Inspection on 17/07/07 for Haythorne Place

This inspection was carried out on 17th July 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

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Haythorne Place 77 Shiregreen Lane Sheffield South Yorkshire S5 6AB Lead Inspector Michael O`Neil Key Unannounced Inspection 17th July 2007 08:50 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 Haythorne Place DS0000069695.V337785.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. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haythorne Place Address 77 Shiregreen Lane Sheffield South Yorkshire S5 6AB 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) 0114 242 1814 0114 242 1370 Southern Cross Healthcare (Focus) Limited Mrs Verlinda Croft Care Home 120 Category(ies) of Dementia (75), Mental disorder, excluding registration, with number learning disability or dementia (9), Old age, not of places falling within any other category (40), Physical disability (20) Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE, maximum number of places 75 Mental Disorder - Code MD, maximum number of places 9 Physical Disability - Code PD, maximum number of places 20 Old Age, not falling within any other category - Code OP, maximum number of places 40 The maximum number of service users who may be accommodated is 120. First inspection since registration of new company. 2. Date of last inspection Brief Description of the Service: Haythorne Place is a purpose built care home situated in the Shiregreen area to the north east of Sheffield. The home consists of six separate two-storey houses, personal and nursing care is provided within Haythorne Place. The home was built in 1995 and was registered with a new company Southern Cross Healthcare (Focus) Limited in January 2007. All residents’ rooms are single and ensuite. There is also a small shop on site for the use of residents and their visitors. The home is situated on bus routes and is near to local shops and other amenities. The manager confirmed that the range of monthly fees from 17th July 2007 were £320 - £1969.87 per week. Additional charges included hairdressing and private chiropody. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil and Shelagh Murphy regulation inspectors. This inspection took place between the hours of 8.50 am and 4:10 pm. Verlinda Croft, registered manager was present during the inspection and Terry Peel, operations manager and Lynn Fearn, regional operations director with Southern Cross Healthcare (Focus) Limited were present for the latter part of the inspection. The CSCI sent out questionnaires asking health professionals, people who use the service, relatives and staff about the care and the service provided. Three people/relatives, 3 staff and 3 health professionals returned questionnaires. The manager submitted an Annual Quality Assurance Assessment (AQAA) to the CSCI prior to the actual visit to the service. Some information from the AQAA is included in the main body of the report. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 7 staff, 2 relatives and 8 people who use the service. The inspectors wish to thank the staff, relatives and people for their time, friendliness and co-operation throughout the inspection process. The manager said a copy of the previous inspection report was available in the service user guides, which are provided in every residents bedroom. Information about how to raise any issues of concern or make a complaint was on display in the foyers of each house. What the service does well: Peoples care plans contained a full range of information, in a concise and easy to read format. People and/ or their relatives were involved in drawing up and reviewing the care plans. People said that the care they were receiving was good and consistently added comments such as ” the staff are nice, friendly and helpful”. Relatives made comments such as “the staff are caring” and “the care at Haythorne Place is very good “. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 6 People said that they had a choice of food and that the quality of food served was generally good. All people spoken to said that they felt safe living at the home. People who use the service, relatives and staff were positive about the manager’s leadership skills and approachability. Staff interviewed said they enjoyed working at the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 7 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 Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 8 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): Standard 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care needs of each person receiving care were assessed in detail prior to them being provided with a service by the service. This meant that staff would be aware of all the persons needs to ensure that they could be met. EVIDENCE: Staff spoken to said that assessments were undertaken prior to admission to ensure the service could meet prospective peoples needs. The home’s manager and social workers of the person carried these out. Three care plans were checked and these contained assessments of the persons needs. The assessments were formulated into a plan of care for each person. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 9 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): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, social and personal care needs were well documented in the care plans meaning that their needs could be met. A range of health care professionals visited the home to assist in maintaining the health care needs of people who use the service. People said that the care they were receiving was good and added other positive comments. Although the actual care delivered in one house was not person centred/individual to that person and was very task orientated. Relatives interviewed confirmed that they felt the needs of their relative were being met and added other positive comments. Medication procedures protected people’s health and welfare. Medication storage did not fully protect people’s health. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 10 Peoples privacy and dignity was not maintained on two of the houses but was promoted on the other four houses of Haythorne Place. EVIDENCE: Four plans of care were checked. Care plans contained a full range of information, in a concise and easy to read format. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Staff were aware of the contents of care plans and were knowledgeable about peoples individual needs. People and/ or their relatives were involved in drawing up and reviewing the care plans. Staff were updating risk assessments and care plans on a monthly basis. Although the care plans were individual this individuality was not promoted in the actual care delivered on House 3. An example of this lack of individual/person centred care is highlighted on issues surrounding meals and privacy and dignity. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, and chiropodists visited the home as requested and they attended the local dentist next door to the home. Relatives said that staff were very good at informing them if their loved one was ill or had had an accident. People said that the care they were receiving was good and consistently added comments such as ” the staff are nice, friendly and helpful”. Relatives made comments such as “the staff are caring” and “the care at Haythorne Place is very good “. Health care professionals said that staff at the home communicated well with them and felt that the standard of care delivered at the home was generally good although there was a concern that on some houses the staff did not always carry out changes to the care prescribed as soon as they should do. Some residents were not able to say whether they felt that they were being well cared for; these residents were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. All medicines in tablet and liquid form were securely stored around the home in locked cupboards. However prescribed creams were found in unlocked rooms around House 1. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 11 Medicine Administration Records (MAR) checked were completed with staffs’ signatures. People said that staff at the home respected their privacy and dignity in a number of ways, for example, by knocking on their doors and waiting for a response before entering. Staff spoke to people in a respectful way and showed patience when providing personal care to them. Peoples privacy and dignity, however, was not fully promoted due a practice observed by both inspectors on House 3.Around lunchtime as a matter of course a plastic apron was placed on every person, presumably to stop spillages. The inspectors observed that some people certainly did not need an apron. This practice is very undignified and institutialinised. People’s dignity could not be fully promoted on House 1 either as the shower rooms were not fitted with Shower curtains. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to make some choices about daily living and being involved in social activities. Some activities were offered to people. To improve choices and maintain interests, activities need to be more individualised to the residents assessed needs and preferences. The home had an open visiting policy, which assisted in maintaining good relationships with people’s representatives. Meals served at the home were of a good quality and offered choice to ensure residents receive a balanced diet. However meals were not available at times convenient to some people. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 13 EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel welcome. Throughout the day friends and family were seen visiting the home and there seemed to be a very friendly and welcoming feel in Haythorne Place. The inspectors saw that some people particularly on House 3 received little or no staff interaction or stimulation. A person on House 1 said they would like to attend more activities outside the home. Activities were occurring during the day and there were trips out planned but these only involved a few residents. Haythorne Place is a very large complex and only 1 activities coordinator is employed. The people in Haythorne Place have varying social needs and there are large variances in their ages. A more individualised activity programme is needed which should encompass the likes and dislikes of people, this information could be discussed with relatives and the person’s key worker. This would enable people opportunity to exercise their choice in relation to social and leisure activities. On House 3, a house where some people have dementia, the staff were not providing information that may help residents with orientation. A small clock was displayed in only one dining room. There was no Information, such as the weather, the place where the residents were living, or a news item, which may help people with orientation to time, and place. The director and managers did say that they would provide some specialist input in House 3 soon to look specifically at the issues highlighted above. People said that they had a choice of food and that the quality of food served was generally good. The inspectors observed that prior to lunch being served the residents on House 3 were sat for periods of up to thirty minutes at dining tables. The residents were sat staring at each other without any stimulation although they were provided with a drink. Staff sat with some people assisting them to eat. This assistance was provided at a relaxed pace although two staff did not inform the person what food was for lunch before they started offering assistance. One staff member, however, Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 14 did introduce himself and informed the person what he was there for, which was positive to hear. Haythorne Place DS0000069695.V337785.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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and staff were aware of these. People and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: All of the people said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. Staff undertook training on adult protection to equip them with the skills needed to respond appropriately to any allegations. All people spoken to said that they felt safe living at the home. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 16 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): Standards 19, 21, 24 and 26. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some of the homes environment was not well maintained and clean which meant that some people did not live in a comfortable and safe environment. EVIDENCE: In the main Houses 2,3,4,5 and 6 were clean and tidy. The cleanliness, decor and housekeeping of House 3 has improved significantly since the last inspection. Although there is generally an issue relating to the environment on every house inspected it must be said that the main reason that a Poor Quality outcome judgement has been made is due to the poor environment found on House 1. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 17 The gardens around the home and sitting areas outside all houses have been improved since the last inspection and offer more pleasant surroundings for people. In House 1 the inspectors found; An unattached urinal catheter bag that was dripping urine onto a person’s bedroom carpet. The dressings storeroom was not clean. Dressings, catheter bags and other medical aids were thrown into the room and some sterile packs were on the floor that was dirty. Several bedroom carpets were marked/dirty and omitted unpleasant odours. The doors of unoccupied toilets were left open around the house. This meant that unpleasant odours drifted down the corridors. People’s bedrooms were generally untidy and surfaces in the rooms were sticky and dusty. Some beds had been remade with dirty sheets and/or pillowcases. Generally House 1 was very untidy, not clean and maintained at a poor level for the people who live there. The inspector asked the manager to accompany her around the house to see for herself the poor level of hygiene and the poor general environment of the House. General issues that apply to other houses and areas of the home include; The laundry and kitchen sited in the basement have recently been flooded but are now operational again. The standard of these areas is not acceptable, however, the management of Southern Cross have made the decision and given verbal assurances that the kitchen and laundry will be resited to a ground floor level in the next two to three months. The manger has been advised to contact the local Authority environmental health officer to discuss the current and future situation. The exterior of the buildings are in need of refurbishing. There are broken doors, doorframes cracked and lead and tiles missing from roof areas. The kitchenettes in all houses are in need of refurbishment. The work surfaces are cracked, doors have handles missing, sealant around the sinks is damaged and tiles are broken. The floor covering is not sealed around the edges. Bathrooms were generally bare, institutionalised cold and clinical. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 18 Some bedding is worn and pillows are lumpy. This bedding needs replacing. A bedroom carpet in House 2 smells damp and musty possibly because it has been cleaned so many times. The carpet needs replacing. Haythorne Place DS0000069695.V337785.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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were generally employed in sufficient numbers to meet the residents needs. Although some staff felt that levels were insufficient. Some staff may not have the required skills to safely meet people’s needs. A majority of staff undertook NVQ training. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. Staff had completed training, including induction, which ensured that they had the competences to meet people’s individual needs. EVIDENCE: On house 3 inspectors observed a staff member assisting a person to eat their lunch. It later transpired that the staff member was a student on placement at the home and the student was only 15 years old. No staff member was concerned that a student was providing personal care to a person who uses the Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 20 service. The manager confirmed that under no circumstances should students on placement at the home be providing personal care to people. The majority of people, staff and relatives said staffing levels were adequate. Relatives said that staff were usually very visible around the home when they visited. Two people, a relative and staff on two houses did raise some concerns over staffing levels at certain times during the day and evening. The manager stated that agreed staffing levels were being maintained and the staff rota identified agreed staffing levels had been met. In view of the comments made, however, and due to the possible changing needs of people, an audit of staffing levels should be undertaken. Staff and people who use the service should also be consulted to highlight and address any areas of concern over the levels of staff employed. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Staff said that the frequency and availability of training had improved since Southern Cross Healthcare became registered providers of Haythorne Place. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were looking forward to start this training. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Two staff files checked identified that the member of staff had received induction training when they commenced work. The recruitment records of three employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them, these were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Haythorne Place DS0000069695.V337785.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): Standards 31, 32, 33, 35, 36, 37 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures and ethos of the home ensure that in the main the home is run in the best interests of people who use the service. Some of the homes procedures did not fully promote the health, safety and welfare of people who use the service and the staff. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 22 EVIDENCE: The care manager is a Registered Nurse and is experienced in the care of older people and has achieved her NVQ level 4 award. She is waiting to receive certification of this qualification. The manager has continued to be very positive about the inspection process and she has managed to coordinate good inroads into improving the service of Haythorne Place. People who use the service, relatives and staff were positive about her leadership skills and approachability. Staff interviewed said they enjoyed working at the home. As highlighted throughout the report there are shortfalls in the management of some Houses where others are performing well. The inspectors discussed these management issues with the managers and director of Southern Cross and the possibility of the service needing more management time. Over the past few months a deputy manager has been provided with some administrative time, which has provided some assistance to the Registered Manager. The home had a quality assurance system. Meetings involving people who use the service, relatives and staff were held and minutes of these meetings were seen. Questionnaires were regularly sent out to relatives and health professionals who visited the home. There was evidence of internal auditing of the homes medication system, care records and general environment. The environment in House 1 was audited by the manager last week some issues highlighted were similar to those that were found by the inspectors. The inspectors would therefore suggest that if senior staff had carried out regular checking of the general environment during the course of every day fewer requirements would have been highlighted by the inspectors. The home handles money on behalf of some residents. A receipting system and statement sheets were seen for each resident. Staff were countersigning each entry on the sheet when money had been withdrawn or deposited in the residents account. Formal staff supervision, to develop, inform and support staff took place at regular intervals. All staff were offered formal supervision and staff said that they found this useful and beneficial. People’s confidentiality was not safeguarded because their care notes were stored in unlocked rooms or cupboards in several houses. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 23 The health and welfare of residents could not be fully protected, as: A hoist sling, found in House 1, used to move and handle people was frayed and may have broken should any person have been moved with it. Moving and Handling equipment must be regularly checked to ensure it is fit for purpose. Potentially hazardous disinfectant products, alcohol and lighter fuel were stored in unlocked cupboards, an electrical control room and other unlocked rooms around the home. Since the last inspection improvements have been made on issues relating to fire safety. The frequency of fire drills have improved so that all staff could participate in a drill and no fire doors were found wedged open. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire and food safety. Two staff records checked confirmed that this training had occurred. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. This will promote the safety and welfare of the service users. Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 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 3 1 X 2 X X 2 X 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 2 Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12 Requirement Personal care delivered to people must be individual to their needs and must take into account their wishes and feeling. Medication must be securely stored in the home. Shower curtains must be fitted in the shower rooms to maintain people’s privacy and dignity. People’s wishes and feeling must be considered when providing personal care including assisting people with their meals. (Plastic aprons) People must have the opportunity to exercise their choice in relation to social and leisure activities. (Previous requirement partially met) Arrangements must be implemented to ensure that people are orientated to date, time and place. Meals at the home must be served at a times convenient to people who use the service. People must be aware of the choices of food available to them DS0000069695.V337785.R01.S.doc Timescale for action 01/09/07 2. 3. 4. OP9 OP10 OP10 13 12 12 01/09/07 01/10/07 01/09/07 5. OP12 16 01/12/07 6. OP12 16 01/11/07 7. 8. OP15 OP15 16 16 01/09/07 01/09/07 Haythorne Place Version 5.2 Page 26 9. OP19 23 10. 11. 12. 13. OP21 OP24 OP26 OP26 23 16 23 23 14. OP26 16 15. OP27 18 16. OP33 24 17. 18. 19. OP37 OP38 OP38 17 13 13 including when they are being assisted to eat. All areas of the home used by people must be well maintained, of sound construction, kept in a good state of repair externally and internally and must be well decorated. (Main body of report) Toilets and bathrooms must be clean and well decorated. Bedding provided for people must be clean and in a good condition. Dressings, catheter bags and other medical aids must be stored in a hygienic manner. All parts of the home must be kept clean and free from offensive odours. (Main body of report) (Previous requirement not met) Kitchenettes must be fit for purpose so that satisfactory standards of food hygiene can be maintained. There must be sufficient numbers of competent and experienced staff on duty at all times.(Age of staff) A system must be implemented to ensure that the homes environment and services are regularly reviewed and action taken to rectify any inadequacies highlighted. Individual notes and records must be securely stored in the home. Moving and Handling equipment must be regularly checked to ensure it is fit for purpose. Substances that are hazardous to the service users health and safety must be safely stored. 01/04/08 01/12/07 01/10/07 01/09/07 01/09/07 01/04/08 01/09/07 01/10/07 01/09/07 01/09/07 01/09/07 Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 27 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 OP27 Good Practice Recommendations An audit of staffing levels should be undertaken. Staff and people who use the service should also be consulted to highlight and address any areas of concern over the levels of staff employed. The need for more management time in Haythorne Place to monitor the service should be explored. 2. OP31 Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Haythorne Place DS0000069695.V337785.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!