Inspection on 27/05/04 for High View Oast Nursing Home

Care Home For Older PeopleHigh View Oast Nursing HomePoulton Lane Ash Canterbury Kent CT3 2HNAnnounced Inspection27th May 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) Mrs Judy Camilla Ramnath 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 YES 5/11/03 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 327th May 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 inspectionMrs Jenny French Area Manager Mrs Judy Ramnath 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 Registered Manager, Mrs Judy Ramnath.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 many Service Users who all said that they were happy with the standard of care and life in the home. Staff spoken to enjoyed working in the home. Choice of Home (Standards 1 ­ 6) 5 of the 6 standards assessed were met The home has worked hard in producing all relevant paperwork, which would ensure that prospective Service Users, their relatives and friends are able to make an informed choice. High View Oast has detailed pre-admission assessments in place, and these combined with good working relationships with other professional bodies, ensure that the home can meet the needs of prospective Service Users. Health and Personal Care (Standards 7 ­ 11) Four of the five standards assessed were met and one was partially met. The healthcare and personal care of Service Users is of prime importance in the home, and all care is well documented and relates well to the plan of care. While in general medication was well administered, staff who are able to administer medication must take great care when signing off medication, and ensure that the appropriate code is used for nonadministration, and that MAR sheets are correctly signed when medication has been given. Daily life and social activities (Standards 12 ­ 15) Four of the four standards assessed were met. Service Users are given every opportunity to control autonomy and choice over their own lives in the home. Every Service User is given the opportunity to participate in some sort of activity on a daily basis. There is good contact with the local community. Service Users have a good balanced menu, and are able to have a choice of meals. Complaints and protection (Standards 16 ­ 18) Three of three standards assessed were met. A clear and accessible complaints system is in place. Staff has access to a whistle blowing policy and procedure. All Service Users have their legal rights protected. Environment (Standards 19 ­ 26) Eight of the eight standards assessed were met. High View Oast provides good, clean, homely accommodation, which is well maintained. Staffing (Standards 27 ­ 30) Three of the four standards assessed were met and one was partially met. The skill mix of staff meets the needs of Service Users. The Manager has a stringent recruitment process. While some staff already have achieved NVQ level 2 others are working towards this qualification, which should be achieved by 2005. A whole spectrum of training courses are available to staff, to ensure that staff are trained to meet changing needs of Service Users. Management and administration (Standards 31 ­ 38) One of the eight standards assessed was commendable and seven were met The Manager of the home has obtained NVQ Level 4 and RMA. The Management approach to running the home is open and positive. All documents are easily accessible in the Managers office on a need to know basis. Quality Standards covers every aspect of the home, and provides an excellent insight into areas of improvement and what the home is achieving. All Health and Safety procedures are in place to ensure the safety of Service High View Oast Nursing Home Page 7 Users and Staff.High View Oast Nursing HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY 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 1 13 (2) OP9 All MAR charts to be signed when medication is administered. 7/06/04RECOMMENDATIONS 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 OP38 Expelair extractor fan in clinical room to be repaired.* 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 10 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 YES YES YES YES NO NA YES YES YES YES YES YES YES YES NO YES NO YES 10 2 1 YES YES YES YES 26 8 27/05/04 9.30 13High View Oast Nursing HomePage 11 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 12 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 (£) 490.54 To (£) 640.00Any charges for extras If yes, please state what the extras are:YESDRY CLEANING; PROFESSIONAL HAIRDRESSING; DAILY NEWSPAPER; TELEPHONE CALLS; PRIVATE CHIROPODY; PHYSIOTHERAPY; SPEECH THERAPY; PRIVATE AMBULANCE; PERSONAL MEDICAL SUPPLIES 3 Key findings/Evidence Standard met? The Inspector was shown a very comprehensive Statement of Purpose, which meets the requirement of Schedule 1 of the National Minimum Care Standards. The Service Users information pack covered all aspects of High View Oast and also included letters of thanks from relatives of Service Users who have lived in the home. Both documents were clearly set out, and easy for both Service Users and their Relatives to understand.High View Oast Nursing HomePage 13 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). 3 Key findings/Evidence Standard met? The statement of terms and conditions has been revised and covers all the requirements of this standard. A copy of this document is supplied in duplicate one for the Service User to retain and one as a copy to be kept in Managers office.Standard 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? Comprehensive pre-admission assessments were in place, which had been compiled by the home Manager. Also available were Care Manager assessments and discharge assessments from hospitals. The Manager, her Deputy and RGNs carry out assessments on prospective Service Users.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. 3 Key findings/Evidence Standard met? The home ensures that it meets the assessed needs of prospective Service Users, by obtaining detailed information through the homes pre-admission assessment, and assessments carried out by other professionals. Should a Service User require specialist equipment, this would be provided by the home or by District Nurses. Immediate post admission assessments are carried out together with risk assessments in regard to specialist equipment. 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. 3 Key findings/Evidence Standard met? Each prospective Service User is invited to visit the home for a day, to meet with other Service Users, and Staff. Relatives and friends of the prospective Service User are also encouraged to visit the home, speak to other Service Users and staff. Prospective Service Users do move into the home on a trial basis and this is incorporated into the terms and conditions/contract of residency.High View Oast Nursing HomePage 14 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? The home does not offer this facility.High View Oast Nursing HomePage 15 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? All Service Users have detailed Care Plans in place, that include pre-admission assessments, post admission assessments on all health and personal care issues, detailed risk assessments. The inspector viewed a number of care plans, all well laid out with monthly reviews taking place. Daily report sheets reflected the care needs of each individual Service User.High View Oast Nursing HomePage 16 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) 1 23 Key findings/Evidence Standard met? On admission of a Service User, there is a detailed assessment in regard to tissue viability, which is placed in the care plan, together with Waterlow assessment, and body maps. Two Service Users were admitted to the home with pressure areas. These pressure areas are improving with good dressing routines, and the provision of specialised cushions and mattresses. Good records are kept in relation to pressure areas and their treatment. Psychologist geriatricians can be accessed through the General Practitioners should a Service User require this service. At the present time a physiotherapist calls into the home each week, but again the physiotherapist needs to be referred through the General Practitioner. The home has an activities co-ordinator, who apart from doing practical activities with the Service Users also does gentle exercise to music. Nutritional screening is undertaken on admission of a Service User, and thereafter weekly weight checks take place, and any loss or weight gain over a sustained period of time is dealt with appropriately. Service Users are able to register with a General Practitioner of their choice, but because the home is situated in a village, this can sometimes be difficult. All Service Users are able to access specialist medical, nursing, dental, chiropody, and therapeutic services and will be given assistance to do this through the Manager and staff at the home. When a Service User has a hospital appointment a member of staff always escorts them. 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. 2 Key findings/Evidence Standard Met? The home has a comprehensive medication policy and procedure, and staff have been trained in the administration of medication. Only trained nurses working in the home are allowed to administer medication. The home has a medication signature specimen form, which, has been signed by all the nurses who administer medication. On inspection the Inspector noticed that several of the MAR sheets had signatures missing with no explanation of whether the medication had been administered to the Service User or declined. The Inspector was shown the bound Controlled Drugs Book, with all drugs in order and signed for by two members of staff. Controlled Drugs are kept in a special locked cupboard in the medical room, which is also locked. Evidence was seen that unused medication is returned to the pharmacist on a regular basis. The home has an up to date BNF. The Inspector spoke to two members of staff who are responsible for administering medication and both were aware that medication needed to be kept for seven days after the death of a Service User.High View Oast Nursing HomePage 17 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? Throughout the inspection it was evident that Service Users are treated with privacy and dignity. The Inspector witnessed staff knocking on bedroom doors before entering, bathroom doors were kept locked while in use. All personal care was being delivered in a quiet, dignified and professional manner. The Manager reported that if a Service User wished to see their G.P., Care Manager, Solicitor, or any other professional in the privacy of their own room, without a member of staff being present then they could do so. Service Users receive their own mail unopened, and receive assistance from staff if requested. During inspection the Inspector witnessed that Service Users are able to choose their own clothes of their choice. If a Service User wishes to have their own private telephone in their room facilities are available for them for them to make this choice. 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. 3 Key findings/Evidence Standard met? Policies and Procedures are available in the staff room, and in the Managers office in regard to how Service Users should be treated when they are terminally ill, or have died. The Policy and Procedure for dealing with a Service User who has died is comprehensive and gives clear indications as to how staff should deal with Service Users from all religious denominations. The home provides a quiet room in which, relatives can stay, when a Service User is terminally ill. Service Users have the opportunity to remain in the home when terminally ill and full support services will be available to them, including religious input if required.High View Oast Nursing HomePage 18 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? The home carries out a social assessment for each Service User, to ensure that each individuals needs for daily life are met. Service Users are able to choose their preferred time of getting up in the morning and going to bed at night. An activities co-ordinator is employed by the home. The activities co-ordinator has a variety of activities available to meet each Service Users needs. Activities provided include, gentle exercises, a variety of games both activity and board orientated, a variety of craft work, planting window boxes, feeding the wild birds, cookery etc. The Inspector witnessed activities taking place. The home also provides regular entertainment for the Service Users, which also involves the input of local schools and the local Brownie group. A daily activities sheet is also kept as a record of what activities that Service Users have participated in. The home also keeps a record of all Service Users birthdays, and these occasions are celebrated with a Birthday cake if the Service Users wishes. Outing are also arranged by the staff of the home, and Service Users are encouraged to get out of the home for short periods if they wish. 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? The home has a policy and procedure for visiting and this is included in the Statement of Purpose and Service User Guide. Service Users are encouraged to visit the local public house, and are accompanied on these trips by relatives and staff. Church of England holds a monthly communion, and other denominations are contacted at the wish of Service Users. Relatives are very much involved in the home, and regular Service User, Relative meetings are held and recorded. The home organises, social afternoons, and barbeques in the gardens for relatives and friends of Service Users. During the course of inspection the Inspector spoke to several visitors to the home, most said that the standard of care, and attitude of the staff was excellent; one relative felt that some things could be better. One visitor to home has registered her dog as a Pat-a-dog. This visitor and her dog visit the home on a regular basis.High View Oast Nursing HomePage 19 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? Service Users are encouraged to exercise personal autonomy and choice. The Inspector looked at several care plans and spoke to several Service Users during the course of the inspection. Service Users said that they were able to make choices in regard to their lives, and were encouraged to remain as independent as their health would allow them. None of the Service Users have a power of attorney, but most request the assistance of relatives to deal with their fiancés. Should a Service User or their relative require the assistance of advocacy services information is available in main entrance hall of the home. All Service Users are encouraged to bring personal possessions into the home with them, and this was evidenced during the inspection. Service Users are very much involved in creating their own records in the home, and are able to see them on request or at reviews. All information is kept securely in locked cupboards in the office, and is available to staff on a need to know basis. The home is registered along with others in the group with the Data Protection Act. 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? The home has a four-week rotating menu, which is changed on a seasonal basis. Service Users are also able to contribute to menu planning. The home provided two cooked meals a day, lunch and high tea. Service Users do have the occasional cooked breakfast, but can have a cooked breakfast everyday if they wish. The cook makes every effort to provide fresh fruit, vegetables and meat. Sandwiches are provided at late supper for diabetic Service Users. All Service Users have a hot supper drink and biscuits, and a variety of cold or hot drinks are offered throughout the day. The dining area in the home is pleasant, and creates a relaxed atmosphere, some Service Users choose to eat in their own rooms, and others prefer to eat in the sitting areas of the home. Staff members give discreet help to those Service Users who require assistance. The cook also visits Service Users in their rooms, which gives Service Users the opportunity to put ideas forward.High View Oast Nursing HomePage 20 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 1 1 0 0 0 0 100 3 Key findings/Evidence Standard met? A comprehensive Complaints Policy and Procedure is in place, and is included in the Statement of Purpose and the Service Users guide. A complaints book is available in the hallway, and anybody is free to write out a complaint. The Manager regularly checks the complaints book, and responds within 28 days below each complaint with the results of her investigation and the action she has taken to remedy the complaints.High View Oast Nursing HomePage 21 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. 3 Key findings/Evidence Standard met? All Service Users are on the electoral role, and choose to use their postal vote, but are able to visit the local polling station if they wish. Advocacy services are available to Service Users, and information with regards to advocacy services are posted in the main hallway.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 03 Key findings/Evidence Standard met? The home has a stringent Abuse Policy together with the County Council guide to dealing with Vulnerable Adults. The whistle blowing policy is comprehensive and gives staff the opportunity to contact an outside agency if they feel uncomfortable, in whistle blowing to the Management of the home. All staff have regular training in what abuse is, how to tackle abuse.High View Oast Nursing HomePage 22 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 well maintained and suitable for its stated purpose. The premises are comfortable and homely with well-decorated and suitable furnishings in the communal accommodation. There are several ramps, which make the outside grounds safely accessible to Service Users. A maintenance man and two gardeners are employed to contribute towards the general upkeep of the building and grounds. The Manager is in the process of purchasing some new garden furniture to enable Service Users to gain more benefit from using the garden. 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. 3 Key findings/Evidence Standard met? The communal space within the home meets the required standards, and offers a variety of places where Service Users can sit. Most of the communal space is provided on the ground floor, and to some extent is open plan, with small walls dividing the dining room and lounge, and the lounge and logia. There are two small rooms within the home, which Service Users are able to use for private visits from relatives and friends, if they do not wish to use their own bedrooms.High View Oast Nursing HomePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of Service Users. 3 Key findings/Evidence Standard met? Each floor has two assisted bathrooms and two assisted toilets. Standing bath hoist provides assistance in the bathrooms, and all toilets have raised seats and handrails conveniently situated close to the toilets.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. 3 Key findings/Evidence Standard met? The home has been fitted with specialist grab rails, handrails, and hoists. There is a shaft lift, which serves the first floor. All other specialised equipment has been purchased or supplied to the home by the District Nurses. Some beds have cot sides, with suitable bumpers to prevent accidents. Cot sides are only used with permission of the Service Users and their relatives, and rigorous risk assessments are carried out and kept on the appropriate care plans, together with signed letters of consent. The garden of the home is easily accessible to Service Users, by means of ramps with grab rails.High View Oast Nursing HomePage 24 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 NO NO YES 14 X 9 X 14 X2 X 9 X3 Key findings/Evidence Standard met? The home provides satisfactory space within individual accommodation. Some of the double rooms are in the process of being refitted to provide more accessible floor space for Service Users.High View Oast Nursing HomePage 25 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. 3 Key findings/Evidence Standard met? Service Users accommodation is well decorated and equipped with suitable furnishings of a good quality. Service Users have personalised their own rooms with small items of furniture, ornaments and pictures from the own homes. The inspector noticed that all rooms were personalised to reflect the wishes of the Service Users. In double rooms there is sufficient screening with curtains to protect the dignity and privacy of the Service Users. In some rooms, nursing beds are provided, and are situated in the middle of the room to allow for ease of access. Some rooms have recently had new carpets fitted. 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. 3 Key findings/Evidence Standard met? All rooms are centrally heated, with radiators that can be thermostatically controlled and fitted with radiator covers. There is emergency lighting throughout the home, and monthly maintenance checks are carried out and recorded. Window restrictors are fitted to all upper floor windows. Pre-set valves are in situ on all hot water outlets and the temperature of each bath is taken and recorded before allowing Service Users to immerse. All bedrooms are fitted with overhead and bedside lighting. 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? The inspector found the home to be clean and free from offensive odours. A laundry room houses industrial washing machines and tumble driers. Hand washing facilities are located close to the laundry. All toilets have signs displayed to promote hand washing to prevent cross infection; all toilets had liquid soap and paper towel dispensers. The home has two sluice rooms with bedpan washers in situ. The home employs five part-time Housekeepers to carry out cleaning duties.High View Oast Nursing HomePage 26 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 518 X X 3228 18 63 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. Staff spoken to during inspection said that the skill mix of staff worked well.High View Oast Nursing HomePage 27 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 6 33 2 Key findings/Evidence Standard met? The home has at the present time 6 care staff qualified to NVQ level 2 or equivalent. At the present time 7 care staff are studying towards NVQ level 2. This would ensure that the home will have over 50 of staff with NVQ level 2 or equivalent by 2005.Standard 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 Inspector was shown the personnel files of four staff. This reflected that the Manager operates a thorough recruitment process, all files showed an application form, two references, letter of appointment, health questionnaire, terms and conditions, evidence of requests for verbal references, induction and appraisals. CRB checks were available for all staff with the exception of 2 and these have been re-applied for. Some CRB checks were received over six months ago, and these have been destroyed as requested, but a record has been kept of the name of the member of staff and the CRB reference number. All staff CRB checks are kept on a separate file. 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? A staff training and development programme is operated within the home to ensure that all staff meet the NTO workforce training targets, many other training courses are offered to ensure that staff can meet the changing needs of Service Users. The training matrix seen by the Inspector showed that all staff take part in training, and indeed this is part of their contract of employment. Certificates in regards to all training undertaken by staff, were available for inspection on all staff personnel files. There is also a programme of in-house training, which is related to TOPSS standards, with an examination at the end, for which the company issues staff with a certificate if they pass the exam.High View Oast Nursing HomePage 28 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. 3 Key findings/Evidence Standard met? The Manager has already achieved her NVQ Level 4 and RMA, and the deputy Manager is about to enrol on NVQ level 4 in September 2004. The Manager regularly updates her training to maintain her knowledge, skills and competence. The Manager is a qualified RGN and is aware of the diseases related to the Service Users in the home. The Manager has incorporated the lines of accountability within the home in the Statement of Purpose. Standard 32 (32.1 ­ 32.7) The registered Manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Manager ensures that there is regular staff meetings held within the home, and these are recorded. All staff have access to all Policies and Procedures in the home, a copy of which are available in the staff room, for access at any time. All staff have a copy of the GSCC code of practice, and have signed to say they have received a copy.High View Oast Nursing HomePage 29 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. 4 Key findings/Evidence Standard met? The Inspector was shown a wide-ranging quality assurance system that has been put in place by the Manager of the home. 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. In the past year there has been a 67 response to the questionnaires. 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, and are due to be reviewed during January /March of 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. 3 Key findings/Evidence Standard met? The area Manager for the trust was available during the inspection. The area Manager confirmed that the trust was financially viable. The aim of the trust was to refurbish each home every five years. The Inspector was shown a current Insurance certificate, which met the requirements of this standard.High View Oast Nursing HomePage 30 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 0 0 03 Key findings/Evidence Standard met? The Manager only deals with personal allowances of Service Users, which are handed to her by the relatives of the Service Users. The Inspector was shown detailed accounts kept for each Service User together with receipts, the Inspector looked at the personal allowances of three Service Users, all of which were correct. The Manager stated that she would not deal with the private finances of a Service Users, but would call on the services of an Advocate. The safe, which hold the personal allowances, is situated in the office, and is locked at all times. 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. 3 Key findings/Evidence Standard met? The Manager has stringent employment policies in place, and induction is to the required TOPSS standard. Supervision is carried out six times per year for all staff. Supervision is recorded and placed on the appropriate personnel file.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. 3 Key findings/Evidence Standard met? All records required for the protection of Service Users, are kept in the office, and available to staff only on a need to know basis. All other records for the effective and efficient running of the home are well maintained, easily accessible to the Manager and relevant others. The home is registered with the Date Protection Act. All Service Users are aware that they can see their files if they wish to do so. Service Users are actively involved in reviews, so therefore have an opportunity to maintain their personal records.High View Oast Nursing HomePage 31 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. 3 Key findings/Evidence Standard met? Certificates were seen for all equipment requiring annual maintenance. All were recent certificates. A fire safety logbook was up to date showing regular checks to the alarm system, and emergency lighting system. All staff receive mandatory training in line with the standards to protect the health and welfare of Service Users and staff. All COSHH products are stored appropriately in a locked cupboard. The home has relevant accident reporting books that are in line with the HSE guidance. All relevant safety posters are displayed around the home for staff and Service Users to refer to. Extensive environmental risk assessments are in place and their review is carried out regularly.High View Oast Nursing HomePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateJune Davies Norma LawsonSignature Signature SignatureHigh View Oast Nursing HomePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.High View Oast Nursing HomePage 34 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 27th May 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible The inspector is thanked for her constructive comments and will see the Action Plan for the immediate implementtation of staff reminders on signing MAR charts and use of nonadministration codes. The good practice recommendation of repairing the extractor fan in the clinical room has been implemented and in addition extractor fans have now been included in the rolling maintenance programme.High View Oast Nursing HomePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments 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 36 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 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 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 Operations DirectorPrint 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 37 - 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. 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