Inspection on 14/12/04 for High View Oast Nursing Home

Care Home For Older PeopleHigh View Oast Nursing HomePoulton Lane Ash Canterbury Kent CT3 2HNUnannounced Inspection14th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment High View Oast Nursing Home Address Poulton Lane, Ash, Canterbury, Kent, CT3 2HN Email address Name of registered provider(s)/company (if applicable) New Century Care (Ash) Limited Name of registered Manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 33 Tel No: 01304 813333 Fax No: 01304 813815Category(ies) of registration, with (number of places) Old age, not falling within any other category (33), Physical disability (6), Terminally ill (5) Registration number H050000325 Date first registered 18th July 2002 Was the Home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 14th January 2004 YES NO 27/05/04 If Yes refer to Part CHigh View Oast Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 32nd December 2004 10:00 am June DaviesID Code141232Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionSheelagh Sanford, Acting Manager.High View Oast Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementHigh View Oast Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of High View Oast Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.High View Oast Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. High View Oast Nursing Home is registered to provide nursing care for up to 33 older people over the age of 65 years. The premises is detached and was converted in 1986 from a working Oast house, and retains many of its original features. There is a well-maintained garden with disabled access in the form of ramps and car parking facilities to the side of Home. One of the communal logia areas overlooks the gardens and has panoramic views of the surrounding countryside, there is another communal lounge area on the ground floor, and an open plan dining area. There is a passenger lift to the first floor. The Home has 14 single bedrooms and 9-shared rooms all rooms have a call bell facility. The Home is located in the village of Ash, and is a short walking distance from local village amenities where a regular bus service can be located. High View Oast is owned by New Century Care Ltd and managed on a daily basis by the Acting Manager, Mrs Sheelagh Sanford.High View Oast Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)High View Oast Nursing HomePage 6 The Management of the Home has worked hard towards meeting the standards and the overall quality of care provided was found to be of a good standard. The Inspector was able to speak with some Service Users who all said that they were happy. Staff spoken to enjoyed working in the Home. Choice of Home (Standards 1 ­ 6) Only Standard 3 was inspected on this occasion and met. The Home has an in depth pre-admission assessment. The Inspector was able to view four files of Service Users and all contained pre-admission assessment together with preadmission assessments of outside professionals. Health and Personal Care (Standards 7 ­ 11) Only Standards 7, 8 and 9 were inspected on this occasion and met. Care Plans seen by the Inspector showed that all aspects of the Service Users care had been appropriately recorded together with good risk assessments and regular reviews. The personal health care of all Service Users is met, both by qualified nurses and care staff in the Home and by outside professionals. The Home uses Boots MDS system for the administration of medication. The Inspector witnessed that all medication had been administered correctly. Staff were well trained and competent. Any unused medication had been properly recorded and returned to the pharmacy. The Inspector made a recommendation that eye drops/creams had the date written on to the bottle on the day of opening and not on the day received into the Home. Daily Life and Social Activities (Standards 12 ­ 15) Four Standards were inspected and met. The Home has a good programme of activities and on the day of this inspection the Service Users were holding a Christmas Coffee Morning. Many of the Service Users take part in activities organised by the activities co-ordinator employed by the Home, and a monthly record of activities is kept in the form of a photograph album. Visitors are always welcome in the Home, and Service Users can choose to entertain their visitors in their own room if they wish. High View Oast has a lot of support from the local community, as well as visits from specialised groups. Service Users can manage their own finances if they wish to, but many choose for their families to deal with their finances. Information is available in the Home regarding local advocacy groups. Service Users are able to bring personal possessions into the Home and an infantry is kept of these possessions is kept on the Service Users care plan. The Home has a rotating menu system, which offers a variety of nutritious freshly prepared food, all Service Users are offered three meals a day, with drinks and snacks as and when required. The Chef confirmed that liquidised food is served attractively and that the Home can cater for a variety of diets. Complaints and Protection (Standards 16 ­ 18) Only Standards 16 and 18 were inspected on this occasion and were met. High View Oast has an up to date complaints policy and procedure, a complaints book is kept which is easily accessible to all, and any complaint made would be dealt with in accordance with this policy and procedure. There are policies and procedures in place for the protection of vulnerable adults. All staff are aware of what is considered to be abuse, and how they would report and incident of abuse. Environment (Standards 19 ­ 26) Only Standards 19 and 26 were inspected on this occasion and were met. High View Oast is suitable for its purpose as a nursing Home. It is homely, tastefully decorated and comfortably furnished. The grounds of the Home were seen to be neat and High View Oast Nursing Home Page 7 tidy. The Home has good procedures in place for the control of infection. The laundry room is sited away from the kitchen facilities and was seen by the Inspector to be clean and tidy and appropriately equipped, with industrial washing machines and a tumble drier. Staffing (Standards 27 ­ 30) Only Standards 27, 29 and 30 were inspected on this occasion and were met. Staffing numbers in the Home meet the assessed needs of the Service Users. Rotas showed that sufficient staff are on duty throughout the day. A thorough recruitment procedure takes place with two references and telephone references being sought together with POVA and CRB checks. All new staff receive Statement of Terms and Conditions and the GSCC code of conduct. National Workforce Training specification is met within six months of employment. All staff receive further job related training throughout the year. Management and Supervision (Standards 31 ­ 38) Only Standards 33, 35 and 38 were inspected on this occasion, two standards were met and one was partially met. Quality assurance audits are carried out for High View Oast on an annual basis. The Inspector has made a recommendation that the published graphs and pie charts sheets should be dated to indicate the year of the survey. The Inspector viewed the recording of personal allowances that Service Users have requested the Home looks after. The records showed that all monies looked after for Service Users was well recorded on individual account sheets and each Service Users money was kept in a separate wallet. The Acting Manager, Sheelagh Sanford ensures that all staff keep up to date with Health and Safety training. Clinical waste from the Home is appropriately disposed of. The Inspector was shown up to date certificates for all equipment in High View Oast. It was noticed by the Inspector that the fire log was not kept up to date with recording of weekly fire safety equipment testing and monthly emergency light testing, and a requirement was made to ensure that this was carried out. All staff receive TOPSS related induction to include Health and Safety induction.High View Oast Nursing HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)High View Oast Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action Schedule 4 OP38 (14) ~The fire system is checked on a weekly basis and this is recorded in the fire log. This should also include a monthly check of the emergency lighting system.1.1/01/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP9 OP33 Eye drops are marked on the bottle with the date of opening and not the date of receipt. On the next publication of the quality assurance, the charts should indicate the year in which the survey has been carried out.High View Oast Nursing HomePage 10 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.High View Oast Nursing HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding Managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO NO YES YES NO YES NA YES YES YES NO YES YES NO NO NO YES NO YES 4 X X NO NO YES YES 36 12 14/12/04 12.00 5High View Oast Nursing HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care Homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.High View Oast Nursing HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to Service Users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the Home; and provides a Service Users guide to the Home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a Home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the Homes Service Users guide. Range of fees charged From (£) 444.04 To (£) 600.00Any charges for extras If yes, please state what the extras are: Key findings/Evidence Not inspected on this occasion.YES HAIRDRESSING, CHIROPODY, SWEETS 0 Standard met?High View Oast Nursing HomePage 14 Standard 2 (2.1 ­ 2.2) Each Service User is provided with a statement of terms and conditions at the point of moving into the Home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Not inspected on this occasionStandard 3 (3.1 ­ 3.5) New Service Users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective Service User, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The Inspector was able to view the files of four of the most recent Service Users. Each file was seen to contain pre-admission assessments carried out by the Acting Manager, Sheelagh Sanford. Other pre-admission assessments were found from Care Managers, Multi Agency assessment profile, patient transfer assessment profile, and in one case a Service User who had been transferred from a residential Home, their file contained the Care Plan from that Home. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective Service Users are invited to visit the Home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 15 Standard 6 (6.1 - 6.5) Where Service Users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable Service Users to return Home. 9 Key findings/Evidence Standard met? High View Oast does not provide this service.High View Oast Nursing HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The Service Users health, personal and social care needs are set out in an individual plan of care. Service Users make decisions about their lives with assistance as needed. Service Users, where appropriate, are responsible for their own medication, and are protected by the Homes 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.Standard 7 (7.1 ­ 7.6) A Service User plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each Service User and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The Inspector viewed four care plans, all contained very detailed information in regard to life history/biography, personal medical details, plan of care, risk assessments, wound care, nutritional assessment, patient dependency, continence assessment, observation charts, collaborative care, action to be taken on death, and daily report sheet, also included in the care plan was permissions and risk assessment for the use of cot sides. Evidence was available to show that care plans are regularly assessed, and that any changes to the care of the Service User are noted and carried through.High View Oast Nursing HomePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. No. of incidents where Service Users have been taken to Accident and Emergency during last 12 months No. of Service Users with pressure sores at time of inspection (from information taken from care notes) X 13 Key findings/Evidence Standard met? A detailed personal care matrix is used for each Service User, which includes all aspects of personal care; the matrix is dated and signed by the member of staff giving the personal care. A trained nurse employed by the nursing Home carries out tissue viability, this is recorded in the care plan, on a waterlow chart, and risk assessments are made, any equipment required to maintain tissue viability is provided to the Service User. In circumstances where a pressure area occurs, this is treated immediately, and recorded in the care plan, along with progress made. The Deputy Manager is a qualified continence advisor and deals with all issues of incontinence within the Home. The Acting Manager, Sheelagh Sanford, stated that if there were any mental health problems she could always call on the assistance of the Community Psychiatric Nurse. A physiotherapist will visit the Home to carry out assessments in regard to mobility. All the staff in the Home understand the importance of keeping Service Users mobile, and encourage Service Users to walk. The Home also employs an activities co-ordinator, who will play games such as hoop-la and skittles with the Service Users. Nutritional screening is carried out regularly and recorded in the care plan. The chiropodist visits the Service Users every six weeks, and more often if required, the Home does not have a visiting dentist, but some Service Users have a dentist in Sandwich who they visit. The optician visits the Home every six months. A Hi-Kent audiologist visits the Home on a regular basis, to replace batteries and tubes on NHS hearing aids.High View Oast Nursing HomePage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and Service Users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? High View Oast has an up to date medication policy and procedure. Medication is administered via the Boots monitored dosage system. The Inspector was able to view all the MAR charts, and noted that all medication administered had been signed for, medication in bubble packs matched the MAR sheet. No alterations had been made on the MAR sheet, and only one MAR sheet had been handwritten for a new Service User. At the present time the Home is not using any Controlled Drugs, and the Inspector witnessed that where Controlled Drugs had been used, these had been appropriately recorded and returned to the pharmacy, and all signatures were in place. At the front of the MAR folder there was a sheet recording all staff with their initials, who were trained and competent to give out medication. The Inspector witnessed that medications not used by the Home were appropriately recorded and returned to the pharmacy on a regular basis. The Inspector has made a recommendation that eye medication is dated on the bottle on the day of opening and not on the day received into the Home. Boots MDS trainer has recently carried out a study day at the Home for staff who administer medication. The Inspector was shown the daily temperature recordings for the medication fridge, and the medication room. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that Service Users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The Inspector witnessed that staff knock on Service Users bedroom doors before entering their room, that bathroom doors are locked when giving Service Users a bath. Service Users are able to have a telephone in their bedroom if they wish, and are always given their mail unopened. The Inspector visited the communal lounges in the Home where several of the Service Users were sitting, and it was noted that all Service Users were appropriately dressed, and in a style that reflected their personality. Part of the induction process for all new staff includes a section on respecting the dignity and privacy of the Service Users. During the course of the Inspection the Inspector met with a G.P. who was visiting the Home to carry out reviews on some of his patients, and it was noted that the G.P. was able to visit the Service Users in their own bedrooms. Screening is provided in the double rooms in the Home to protect the dignity and privacy of the Service Users.High View Oast Nursing HomePage 19 Standard 11 (11.1 ­ 11.12). Care and comfort are given to Service Users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 20 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit Service Users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? On the day of the unannounced inspection the Home was having a Christmas coffee morning. Many of the Service Users were in the main hallway, waiting for the raffle to be drawn; there were also many visitors in the Home. The Home employs an activities coordinator, who regularly plays games, and holds craft sessions with the Service User. The Inspector was shown some of the crafts that had been made by the Service Users for the Christmas coffee morning. The Home also has a monthly activities photograph album. Interests of Service Users are recorded in their care plans. Standard 13 (13.1 ­ 13.6) Service Users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with Service Users preferences. 3 Key findings/Evidence Standard met? Service Users are able to receive visitors at any time in the privacy of their own bedroom if they wish. Some Service Users are going to the village church to watch the nativity play, but many of the Service Users are not able to go out, and arrangements have been made for the local choral group, and church choir to visit the Home over the Christmas period. Just recently the local school children came into the Home to entertain the Service Users. A lady with PAT dogs visits the Home on a regularly. Visitors from Age Concern, and the Parkinsons Disease Society also visit the Home to talk to the Service Users. The children from the local boarding school sent hampers into the Home for harvest festival. After Christmas the local drama group will be visiting the Home to perform a pantomime. The village church holds monthly communion in the Home.High View Oast Nursing HomePage 21 Standard 14 (14.1 ­ 14.5) The registered person conducts the Home so as to maximise Service Users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Where Service Users choose to, they manage their own financial affairs. Information is available in the Home as to how Service Users and the families can contact local advocacy services. The Inspector witnessed that Service Users are able to bring personal possessions into the Home, and an infantry of these items is kept on the Service Users, care plan. All personal records are kept in accordance with the Data Protection Act 1998. Standard 15 (15.1 ­ 15.9) The registered person ensures that Service Users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Weekly menus are displayed at the entrance to the dining room the Inspector observed that food offered to the Service Users, is fresh, varied, wholesome and nutritious. The Inspector was able to speak with the Chef, who confirmed that he often discusses meals with the Service Users. Some Service Users need their food liquidised, and each item of food is separately liquidised, then served to ensure the meal looks appetising. The Home can cater for a variety of medical diets as well as for vegetarians. Each Service User has three meals a day, with snacks and drinks in between if they wish. The Inspector noted that a water dispenser is placed for Service Users just inside the dining room, and the Acting Manager, Sheelagh Sanford confirmed that Service Users make good use of this.High View Oast Nursing HomePage 22 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The Home has a recently reviewed complaints policy and procedure. There have been no complaints made since the last inspection. There is a complaints book placed in the main entrance hall, and this is available to Service Users and visitors.High View Oast Nursing HomePage 23 Standard 17 (17.1 ­ 17.3) Service Users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 18 (18.1 ­ 18.6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Standard met? High View Oast has up to date policies and procedures for the protection of vulnerable adults. All staff in the Home are aware of these policies and procedures. Recently there has been an incident of alleged abuse that was correctly reported to all agencies, investigated by the police, and found to be not found. It was evident from reports seen by the Inspector and follow up letters that this incident was dealt with appropriately by the Home.High View Oast Nursing HomePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the Home is suitable for its stated purpose; it is accessible, safe and well maintained; meets Service Users individual and collective needs in a comfortable and Homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? High View Oast is situated in a country lane in the village of Ash; all entrances to the Home have ramps in place for easy access for wheelchair users. The Home has a rolling maintenance programme, which ensure that the Home is always in good decorative order. The Home is comfortably furnished and well decorated. The grounds were seen to be neat, tidy, well maintained, and easily accessible for Service Users. The building has relevant fire and environmental health certificates in place. Standard 20. (20.1 ­ 20.7) In all newly built Homes and first time registrations the Home provides sitting, recreational and dining space (referred to collectively as communal space) apart from Service Users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each Service User. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 25 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of Service Users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of Service Users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 26 Standard 23 (23.1 ­ 23.11) The Home provides accommodation for each Service User which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence Not inspected on this occasion. NO NO YES 14 X 9 X Standard met? 0 14 X2 X 9 XHigh View Oast Nursing HomePage 27 Standard 24 (24.1 ­ 24.8) The Home provides private accommodation for each Service User which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the Service User. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of Service Users accommodation meet the relevant environmental health and safety requirements and the needs of individual Service Users. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? On the day of the inspection the Home was clean, tidy and free from offensive odours. The Home has its own laundry room sited away from the main kitchen. The Inspector noted that red, water disposable bags were being used for foul linen. The laundry was clean and tidy. There was a Laundry Guide, Weekly and Daily job charts, laundry training programme, universal hand washing precautions, all displayed on the wall in the laundry room. Also available in a file were the updated COSHH sheets and all instruction manuals. The laundry room has two industrial washing machines that have sluicing facilities and a tumble drier.High View Oast Nursing HomePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · 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 Homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the Service Users, the size, the layout and purpose of the Home, at all times. Number of staff /hours in respect of Service User needs based on guidance recommended by Department of Health. Personal Nursing Care No. Service Users High No. staff hours X X X needs allocated No. Service Users Medium needs No. Service Users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 31 X 840 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 840 X X X12 12 120 Key findings/Evidence Standard met? The Inspector was shown staffing rotas for the Home, which reflected that a sufficient skill mix of staff is used to provide nursing and personal care to all Service Users. The rota showed that on a regular basis 2 RGNs and 6 Carers are on duty in the morning, in the afternoon there are 2RGNs and 3 Carers and at night 1RGN and 2 waking Carers. Two RGNs have speciality caring duties, the Deputy Manager is an incontinence advisor and another RGN is the lead clinical nurse.High View Oast Nursing HomePage 29 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered Manager and/or care Manager, and in care Homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not inspected on this occasion. 8 66 Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 3 Key findings/Evidence Standard met? The Acting Manager, Sheelagh Sanford, operates a thorough recruitment procedure, CRB checks are always sought for new employees, new staff employed since the end of July have been POVA checked, all staff need to give two references, one of which must be their previous employer, and the Sheelagh always follows these references by seeking telephone references. Telephone references are always recorded. All staff receive terms and conditions of employment, and the GSCC code of conduct. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 3 Key findings/Evidence Standard met? All staff receive National Training workforce training, within the first six months of their employment, this includes First Aid, Manual Handling, Fire Safety, Health and Safety, Infection Control. All new staff receive induction training (TOPSS) within the first six weeks of their employment. Other training recently undertaken by some staff are Boots MDS, Tena-care and Incontinence Care, Audiology, Rosemont Liquid Medication, and Audiology. All staff receive at least three paid days training per year.High View Oast Nursing HomePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 Homes record keeping policies and procedures. The health, safety and welfare of Service Users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 32 (32.1 ­ 32.7) The registered Manager ensures that the management approach of the Home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected on this occasionHigh View Oast Nursing HomePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the Home. 3 Key findings/Evidence Standard met? The Inspector was shown a wide-ranging quality assurance system that has been put in place. Eleven basic audits are carried out during the course of a year, which centres on the philosophy of the Home, the care service given, and health and safety issues. Together with this audit system there are Service Users surveys, Relative and Visitor Surveys, and spot monitoring of call bell response. From the quality assurance findings, which includes the audits and questionnaires a graph is developed and from the graph pie charts are generated. These pie charts are then put on display in the main hallway to show areas in which the Home hopes to improve, and the standards that the Home has achieved. All Policies and Procedures are reviewed on an annual basis. The Inspector noted that while the quality assurance results had been published for this year, there was no date on the graphs and pie charts to show that these have been compiled for the year 2004/2005 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 32 Standard 35 (35.1 ­ 35.6) The registered Manager ensures that Service Users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the Service User. Number of Service Users subject to Power of Attorney processes Number of Service Users subject to Enduring Power of Attorney processes Number of Service Users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? The majority of Service Users have requested that their relatives are responsible for sorting out their financial affairs. Therefore the Home looks after the personal allowances for most Service Users. Relatives bring the personal allowances into the Home, and hand them into the office, these monies are then recorded onto separate accounts sheets for each Service User and money is then placed into separate wallets for each Service User. Where the KCC handle the monies of some Service Users, the personal allowances are paid in cheque form directly to the Home, this cheque is then cashed and entered onto the personal allowance account sheet for that Service User and money placed in a wallet. All receipts of purchases are kept. All monies belonging to Service Users is kept securely in the office. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the Home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not inspected on this occasion.High View Oast Nursing HomePage 33 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 38 (38.1 ­ 38.9) The registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 2 Key findings/Evidence Standard met? The Acting Manager, Sheelagh Sanford, ensures that staff keep up to date with Moving and Handling training, Fire Safety training, First Aid training, Food Hygiene training, and Infection Control training. The Home has a clinical waste bin, and all clinical waste is collected in the appropriate yellow sacks and disposed of in the clinical waste bin. The Inspector was shown up to date service certificates for the Fire Alarm System, Emergency Lighting System, Arjo Hoists, Apollo Baths, Passenger Lift, Sluices, Washing Machines, Gas Force, Electrical Circuit and Portable Appliances Electrical Testing, Fire Extinguishers, all hot water control valves, and Legionella testing. There is a fire risk assessment of the building, carried out by a professional fire safety officer. The Home has an accident book for Service Users, which complies with HSE. The Inspector noticed that the Fire System weekly checks are not recorded although are written in the diary, and that Emergency Lighting is not checked monthly, therefore a requirement has been made to ensure that the Home carries out regular tested and records this testing in the appropriate place in the fire log. All staff receive TOPSS related induction training, which would include Health and Safety.High View Oast Nursing HomePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJune Davies Norma LawsonSignature June Davies Signature SignatureHigh View Oast Nursing HomePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.High View Oast Nursing HomePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 2nd December 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible The Inspector is thanked for her helpful and constructive comments during the inspection of High View Oast Care Home. The report is fair and factual and reflects the services provided by the Home.High View Oast Nursing HomePage 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOHigh View Oast Nursing HomePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Jenny French of High View Oast Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of High View Oast Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: JENNY FRENCH ( for PAUL WARREN) Jenny French Operations Director 06/01/2005Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.High View Oast Nursing HomePage 39 High View Oast Nursing Home / 14th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000026099.V192366.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!