Inspection on 20/06/06 for High Broom Care Home

This inspection was carried out on 20th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

High Broom Care Home 18/10/05

High Broom Care Home 23/06/05

High Broom Care Home 28/01/05

High Broom Care Home 08/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE High Broom High Broom Road Crowborough East Sussex TN6 3SL Lead Inspector Elaine Green Key Unannounced Inspection 20th June 2006 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 High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service High Broom Address High Broom Road Crowborough East Sussex TN6 3SL 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 654027 01892 665713 HighBroom@agecare.org.uk The Royal Surgical Aid Society Age Care Mrs Anita Louise Clarke Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That a maximum of forty two (42) older people be accommodated. A maximum of thirteen (13) older people are accommodated in the close care cottages. That the service users are aged 65 years or over on admission. That one (1) service user can be accommodated aged between 60 and 65 years on admission as long as their individual needs can be met. 18th October 2005 Date of last inspection Brief Description of the Service: High Broom is a large detached house set in extensive grounds in a quiet country lane on the outskirts of Crowborough. The home is one of a group of four homes run by Age Care, a charity that was formed in 1863 under the Royal Surgical Aid Society. Crowborough town is approximately one mile from the home, with access to local shops, banks and other services. There are rail services to London and bus services to Tonbridge Wells and Brighton. The home is currently registered for 42 older people that includes accommodating a maximum of 13 users in semi- independent cottages located within close proximity to the main house. The service users of the cottages choose how much contact they have with the other service users and staff and often join the residents of the main house at meal times. Staff check on service users in the cottages in the morning and there is a call system. If the needs of the service users change over time, they can be admitted to the main house as vacancies occur. High Broom provides a comfortable home for service users. Independence and activities are promoted. A new extension to the lounge, new conservatory and front office was completed in 2004. A lift is available in the main house. Fees are broken down into 3 elements; hotel charge, care requirements and accommodation. Charges vary according to room size but currently range from £1,900 per to £3,350 per month. All the entertainment and activities provided by the home for service users are included in the fees. Additional charges are made for hairdressing and chiropody. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of High Broom a site visit took place to the home. This took place between 10 am and 5.30 pm on the 20th June 2006. The Inspector had a tour of the building, joined service users in the dining room for their midday meal and had the opportunity to meet with two visiting relatives and a visiting health care professional. The Inspector had discussions with the visitors, 6 service users, the manager, members of staff team and the Responsible Individual for the home and their comments will be reflected within the report. A range of records and documentation were also examined and included some of the homes’ policies, procedures, guidelines and daily records, service users care plans, medication records and records pertaining to health and safety. Service user questionnaires were sent by the CSCI prior to the visit and feedback from the ten completed questionnaires received will be included within the report. What the service does well: The manager of the home appropriately assesses prospective service users prior to their admission to the home. Care plans contain detailed and informative information for staff to follow in relation to supporting service users appropriately. The newly appointed Head of Care is planning to further modify the way information is recorded on care plans so that they are more individualised. The management of the home takes steps to ensure that they run the home in the best interest of service users and have several methods for gaining their views on the services they receive. Complaints are investigated appropriately and service users stated that they know how to make a complaint should they need to. The health care needs of service users resident in the home are met and the medication policies and procedures adopted by the home are safe. All staff receive training in the administration of medication and a visiting health care professional spoke highly of the care provided by the home. The quality of the food provided to the residents of High Broom is good and all the comments received by the Inspector in relation to the food were positive. The food served for the midday meal on the day of the site visit was hot, homemade and of good quality and an alternative was available. Many service users stated that they have their breakfast in their rooms and enjoy this. Service users have control over their lives, for example, they have a choice of what time they get up or go to bed and what time they have their breakfast. There is a varied and stimulating programme of activities on offer at the home that the service users are happy with. The home and grounds are clean and hygienic and maintained to a high standard and domestic staff are employed. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 6 One service user wrote that the standard of cleanliness in the home was ‘excellent’. Staff are employed in sufficient numbers to meet the needs of the people who reside there and receive a comprehensive induction and training programme. The staff team are enthusiastic and open to new ways of working, appear relaxed and interact well with service users. 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. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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): 1,2,3,4,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior admission however, not all service users have been provided with the documented information they required to make an informed decision about whether or not to reside there. EVIDENCE: Preadmission assessment documentation was examined and found to be in order. The home has obtained copies of relevant assessments where possible and this information had been transfered onto the care plan. In addition to the pre admission assessment the manager asks the prospective service user or their relative to complete a questionaire which provides the home with valuable information about service user. It would be useful for staff to have access to this information when getting to know the service user and it is recommended that this information is included in the care plan where appropriate. Service users are able to visit the home to look round and the first three months stay is on a trial basis. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 10 Presently the manager informs prospective service users verbally of whether or not the home can meet their needs. It is required that following a preadmission assessment, that the prospective service user is informed in writing of the outcome. In addition all prospective service users must be provided with an up to date service user guide and statement of purpose prior to moving into the home and exsiting service users should be provided with up to date copies when they are available (currently under review). The manager and the Responsible Individual for the home explained to the Inspector that not all service users resident in the home have a contract due to the fact their contracts are being reviewed to reflect new legislation and are in the hands of the Society’s lawyers. They further assured the Inspector that in future no service user will be admitted to the home without receiving all the relevant information relating to the services offered by the home and information relating to fees and what they cover. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users care plans provide the guidance required for staff to support service users in their daily lives and the policies and procedures adopted by the home in relation to the administration of medication are safe. EVIDENCE: Three Care plans were examined and found to be in order. The information provided is detailed. Although the manager stated that the care plans are reviewed on a regular basis and ammended as and when needed a requirement is made for all care plans to be reviewed on a monthly basis and that the person undertaking the review signs to confirm this. The new Head of Care recently employed by the home explained to the Inspector that she plans to further improve the care planning system currently used by the home in order to make them more user friendly and more personalised, this should help ensure the care provided is service user focused. Medication records were examined and were in order. Staff were able to discuss with the Inspector the codes used on the medication administration sheets and demonstrated a good understanding of the medication being High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 12 administered and what it had been prescribed for. Observation of the administration of medication confirmed that the homes’ policies and procedures were being followed and were safe. One member of staff explained that they were relatively new to the home but had been given a thorough induction in relation to medication. A visiting health care proffessional confirmed that appropriate referals are made, that they see service users in the privacy of their own rooms and that they had no concerns in regard to the care and support given to service users by staff of the home. Discussions with service users and feedback from service user surveys indicates that service users are usualy supported in the way they prefer and don’t usually have to wait long for assistance when they ring their call bell. Observation of practice on the day of the site visit confirms that staff speak to service users in a dignified and respectful manner. Staff appeared to support service users appropriatly and allowing them to take their time. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. Service are provided with the opportunity to participate in appropriate leisure and social activities. The food provided is wholesome and nutritious. EVIDENCE: The home provides service users the opportunity to participate in approprite, enjoyable and stimulating activities. A visiting relative stated that their was always something going on and service users stated they were happy with the activities on offer and the frequency of them. Care plans don’t specify individual preferences in relation to their prefered leisure activities. It is recommended that an activity programme is included in service users care plans to illustrate this, including how and when individuals like to maintain contact with their friends, relatives and the wider community. Activities currently on offer in the home includes, quality circle group, summer fete, Club ‘100’, painting class’s, library of books both the homes’ own and books form the local library, greetings cards are for sale in the hallway where there is also a post box and information about activities and events on in the local area. All activities provided by the home are included in the fees with the excpetion of hairdressing and chiropody. There is a function room in the bungalow annex which is available free of charge for service users to book. This is used to High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 14 entertain visitors hold celebrations etc. one service user had booked it to watch the World Cup with her friends staff stated it was a well used resource. Two visitors came to the home on the day of the site visit and both of them confirmed that they are welcomed into the home and that their visting times are not restricted. Service users stated that they have choice and control over their lives and are able to choose for themselves when to get up, go to bed, what they eat, when they eat, what to wear and whether or not they participate in the activities on offer in the home. On the day of the site visit several service users had chosen to have a lie in and were given the support they required when they requested it. The Inspector joined service users for their midday meal. The food served was hot, wholesome, nutritious and well presented. A choice was available and service users stated that they are asked on a daily basis what their preference is for the day. The homes’ menu was examined and confirmed that a varied diet is provided. It is recognised that the home has worked hard to make improvements to the arrangements for the provision of food at meal times and continues to do so. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a positive attitude towards complaints and investigates them appropriatly. Service users are protected by homes adult protection and policies and procedures and service feel they are listened to. EVIDENCE: Appropriate safeguarding referrals are made by home when required and a visiting health care professional confirmed this. None of the service users currently resident in the home present a level of behaviour that is challenging however when this did occur the manager reassessed the individuals needs and a more appropriate placement was then found. The home has a copy of the local adult protection policies, procedures and guidelines and provides staff with the appropriate training in recognising abuse. A complaint made to the Commission of Social Care Inspection (CSCI) in relation to the services provided at High Broom particularly in relation to the arrangements for the provision of food, issues relating to the use of a high number of agency staff, of confidentiality in relation to the administration of medication in the dining room and the way in which the investigation into the complaints was managed by the then, management of the home. This complaint was passed to the Society to investigate. The Society upheld the complaint and improvements have been made. The CSCI feels the complaint was thoroughly and appropriately investigated and that all the concerns raised have been addressed. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 16 The newly appointed Head of Care explained that the home now records all complaints no matter how small in an attempt to improve the services provided. An examination of the complaints record confirmed that complaints are recorded on a regular basis and are addressed as soon as possible with the action taken and outcome documented. The complaints that have been made to the management have been investigated appropriately. The homes complaints policies and procedures are satisfactory and service users stated that they confident in approaching the manager and staff if they had any complaints. All service users and their relatives have been provided with an up to date copy of the homes’ complaints policy and procedure, which has been amended to include the contact details for the CSCI. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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): 19,20,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, homely, safe, well maintained and clean environment for service users to reside in. EVIDENCE: The Inspector had a tour of the building and grounds on the day of the site visit. The gardens surrounding the home are immaculately maintained and are accessible to service users via level access and ramps from the main house and bungalows. Ample seating is provided around the garden and there are tables and chairs to the rear of the building on the patio where shade is provided by umbrellas. The communal areas of the home are decorated and furnished to a high standard and there is a water dispenser in the lounge. Domestic staff are employed and all areas of the home was found to be clean and hygienic. Service users bedrooms are personalised and meet their needs. Some service High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 18 users have brought their own furniture and others have chosen to use those provided by the home. The head of care has identified some health and safety issues and assurances were given to the Inspector that these would be addressed. They include the need for a window restrictor to the fitted and for risk assessments to be undertaken in relation to the stairs to the fire escape on the top floor. In addition it is recommended that the home further investigates alternatives to the arrangements for access to the 4 rooms on the top floor which are currently accessible only via a small flight of stairs. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skills of the well trained staff employed by the home. The recuitment procedures adopted by the home are safe. EVIDENCE: The staff employed to work at High Broom appear to be happier and more relaxed than at the last Inspection. This is having a positive affect on the service they are providing to the service users resident in the home and was evident to the Inspector. The home provides a comprehensive, induction and training programme for all the staff employed. The staffing rotas were examined and there are sufficient numbers of staff on duty at all times to meet the needs of the service users resident in the home. Service users stated that under normal circumstances that the staff are able to give them the support they require in a timely way and that they are never rushed. The use of agency staff is now limited and this is an improvement made since the last Inspection that is having a positive affect on the quality of life experienced by the service users resident in the home. The level of agency staff used could further be reduced should the home increase its’ staffing levels so they could cover staff holidays and sickness by using their own permanent staff. It is recommended that the home reviews its’ staffing levels to this affect. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 20 Staff stated that they felt the manager and the head of care supported them and that they are approachable. Observations of the staff practice on the day of the site visit confirm that staff are competent. Several staff were able to detail the support required by individual service users and how this support should be delivered. The staff team as a whole appear positive, enthusiastic and open to new ways of working. The staff room contains detailed information for staff to refer to in relation to dementia care, Parkinson Disease, Diabetes, Osteoporosis, Manual Handling and strokes etc. There is also information on forthcoming courses that staff can nominate themselves for. The target of 50 of the care staff employed by the home achieving a national Vocational Qualification (NVQ) in Care at Level 2 or above has been met. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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): 31,32,33,35,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.The manager is appropriatly experienced and qualified and runs the home in the best interest of the service users who reside there. The health safety and wellfare of service users and staff is largely protected and promoted. Staff receive formal supervision and the home has several ways of monitoring their own performance in relation to the quality of the services that they provide. EVIDENCE: The manager of High Broom is qualified and experienced and has managed this home for a number of years. The service users, relatives and health care professional that the Inspector had discussions with on the day of the site visit all stated that the new head of care and the manger were approachable. Two visitors stated that they are kept informed of any changes in the condition of the individual they visit. Staff stated that they felt supported by the manager High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 22 and the head of care and that they felt there had been improvements in the running of the home in recent months The home gathers stake holders views in a number of ways, service users have the opportunity to attend quality circle meetings on a regular basis to discuss relevant issues. There is a staff representative committee that meets 4 times a year where staff from all the Surgical Aid Societys’ homes meet with the Chief executive and an elected member to discuss issues relating to the services they provide. Service users, relatives and staff are given satisfaction surveys to complete twice a year and these are then audited in order to make improvements where possible. In addition to this a residents and relatives committee is in the process of being set up and a clinic governance group meets 4 times a year to look at infection control, pressure care, complaints, accident reports etc. Health and safety records were examined and found to be in order. Although water temperatures are monitored the frequency of this must increase, it is required that the temperature from all hot water outlets accessible to service users is monitored and recorded on a monthly basis. The home is aware of the need to ensure that they protect service users from the risk of Legionnaires Disease A comprehensive fire risk assessment has been undertaken however, in addition to the fire risk assessment for the home it is required that a fire evacuation plan is implemented for all service users in the home and that each plan is based on an individual risk assessment. It is recognised that the home has worked hard to meet the requirements set at the last Inspection and endeavours at all times to improve the services that they provide. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 2 High Broom DS0000021134.V292818.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1,2) 5(1) 6(ab) Timescale for action That all service users are 30/08/06 provided with an up to date service user guide and Statement of Purpose. All prospective service users are provided with this information prior to admission to the home. All service users must be 30/07/06 provided with and up to date contract or statements of terms and conditions of residency. Prospective service users must be provided with this information prior to admission to the home. Following a preadmission 30/07/06 assessment the prospective service user must be informed in writing of whether the home can meet their assessed needs. That care plans are reviewed on 30/07/06 a monthly basis. It is required that the 30/07/06 temperature from all hot water outlets accessible to service users is monitored and recorded on a monthly basis. A fire evacuation plan must be 30/08/06 implemented for all service users in the home and each plan must DS0000021134.V292818.R01.S.doc Version 5.1 Page 25 Requirement 2. OP2 5 (1c,3) 3. OP3 14(1abcd) 4. 5. OP7 OP38 15(1) 12(1a,4ab c) 6. OP38 12(1a,4ab c) High Broom be based on an individual risk assessment. 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. 2. 3. Refer to Standard OP3 OP19 OP27 Good Practice Recommendations That the information gathered from the service user questionnaire completed on admission is included on the care plan. That the home further investigates alternatives to the arrangements for access to the 4 rooms on the top floor which are currently accessible via a small flight of stairs. That the home reviews its staffing levels in respect of employing staff in sufficient numbers to cover for staff holidays and sickness without the use of agency staff. High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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 High Broom DS0000021134.V292818.R01.S.doc Version 5.1 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. 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!