in place and staff receive training in the topic. Staff were observed to wear personal protective clothing and follow good hygiene practices. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes recruitment and staffing levels protect Service users. Staff are trained to a good standard, however further training provision on the specific needs of service users residing in the home would ensure all service users needs are fully met. EVIDENCE: At the inspection staffing rotas were examined and these evidenced that two nurses and 4-5 carers are provided on each floor in a moring and 1 or two nurses and 3-4 carers in an afternoon/evening demonstrating sufficient staffing levels. Service users were happy that staff attended them promptly, no concerns were raised from relatives about staffing levels. Two staff surveys were received, which both commented that staffing levels could be better and one felt that the skill mix of staff could be better. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 22 Staff spoken with on the day of the inspection expressed no concerns about staffing levels. All confirmed the induction process, appraisal and supervision arrangements, which documentary evidence viewed also supported this. Four staff files were viewed and these contained the necessary recruitment and training documentation. The home provides training for staff in essential topics and some specific needs training such as diabetes care and palliative care, however training had not been provided for staff in specific needs of all service users, such as supportimng people with a learning disability, supportimg people with epilepsy, supporting people with communication needs and Equality and Diversity training. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home where the manager provides, a good ethos and leadership approach to the home and where the health and safety of service users is generally promoted and protected, however there is some weakness in record keeping in respect of incidents and accident reporting by staff, which may compromise service users health and well being. EVIDENCE: Mrs Tuddenham has managed the home since it opened. She is a Registered Nurse and completed the Registered Managers’ Award in June 2005. Her own development has been continuing through regular bi-monthly meetings with Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 24 other managers and links with the local authority Social Services Department who commission services. Staff and relatives praised the manager, saying she is supportive and approachable and the home has received good feedback from the Social Service Department, they state, “ Standards of care are high and the needs of the carer considered. Staff demonstrate good knowledge of service users and family issues”. The manager reported that the home has a quality assurance system to gain the views of people living and working at the home, which includes meetings, satisfaction surveys and company audits. Minutes of meetings and audits were viewed but not any evidence of surveys or feedback from these. The manager stated that a survey had been undertaken in August 2007 and these had been returned to the provider for evaluation. Evidence was seen of monthly visits made to the home, by a representative of the provider. The manager reported in the Annual Quality Assurance Assessment “We hold 6 weekly resident meetings. Minutes are taken and are available in reception and action taken as result of any issues highlighted. We have introduced some new menus, which provide additional choices of food. We now offer the opportunity for an individual care review meeting for residents and their relatives”. The home does not hold any monies on behalf of service users. Relatives or solicitors handled finances and bills had been sent for hairdressing, chiropody and newspapers. Each bedroom had a lockable facility for service users use if they chose to keep some cash or valuables, but not all service users hold keys. [See Standard 18] Record keeping is an area for improvement, particularly in respect of care plans, incident and accident records and reporting, which suggests that service users may be placed at risk. There are a good range of policies and procedures regarding health and safety available to guide and instruct staff. There is also a programme in place to service and maintain the equipment in the home on a regular basis. Information provided to the Commission prior to the visit and sampling on the day of the visit showed that appropriate checks on equipment such as hoists and fire equipment had taken place. The home also has a Health and Safety Committee, which meets three times a year with a representative from head office, to ensure all health and safety issues are appropriately dealt with. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 25 Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 1 2 Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP3 OP7 Regulation 14,15 Requirement Ensure the assessment and care plan documentation of all service users is fully completed to ensure service users personal, social and healthcare needs are fully being assessed and met. Ensure all events of accidents and/or falls are monitored and appropriate care plans and risk assessments implemented. This will ensure service users personal, social and healthcare needs are fully being met. Ensure all service users nutritional needs are appropriately assessed and monitored and action taken when they are identified to be at risk. This will ensure service users personal, social and healthcare needs are fully being met. Ensure service users with epilepsy have a care plan and risk assessment in place. This will ensure service users Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 28 Timescale for action 05/01/08 2 OP8 OP7 OP38 12,[1] 13,[1][b] 14,[2][a] [b] 15, [1] 05/01/08 3 OP8 OP15 12,[1] 14[1][a], 14 [2], 13[1][b] 05/01/08 4 OP7 OP8 12,[1] 14[1][a], 14 [2], 13[1][b] 05/01/08 5 OP18 OP37 13[6], 37[1][e], 37,[1][c] personal, social and healthcare needs are fully being met. Ensure all safeguarding issues are reported under safeguarding adult protocols and to the Commission for Social Care Inspection [CSCI] as required under Regulation 37. This will ensure service users health and welfare is promoted and protected 05/01/08 6 OP37 OP38 17, schedule 3 and schedule 4 05/01/08 Ensure all records are completed as required by regulation. 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 OP1 Good Practice Recommendations Extra information about how to accessing inspection reports be posted around the home and include the CSCI web site details. Person Centred Planning formats be introduced for all service users, particularly those that are under 65 years of age. Information pertaining to specific needs of those with cultural, religious, disability or communication needs, should fully documented within the care plans. The menus should be improved by offering a further option, which suits the cultural needs of service users residing in the home. Service users and /or their representatives should be asked to sign as to their involvement or agreement to the assessment or care plan. Ensure the practice of use of body mapping tools is DS0000069212.V354793.R01.S.doc Version 5.2 Page 29 2 OP3 OP4 OP6 OP3 OP4 OP12 OP15 3 4 5 OP3 OP6 OP8 Forest Hill Care Home OP18 OP37 6 OP38 OP8 consistent. 7 OP9 OP37 Where service users cannot verbally express pain, information from relatives should be obtained about how the service user may have expressed discomfort or pain prior to moving into the home. Ensure where any medication is not given, that the medication record charts are always appropriately signed or coded Monitor and record the storage temperatures of medicines Ensure life history information and the social and leisure interests of service users are always obtained. Improved mapping of individual social profiles and the activities that are provided would further enhance the service users lifestyle and choices. Research, innovation and use of communication aids, symbols and pictures should be developed to ensure all service users needs are addressed and catered for. 8 OP3 OP12 9 OP16 10 11 12 13 OP18 OP8 OP18 OP18 OP30 14 OP33 OP37 A larger print version of the complaints procedures should be placed in a more accessible position such as above the visitor’s book and on service user information boards around the home. Where service users do not wish to hold or are not able to hold a key to their bedroom door or lockable facility an agreed risk assessment must be in place for this purpose. Ensure that where risk assessments are in place for the use of bedrails, the service user and / or their representative always agree these. Improve the training and systems for reporting issues so safeguards are in place to protect the people who use the service. Training should be provided for all staff[including activities co-ordinators] in specific needs of all service users, such as supportimng people with a learning disability, supporting people with epilepsy, supporting people with communication needs and Equality and Diversity training. Ensure evidence of surveys and any feedback from these is kept in the home for inspection. Forest Hill Care Home DS0000069212.V354793.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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