Inspection on 29/10/07 for Forest Hill House Nursing Home

This inspection was carried out on 29th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Forest Hill House Nursing Home 10/07/06

Forest Hill House Nursing Home 22/11/05

Forest Hill House Nursing Home 21/07/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Forest Hill House Nursing Home Rushall Lane Corfe Mullen Wimborne Dorset BH21 3RT Lead Inspector Chris Gould Key Unannounced Inspection 29th October 2007 10:00 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 House Nursing Home DS0000064305.V353618.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 House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Forest Hill House Nursing Home Address Rushall Lane Corfe Mullen Wimborne Dorset BH21 3RT 01202 631741 01202 632742 foresthilloffice@aol.com / julzwilson@hotmail.com Royal Bay Care Homes Ltd 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) Mrs Julie Louise Dove Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person (as known to CSCI) over the age of 65 may be accommodated to receive nursing care in the category MD. One named person (as known to CSCI) in the age range 40-64 may be accommodated to receive nursing care. 10th July 2006 Date of last inspection Brief Description of the Service: Forest Hill House is set in a rural area with spacious wooded grounds and a large gravelled parking area. Forest Hill House is registered as a care home with nursing for people over the age of 65. It offers accommodation on three floors for 36 elderly people with 18 single rooms and 9 double rooms. Many of the rooms have en-suite facilities and there are sufficient communal W.Cs and bathrooms. There is a passenger lift to all three floors and a stair lift to the first floor. There are a variety of aids and adaptations around the building to allow residents to move about more independently. There is a large sitting room, a dining room and a conservatory, which leads out on to a small patio area with a pond and raised flowerbeds. There is a bird table and a variety of outdoor seating arrangements. The current fees for this home range between £575 and £775 per week. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the findings of a key inspection to Forest Hill House Nursing Home that took place between 10am and 5pm. The aim of the inspection was to evaluate the home against the key standards for older people. Surveys were returned from ten residents of the home, four relatives of residents, five healthcare professionals and eight members of staff. The views contained within these were also used to help form the judgements on the service. During the inspection three staff files, three residents care records and relevant documentation and policies and procedures relating to the running of the home were inspected. Ten residents were spoken with about their experience of living at the home. A tour of the premises was made, staff spoken with and time spent with the senior nurse on duty and one of the directors. The registered manager was unavailable on the day of the inspection. The Annual Quality Assurance Assessment form had been completed and returned to the Commission for Social Care Inspection prior to the inspection. What the service does well: The residents live in a home that is well managed and maintained with the appropriate number of trained staff to meet their needs. An assessment is undertaken before admission to ensure that the resident knows that the home they are moving into will meet their needs. Comments received from residents include ‘have previously been in a home where I was unhappy but am very impressed with the care and attention at Forest Hill House’ and ‘very happy no complaints’. One health professional commented ‘provide excellent care to frail vulnerable people’. The staff treat residents with respect and provide encouragement to pursue their own lifestyle, where feasible, and to make choices about their daily lives. Residents spoken with agreed that they were always addressed in the way they had requested. There is a good programme of activities on offer at the home. Some activities are structured and well organised, others are 1-1. Residents are able to do as they wish at the home and join in or not with the activities on offer. Comments received from relatives included ‘the social needs of my mother are well cared for, she likes helping with the planting of hanging baskets and tubs also helping to choose the plants for these. There are plenty of entertainment and outings for those able to take part. My mother is extremely happy and very well cared for’, and ‘the home throws itself into celebrations of any kind Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 6 with the greatest enthusiasm. All the residents are included as well as friends and relative’. Residents are offered a menu that provides a varied and well balanced diet that is served in pleasant surroundings. Residents who commented were generally very positive about the quality of the meals provided. What has improved since the last inspection? What they could do better: All the residents have a care plan identifying their needs however they do not consistently contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their assessed care needs. The care plans must be reviewed and updated to ensure they relate to the actual care being provided and are focused on the individual needs of the resident. Where equipment, such as bed rails, is in use that physically restrains residents the home must carry out assessments outlining why the equipment has to be used, how it is to be used and written permissions for its use have to be given. Assessments must be regularly reviewed to make sure that the use of such equipment remains the best option to maintain the safety of the residents. Care records must provide clear guidance to indicate when prescriptions marked ‘as needed’ or ‘prn’ should be given when the resident is unable to request the medication. The temperature of the medicines refrigerator must be monitored daily when in use, using a maximum/minimum thermometer and recorded. Care staff should have a clear understanding of the action to be taken if the temperature is outside the normal range. Staff must not be employed to work at the home until a satisfactory check in relation to the Prevention of Vulnerable Adults as specified in the regulations has been obtained. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 7 Before allowing a new member of staff to work at the home certain pre employment checks have to be carried out and information and documents obtained to protect residents from potentially unsuitable people working at the home. At this inspection and the last inspection there were shortfalls in the records seen of new members of staff. 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 House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 8 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 House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place ensure that the resident knows that the home they are moving into will meet their needs. EVIDENCE: The three files of recently admitted residents showed that prior to them moving to the home their needs were fully assessed by a senior member of staff from the home. All three had resulted in successful placements with residents moving into the home within a couple of days of their assessment. Two of the three pre admission assessments had been carried out during a visit by a senior member of staff to the person while in hospital. The third assessment had taken place over the telephone. Discussion with staff confirmed that they were aware of the resident’s needs at the time of their admission. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 10 Forest Hill House does not provide intermediate care therefore standard 6 is not applicable. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have a care plan that meets their needs and they feel that they are treated with respect and their privacy upheld by the care workers. However shortfalls in the detail provided and the shortfall in risk assessments may put the residents at risk. EVIDENCE: All residents have individual plans of care based on a pre-admission assessment of need. The three residents care records inspected had been reviewed at least monthly. The care plans were inconsistent in the information provided and at times did not provide sufficient detail specific to the individual resident. One resident has hearing problems and the care plan specified the actions to be taken to ensure effective communication. Two care plans stated ‘to use cotsides at all times whenever bed bound’. A risk assessment was not available for either resident and one did not use cotsides. One resident’s care plan includes ‘to Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 12 ensure specific diet is followed at all times’. There is no further detail relating to the specific diet required. In one care plan to assist with the management of continence a toileting regime was to be followed throughout the day. The toileting regime had not been specified. In the care records viewed there was no information available relating to oral health and hygiene including whether the residents had their own teeth or dentures. When visiting one resident it was evident that their needs and the care being provided had changed from that recorded in their care plan. Most residents at this home are registered with a surgery whose GPs make fortnightly visits to the home. This makes GPs very accessible to residents and enables a prompt response to any concerns raised by them or the staff in respect of their health. It is documented when people need to seek medical advice and why, along with the outcome of the consultation. Residents also have access to the range of community services e.g. chiropodists, dentists and opticians. Some come to the home, others have to be accessed in the community. Where this is the case residents get the support of the home in accessing and going to appointments. Residents spoken to at the visit or completed a survey were generally very pleased with the level of care they received at the home. Comments include ‘have previously been in a home where I was unhappy but am very impressed with the care and attention at Forest Hill House’, ‘very happy no complaints’ and ‘sometimes slapdash’. One health professional commented ‘provide excellent care to frail vulnerable people’. Most medicines are supplied in monitored dosage system (MDS) blister packs. The receipt and disposal of medicines is recorded. The Medication Administration Records (MAR) in use at the time of the inspection had been appropriately completed when medication was administered. An audit is undertaken monthly and the records demonstrated that actions are taken to address the issues identified. The home still needs to include on residents’ records a care plan relating to their medication needs. The care records did not always provide clear guidance to indicate when prescriptions marked ‘as needed’ or ‘prn’ should be given when the resident is unable to request the medication. There is a separate medicines refrigerator with a minimum and maximum thermometer. The temperature was not being recorded. Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. Residents spoken with said that they were always addressed in the way they had requested and the staff are always polite, considerate and thoughtful. One health professional commented ‘Respects residents autonomy as far as possible’ and a relative said that ‘The staff give support and encouragement to maintain a normal life despite their disabilities with respect and dignity’. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. The flexibility of the home and the activities provided enable residents to retain control over their lives where feasible and take part in social activities that meet their expectations. EVIDENCE: Forest Hill House has a dedicated activities organiser demonstrating the home’s commitment to providing a stimulating environment for residents. Emphasis is placed on providing activities linked to the world outside the home e.g. seasons, the queen’s birthday, sporting events, fundraising activities for worthy local causes. On the day of the inspection residents were enjoying decorating witches hats in preparation for Halloween celebrations. Photographs showing the residents participation in various social activities throughout the year and the entertainments programme are displayed in the reception area. Comments received from relatives included ‘the social needs of my mother are well cared for, she likes helping with the planting of hanging baskets and tubs also helping to choose the plants for these. There are plenty of entertainment and outings for those able to take part. My mother is extremely happy and Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 14 very well cared for’, and ‘the home throws itself into celebrations of any kind with the greatest enthusiasm. All the residents are included as well as friends and relative’. One health professional felt that there was a ‘need to provide more stimulation for the residents’. Information is given to residents and their relatives / friends about staying in contact and visiting the home. The visitors’ book confirms the number and range of visitors to the home. Relatives spoken with all agreed that they always felt very welcome when they visited the home. One relative commented ‘as my mother finds it difficult to hear on the telephone, the staff keep me in touch with her’. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and when they got up in the mornings and went to bed at night. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. Menus are based around the known likes and dislikes of the residents. The home has summer and winter menus on a six week rotation. The menus were viewed and found to be varied and well balanced offering at least five pieces of fruit or vegetable every day. Residents are offered meal choices on the day and alternatives can be provided. The menu is displayed on a blackboard in the dining room. The meal served on the day of inspection was lasagne with chips and fresh vegetables followed by chocolate bread and butter pudding. An alternative was provided to one person who chose not to have the main menu. Residents spoke highly of the food and said that they look forward to mealtimes. The lunchtime meal was served and eaten in a very relaxed manner at the resident’s own pace. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 15 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. The systems in place provide residents with the confidence that their complaints will be listened to and acted upon. The home has an adult protection procedure and provides training to prevent abuse however shortfalls in staff employment checks may put the residents at risk. EVIDENCE: Forest Hill House has a clear complaints procedure illustrating timescales and how complaints are dealt with. The procedure is included in the Service User Guide. Copies of the guide were seen in the residents bedrooms visited. The home has had one complaint since the last inspection that when investigated was found to be unsubstantiated. Residents who completed a survey all agreed that they know who to speak to if they are unhappy with their care and relatives commented that although they had not had to make a complaint they are aware of the home’s complaints procedure. One resident commented ‘I’m sure that it will never happen. I am quite happy’. The home has an adult protection policy and there is ongoing staff training in abuse awareness at the home. Staff themselves, along with their training records, confirmed this. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 16 The recruitment records of two recently employed members of staff did not evidence that a satisfactory enhanced Criminal Records Bureau (CRB) or a Prevention of Vulnerable Adults check had been obtained by Forest Hill House prior to them starting work. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing the residents with a comfortable, clean and well maintained place to live. EVIDENCE: The home is well decorated and maintained throughout. In the past year the main lounge, dining room and reception area has been decorated and refurbished. All chairs have been replaced in the lounge and conservatory. The top floor shower room now provides bathing facilities that are easier for the resident and care staff to use. A new bath has been installed in the ground floor bathroom that has been altered to provide a larger working area. Plans for the coming year include the continuing refurbishment of the shower and bathrooms and the residents’ bedrooms. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 18 Recent inspection visits by the Fire and Rescue Service and Environmental Health were satisfactory. The home has a Fire Risk assessment in place. A suitable laundry room with appropriate equipment is in place at Forest Hill House. Talking to staff and viewing training records evidenced that all staff have received training in infection control. Residents are asked to mark their clothes with their names to ensure that they don’t get confused with other peoples. Staff at the home strive to look after residents’ clothes well and get them back to their owners. One relative commented ‘the home is always clean and fresh’. One resident felt that ‘more care could be taken when laundering clothes’. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The home employs sufficient staff that are appropriately trained to meet the present level of dependency and number of residents at Forest Hill House. However the recruitment practices within the home do not consistently protect the residents ensuring that they are in safe hands at all times. EVIDENCE: Clear staffing rosters are in place that show who is on duty, when and what jobs they do. At least one qualified nurse is on duty at all times, with the registered manager additional to the qualified staff. 6 health care assistants are on duty between 8am and 2pm and 4 between 2pm and 8pm, three care assistants are on duty at night. Talking to residents, staff and viewing staff rotas confirmed that the number of staff on duty meets the needs of the present dependency levels of the residents at the home. Residents that completed the survey generally agreed that they receive the care and support they need and staff are available when they need them. Health care assistants are encouraged to undertake study for NVQs in care. The Department of Health target is that 50 of care staff in every home should have this qualification. This home reports that they are currently meeting this target. Two health care assistants spoken with confirmed that they had achieved their NVQ in care. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 20 Three files were reviewed at this visit for members of staff who had recently started working in the home. The findings were the same as identified during the last inspection ‘no files contained all the pre and post employment information required by law. In addition it was not clear from the information held on file that, in the case of a worker from abroad, they had the right to work in this country or at the home’. Records are kept of training that staff undertake. These records show that staff have access to a good range of basic training. A new structured staff induction has been introduced with documentation to record all training that has been received. Viewing induction and ongoing training records and talking to staff confirmed that the home has developed and implemented a programme of induction and ongoing training. Staff who responded to the survey all agreed that they were being given training relevant to their role. One health professional expressed a view that ‘the RGNs skills in palliative care could be updated’. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 21 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements at the home and the quality assurance system ensures that the residents live in a home that is well managed and the service provided meets their needs. EVIDENCE: The home is managed by Julie Wilson a first level registered nurse who has attained the Registered Managers Award. In her absence rosters show that it is always clear who is in charge at any time in the home. The home is part of the Royal Bay Care Homes Ltd group. The Responsible Individual registered with the Commission for this company – Russell Wilson has his office on the premises, so is closely involved in the day to day running of the home. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 22 The home has achieved the ‘investors in people’ award. The registered manager returned the completed Annual Quality Assurance Questionnaire to CSCI prior to the inspection. This will now form part of the home’s quality assurance programme. Residents are provided with an annual satisfaction questionnaire to enable the home to monitor what they are doing well and what could be improved. A resident’s forum has been introduced where ideas on improvements are discussed. Family, friends or professional advisors assist all residents to manage their financial affairs. Pocket money is held for a number of residents and all transactions are recoreded clearly and accurately. Two residents records were randomly checked and found to be correct. All gas installations, central heating, electrical wiring and appliances and equipment used to meet service user needs have been checked. Policies and procedures are available relating to health and safety, Control of Substances Hazardous to Health (COSHH), infection control, manual handling and first aid. Fire training, drills and fire safety checks have been completed as required. Accident records are maintained. An accident to a resident identified in their care records had been recorded on the accident form. Staff have received training in health and safety including manual handling and first aid. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement The registered person shall ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. The care plans must be reviewed and updated to ensure they relate to the actual care being provided and are focused on the individual needs of the resident. 2. OP7 13 Where any equipment is in use that physically restrains the person this should only be employed when this is the only practicable means of securing the welfare of the person and there are exceptional circumstances. There must be an assessment outlining why the equipment is in use, how it is to be used and written permissions for its use given. The assessment must be regularly reviewed. Timescale of 01/09/07 not met DS0000064305.V353618.R01.S.doc Timescale for action 28/02/08 28/02/08 Forest Hill House Nursing Home Version 5.2 Page 25 3. OP9 13 The Registered Person must ensure that the care records provide clear guidance to indicate when prescriptions marked ‘as needed’ or ‘prn’ should be given when the resident is unable to request the medication. The temperature of the medicines refrigerator must be monitored daily when in use, using a maximum/minimum thermometer and recorded. Care staff should have a clear understanding of the action to be taken if the temperature is outside the normal range. 28/02/08 4. OP18 19 and Schedule 2 The Registered Person must ensure that staff are not employed to work at the home until a satisfactory check in relation to the Prevention of Vulnerable Adults as specified in the regulations has been obtained. Before allowing a new member of staff to work at the home the information and documents listed in regulation 19 and schedule 2 must be obtained. Once employed the information listed in schedule 4 as per regulation 17 must be kept. Such records must be available for inspection at all times. Timescale of 01/09/06 not met 28/02/08 5. OP29 19 and 17 28/02/08 Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard OP7 Good Practice Recommendations Care plans should include a section on medication. Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Forest Hill House Nursing Home DS0000064305.V353618.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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