Inspection on 16/10/06 for Harecombe Manor

This inspection was carried out on 16th October 2006.

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

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

Other inspections for this house

Harecombe Manor 02/09/08

Harecombe Manor 09/12/05

Harecombe Manor 13/01/05

Harecombe Manor 08/07/04

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

CARE HOMES FOR OLDER PEOPLE Harecombe Manor Southview Road Crowborough East Sussex TN6 1HG Lead Inspector Rebecca Shewan Key Unannounced Inspection 16th October 2006 09:40 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 Harecombe Manor DS0000013993.V309257.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. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harecombe Manor Address Southview Road Crowborough East Sussex TN6 1HG 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) 01892-652114 Mr Alexandre Ollivier Mrs Evelyn Ollivier Mrs Mohamed Biby Gulamaideen Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (51) of places Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the maximum number of service users to be accommodated is fifty-one (51). Service users must be older people aged sixty-five (65) years or over on admission. Service users may also have a physical disability. A maximum of ten (10) service users in receipt of personal care only can be accommodated. That the home may from time to time accommodate service users under sixty-five (65) years of age. 9th December 2005 Date of last inspection Brief Description of the Service: Harecombe Manor is a privately owned care home that is registered to accommodate up to 51 residents. Nursing care is provided whilst a maximum of 10 places can be utilised to accommodate residents in receipt of personal care only at any given time. The home is located opposite Crowborough Hospital and is on the outskirts of town and there are some local amenities within walking distance of the home. The home comprises of 41 single bedrooms (21 of which have en-suite facilities) and 5 double bedrooms (3 of which have en-suite facilities). There are additional toilet and bathroom facilities throughout the home. Rooms are located over two floors, accessible by two passenger shaft lifts. The home has a number of specialist equipment in use such as mobility aids, specialist nursing beds and bath and moving/handling hoists. There are extensive attractive gardens to the rear of the property that are accessible to residents. There are car-parking facilities to the front of the premises. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £500 - £650 per week, with additional charges made for newspapers, hairdressing, dry cleaning and chiropody. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 16th October 2006. Incident reports, Monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took eight and a half hours. A tour of the whole home was undertaken and the Registered Provider, Registered Manager, five staff and four service users (known as Residents), were spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which ten were returned (NB: five were completed by a residents relative or representative). Comments received included: ‘We cannot praise this home enough for the care they give’ ‘All the staff are very helpful and friendly’ ‘I like living here, they treat me very well’ ‘Sometimes I don’t like the food very much, it would be nice to have more choice and the occasional curry’ ‘I have no complaints about living here, I am very well looked after’ ‘We have noticed how different the home is when no activities are available – staff sickness has meant we haven’t had our usual plan but the care staff do try to entertain us, but its not the same!’ The home were requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. Forty seven residents were accommodated at the home at the time of the inspection. What the service does well: The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 6 The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Activities are arranged according to resident choice. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. There is an efficient complaints procedure in place and the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. The management and administration of the home is good, with evidence of consideration being given to resident’s and/or relatives opinion. What has improved since the last inspection? Following the previous inspection of the home in December 2005 the home has made improvements to ensure that the following previous inspections Statutory Requirements and Recommendations have been addressed. Pressure area care assessments now detail the action that is to be taken by staff in order to maintain service user’s tissue viability, ensuring that the risk of pressure area sores are well recorded and strategies are in place for their prevention and/or treatment. Clear medicine records are kept of the actual dose administered as per the ‘as and when required’ criteria, thereby reducing the risk of overdose or underdose of when required medications. The variety of activities offered by the home are planned in advance and in consultation with residents, ensuring that the activities provided are in accordance with service user choice. Action plans have been forwarded to the CSCI (with timescales) for the replacement of old and worn furniture, flooring in each of the bathrooms and the replacement of poor quality carpets, ensuring that there is an on going refurbishment plan in place, which is adhered to. Footrests are used at all times when transferring residents in wheelchairs, thereby reducing the risks associated with the inappropriate use of wheelchairs. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 7 Daily menus and alternatives are displayed within the dining area and other areas of the home, allowing service users with an opportunity to choose their meals more freely. The Statement of Purpose and Service Users’ Guide has been dated to evidence that it is current. 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. Harecombe Manor DS0000013993.V309257.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 Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met, with some improvement recommended to ensure that the information relating to the home is consistent and up to date. EVIDENCE: The homes Statement of Purpose and Service User Guide were viewed and it was evidenced that following the previous inspection of the home in December 2005, the Statement of Purpose and Service Users’ Guide has been dated to evidence that it is current. However it was observed that although these documents contain all the items specified by the National Minimum Standards, these documents refer to residents as ‘clients’, ‘service user’s’, ‘patients’ and ‘residents’, whilst the Statement of Purpose detailed the starting range of fees as different to those specified in the homes Pre-Inspection Questionnaire. It was also evidenced that the Complaints procedure detailed in both documents were in conflict with each other. Therefore a recommendation has been made. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 10 The home’s Registered Manager, a Senior Nurse and/or a Senior Carer carry out pre- admission assessments. Records inspected showed that preadmission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. Residents confirmed that they had been involved in the assessment process and had felt included in their admission to the home. Intermediate care is not offered by this home. Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvements are required to ensure that medication records are maintained appropriately in order to prevent the risk of errors being made by staff when administering medication to residents. EVIDENCE: Four residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Residents informed the inspector that care plans are devised with their involvement. It was also noted that details of any specialist interventions required e.g. for the management of nutrition, pressure area care and wound dressings are specified and recorded in residents care plans. Suitable risk assessments were also found to be in place. Documented records viewed supported this. The home has made improvements since the inspection of December 2005 to ensure that pressure area care assessments detail the action that is to be taken by staff in order to maintain tissue viability. Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 12 From the records sampled and from discussions with staff, it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. The Registered Manager said that residents can be registered with a GP of their own choice or one from any of the local surgeries. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist, Dietician and Audiologist are made via the GP or the hospital. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. The home has made improvements since the inspection of December 2005 to ensure that clear medicine records are kept of the actual dose administered as per the ‘as and when required’ criteria. The controlled drug register and controlled medication were audited and were found to be correct. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. It was evidenced that where medication had been omitted, the recording for the reason of this omission was not clearly recorded, with the code ‘O’ being recorded without an explanation being recorded onto the back of the MAR sheet. Daily medication fridge temperature records were also viewed and it was observed that on six occasions the temperature had not been recorded. It was also evidenced that where medications such as creams/lotion/ointments/shampoo’s have been prescribed, entries onto MAR sheets are not completed. Therefore Immediate Statutory Requirements were made. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the ten service user surveys received six stated that they always received the care and support that they needed, whilst four responded that they usually received the care and support that they needed. One comment received stated that ‘the staff go out of their way to be helpful and keep me informed of every aspect of my relatives health and well being’ Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a specialist diets to residents, with resident’s choice and wishes being respected. EVIDENCE: The home has made improvements since the inspection of December 2005 to ensure that the variety of activities offered by the home are planned in advance and after consultation with residents. Residents said that they enjoyed many of the home’s activities and that the home staff were flexible in allowing residents to choose the level of activities attended. A published list of activities is made available to residents, with residents being informed of special events being held in the home. Activities include: ball and hoop games, Monday quiz questions, art activities, prize bingo, poetry and reading, 1:1 sessions and trips to places of local interest. Of the ten service user surveys received three responded always, two responded usually and four responded sometimes to the question that asks ‘are there activities arranged by the home that you can take part in?’ One responded never but stated that ‘this is because their relative prefers their own company’. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion if they wish. Discussions with the Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 14 Registered Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and residents. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents spoken with confirmed this. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and resident’s guests are also welcome to have meals at the home. Drinks and snacks are available at all times. Medical, therapeutic or religious diets are provided as needed. The home has access to the specialist services of Speech and Language Therapist, who provides training and assistance with PEG feeding. Of the ten service user surveys received three responded always, six responded usually and one responded sometimes to the question that asks ‘Do you like the meals at the home?’ Comments received included: ‘would like more salads in summer’, ‘would like more variety’, ‘present cook does not provide much variety – cakes etc’ and ‘my relatives plate is always clean when I visit!’ Harecombe Manor DS0000013993.V309257.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received five complaints within the past twelve months, all of which have been recorded as addressed within the twenty-eight day response time as specified by the home’s policies and procedures. Each of the five complaints have now been resolved and appropriate action was taken by the home to address the concerns raised. From the section in the service user surveys received relating to complaints, this showed that seven ‘always’ knew who to complain to and two ‘usually’ knew who to complain to and one did not respond. One resident commented that they do they do know who to complain to but that to date it has not been necessary. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Verification of nursing staff’s registration to practice is obtained from the Nursing and Midwifery Council (NMC) prior to nursing staff commencing employment. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has a Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 16 copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. The home has been involved in one Adult Protection Alert process in the last twelve months. Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is hygienic and well maintained, with some consideration being required to maintaining an odour free environment. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. Residents spoken with said that they liked their bedrooms and that the communal areas of the home were comfortable and decorated nicely. The home has made improvements since the inspection of December 2005 to ensure that an action plan is forwarded to the CSCI with timescales for the replacement of old and worn furniture, flooring in each of the bathrooms and the replacement of poor quality carpets. It was evidenced that new bathroom Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 18 flooring had been laid in two of the homes bathrooms areas and that progress was being made to obtain new furniture. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records, by staff spoken with and by observation of staff adhering to procedures. It was evidenced that a clinical waste contract is in place. Of the ten service user surveys received seven responded always, two responded usually and one did not respond to the question that asks ‘Is the home fresh and clean?’. However on the day of the inspection it was evidenced that the there was a strong malodour of urine in the corridor between bedrooms numbers seven and twenty. Therefore a requirement has been made. Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s pre-inspection questionnaire. Of the ten service user surveys received four responded always, five responded usually and one responded sometimes to the question that asks ‘Are the staff available when you need them?’ Comments received included: ‘Sometimes there is a delayed wait’ and ‘staff have been available even when I have visited my relative at unsociable times’. The home has a permanent care staff team of seventeen care assistants, seven of which are trained in National Vocational Qualification (NVQ) level 2 in care. Whilst a further three are currently undertaking the NVQ level 2 course. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. Staff recruitment files were viewed and it was evidenced that these files now contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities. A number of the current staff team are from abroad. All necessary visa and Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 20 Home Office related documents were found to have been obtained and kept on file for these employees. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Fire Training, Health and Safety, Moving & Handling, Infection Control and First Aid. Other training related to the needs of the resident’s such as slips/trips/falls, wound care, communication, swallowing difficulties, PEG feeding and mentorship have also been undertaken. Registered Nurses spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the NMC. The home is also an approved provider of Adaptation Nurse Training, whereby nurses who are qualified overseas can train to be the UK equivalent. Harecombe Manor DS0000013993.V309257.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion, with urgent improvement required to ensure that the health, safety and welfare of residents and staff is being protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people. The Registered Manager is a qualified Registered Nurse, has achieved the Registered Managers Award and is a qualified NVQ assessor. Residents, relatives and staff spoken with said that the Registered Manager is friendly, approachable and any issues raised are actioned quickly and efficiently. There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires are distributed to residents, Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 22 their representatives and other interested parties on an annual basis. The results of which are published and made available to all upon request. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. Staff meetings are held, the minutes of which were viewed and these were found to be detailed in content and included actions taken to address previous issues raised by staff. The Registered Provider reported that the home does not take any responsibility for resident’s finances and that most residents have family/representatives/friends who protect their financial affairs on their behalf. However, individual residents ‘pocket money’ accounts are maintained by the home. These were found to be maintained in an appropriate manner with detailed records and accounts of all monies credited and debited to/from accounts. From the Pre-Inspection Questionnaire provided by the home it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. It was evidenced that accidents are well documented in the home’s accident book and that fridge, freezer and food temperature probe readings are recorded on a daily basis. The home has made improvements since the inspection of December 2005 to ensure that footrests are used at all times when transferring residents in wheelchairs. However from the tour of the premises it was evidenced that the broken window in room 32 remains in need of repair and has not been replaced and is still held together with adhesive tape. The Registered Manager reported that due to the specialist glazier skills required for such windows, quotes have been obtained for the work to be completed. However as this remains outstanding from the previous inspection this has now been made an Immediate Statutory Requirement, to be completed within twenty one days of the date of the inspection. It was also evidenced that the window restrictor in bathroom No 7 was broken and in need of repair. A number of clearly marked fire doors were also noted to have been wedged open despite clear signage stating ‘This is a fire door, please do not prop open’. Therefore Immediate Statutory Requirements have been made. Harecombe Manor DS0000013993.V309257.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 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 3 3 X 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Harecombe Manor DS0000013993.V309257.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 OP9 Regulation 13 (2) Requirement That all ‘O’ omission codes on MAR sheets must be recorded on the back of the MAR sheet. This is an immediate requirement. That medication fridge temperatures must be maintained and recorded on a daily basis. This is an immediate requirement. That all medications administered including ointment/cream/lotion/shampoo must be signed for as either administered or omitted. This is an immediate requirement. That the home is odour free throughout. The window restrictor in bathroom No 7 must be repaired and rendered safe. This is an immediate requirement. The window in bedroom 32 must be repaired and rendered safe for use. (THIS IS OUTSTANDING FROM THE PREVIOUS DS0000013993.V309257.R01.S.doc Timescale for action 18/10/06 2. OP9 13 (2) 18/10/06 3. OP9 13 (2) 18/10/06 4. 5. OP26 OP38 16 (2) (k) 13 (4) (a) (b) (c) 16/11/06 18/10/06 6. OP38 13 (4) (a) (b) (c) 21/10/06 Harecombe Manor Version 5.2 Page 25 7. OP38 13 (4) (a) (b) (c) & 23 (4) (a) INSPECTION OF DECEMBER 2005). This is an immediate requirement. That all fire doors must not be wedged open in the interests of the health safety and welfare of residents and staff. This is an immediate requirement. 16/10/06 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 That the Statement of Purpose and Service User Guide is amended to reflect the current range of fees, to reflect the correct complaints procedure and to refer to residents by one form of address. That daily menus and alternatives are displayed within the dining area and other areas of the home. 2. OP15 Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Harecombe Manor DS0000013993.V309257.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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