CARE HOMES FOR OLDER PEOPLE
Highbury House Steyning Road Rottingdean Brighton East Sussex BN2 7GA Lead Inspector
Elizabeth Dudley Unannounced Inspection 7th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Highbury House Address Steyning Road Rottingdean Brighton East Sussex BN2 7GA 01273-309447 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Zeenat Nanji Dr Tasneem Osman Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users should be aged sixty-five (65) years or over on admission The service can provide up to thirty (30) nursing places and twelve (12) personal care places The maximum number of service users to be accommodated is thirty (30) That no more than four (4) service users who are terminally ill can be resident in the home at any one time. This is to include service users who are already resident within the home and become terminally ill 13th July 2005 Date of last inspection Brief Description of the Service: Highbury House provides accommodation with nursing for up to 30 older people, it may also 12 older people who need only personal care and assistance. Situated in Rottingdean, all rooms have pleasant views, some with a sea view and there are well-maintained gardens which are accessible to service users who use wheelchairs. Highbury House provides a pleasant environment and one which service users are encouraged to treat as home’. Public transport passes within walking distance of the home and there is restricted parking in the area of the home, however unrestricted parking is available in roads around the home. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 7th December 2005 over a period of five hours. This forms part of the inspection programme for this home and was facilitated by Ms Sigi Sebastion, senior RGN and later by Mrs Nanji, registered provider. During the course of the inspection a tour of the home took place, thirteen residents, six members of staff and five visitors were spoken with and various documents examined. These included care plans, menus, catering records, personnel files and health and safety documentation. Thanks are extended to all staff, residents, visitors and management for their help, courtesy and documentation during the course of this inspection. What the service does well:
Highbury House offers a good standard of care to all its residents, this is underpinned by the commitment to training it provides for the staff and also by providing more staff than would normally considered necessary for the amount of residents it accommodates. There are two registered nurses on duty during the day, most days, and six care assistants support them. Discussion with the provider showed that she valued the staff, stating that she was ‘so lucky to have such good staff’ and this in turn has made staff feel valued, staff stating that they enjoy working at the home and have plenty of training opportunities. Staff turnover is therefore very low, providing residents with continuity of care and familiarity with staff and therefore adding to their security. The documentation within the home is good at all levels and provides a clear picture of the care needed by the residents, the policies and protocols used in the home and training provided for staff. The quality of food is good and the meals are plentiful. All meals are home cooked and residents stated “ the food is lovely”, “ this food is really good” and “ they provide such lovely meals”. The menu is varied and the cook obviously takes a pride in his work. There has been a change of manager in the home this year, staff and residents made very positive comments about this and also said the “atmosphere within the home is very good”. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 6 The provider and manager both take an interest in the home and resident meetings are held on a regular basis, the minutes of these are kept by the front door to be available for anyone who wishes to see them. Although several requirements have been made, these were, in the main, minor and related to ensuring the control of matters that could lead to possible infection, and some matters that were practiced but have recently been overlooked. Highbury house provides a good standard of care within a comfortable home, and has a core group of staff that have been working at the home for some years that aim to provide quality of life for residents within a family atmosphere. What has improved since the last inspection? What they could do better:
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 7 Although there have been great changes in the home the kitchen storeroom requires regular cleaning. It was suggested that as the cook is so interested in producing the well cooked and presented meals that a cleaner is allocated to the kitchen to take responsibility for the cleaning of the storerooms etc. The main part of the kitchen is reasonably clean although could be improved. This was a previous requirement. The cook and kitchen assistant both need to renew their food hygiene course and this has been arranged. All medications apart from one had been signed for on administration, however some rectal medication was found to be past its expiry date therefore a requirement has been made around medications due to the health and safety issues involved. Staff must be reminded not to leave the downstairs lounge unattended when they go to help other residents with their food at lunchtime and the manager must also ensure that staff honour the resident’s right to choose. Some attention must be paid to the laundry, as there was a complaint that wet clothes were put into a resident’s room and that other people’s laundry was delivered to her. The provider must also enquire why the ironing board is left in the corridor; this has been seen on several inspections and could be a risk to health and safety. The regular testing of hot water outlets appears to have been overlooked recently and this must recommence. Staff must ensure that the residents who are in for personal care only, receive visits from staff during the day. This can be difficult when the nursing care takes up so much of the time, but two residents stated that they were always glad when staff could spend the time to come and talk to them. Staff must also ensure that these residents are involved in the activities on offer and are aware of what is going on. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The home provides sufficient information to allow prospective residents to decide whether to make Highbury House their home. EVIDENCE: The statement of purpose and service users guide were examined at the last inspection and found to have been reviewed to identify management changes within the home. The senior registered nurse stated that all residents receive a copy of the service users guide. All residents receive a copy of the terms and conditions following their admission to the home. Residents are assessed prior to their admission to the home by the manager or a senior registered nurse. It is recommended that the service users guide be taken on assessment to show to the prospective residents if they are unable to visit the home. The senior registered nurse stated she was aware of the category of resident that the home is registered to accommodate, and an assessment form that she had completed was seen. This identified all the criteria necessary to form the
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 10 initial care plan from the assessed needs of the resident. Prospective residents and their representatives can visit the home prior to deciding whether to move there, and to determine whether the home can meet their needs. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, The home appears to provide a good standard of welldocumented care, which ensures that resident’s health care needs are met. EVIDENCE: A percentage of care plans were examined and these identified that monthly reviews were taking place, that the majority of residents or their representatives had been involved in the formation of the care plan and that consent forms for bedrails and risk assessments were in place. The risk assessments addressed all the risks relevant to the specific resident. Care plans were in place to address health and personal care needs, psychological needs and in most instances social care needs. Some care plans held a very good social needs plan and also a daily activities diary, but for some more recently admitted residents, these were absent. Registered nurses must assist senior care assistants to put these in place for all residents. Although all care needs were identified in the care plans, it is recommended that the care plans are reformatted to promote clarity of use, as in some
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 12 places it was difficult to assess whether this part of care was finished and only the new plan was to be followed or both to run in conjunction with each other. Risk assessments indicating whether the resident is able to hold a key to their room, and to identify that this has been made a choice for the resident, should be kept in the care plan. All health care needs including wound care were documented and it was evident that the wound care nurse and other health care professionals visit the home as required. A visiting GP stated that he was happy with the standard of care provided by the home. The home has several residents with high nursing needs and these residents were seen to be comfortable with appropriate nursing interventions taking place. It is recommended that the catheter batch labels be kept in the care plans following re-catheterisation in order to facilitate identification in case of adverse reactions. Some residents required feeding by PEG (tube feeding) and staff appeared to be knowledgeable about this and the administration of medication through the PEG feed tube. One new resident to the home said that she felt comfortable with the staff ‘s knowledge of both her condition and the PEG feed and felt that she had ‘come into a good home’. Residents spoken with felt that they were given privacy and they were seen to receive doctors visits in their own rooms. Residents stated that the staff were polite, but some said that staff do not always knock the doors before entering their rooms. The manager must address this. The majority of medication was signed for following administration, although there were two omissions, and the storage of medication was good. Some rectal Diazepam was seen to be out of date whilst some other rectal preparations were nearing their expiry date. Controlled drugs that are being kept for residents that do not often require them must be checked and signed as correct on a regular basis. It considered good practice to check controlled drugs on a weekly basis. The home is registered for the care of the terminally ill resident and staff attend courses at the local hospice in palliative care and in the use of syringe drivers and other analgesia. It is recommended that the home accesses
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 13 information about the Liverpool Care Pathway and other pilot schemes relating to the care of the terminally ill resident in care homes. An awareness of the needs of the terminally ill resident was evident, both in the way those who had high needs were being nursed and in the information and documentation available within the home. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The home seeks to provide a comfortable lifestyle for those living there. Most residents felt that they could make choices relating to activities and food, but the manager must ensure that all residents are aware of the right to choose in order to provide a good quality of life for residents. EVIDENCE: Residents spoken with stated that they could choose what time they get up and go to bed. One resident stated that she wasn’t sure if she was asked about this and felt that the staff took them in rotation. Her condition made speech difficult, and therefore the manager must check that this is not happening, and that all residents choose what they wish to do. Residents said that they had a choice of whether to join in activities or not. The care assistants provide the activities at the home and these include card and board games, art, music for health and outings. A programme of activities is displayed and individual care plans, in the main, identify that residents have taken part in these. The home is providing a Christmas party to which relatives and friends have been invited. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 15 Some residents who are admitted for personal care only, stated they were always pleased when staff had time to come in and talk to them, but felt the staff were too busy with those who needed nursing to do this very often. These residents said they were not always aware of what activities were on offer and did not join in these. There is open visiting in the home, and previously the provider has arranged for one visitor to stay overnight with a resident to give them more time together. The catering is of a good standard, with the cook producing home cooked cakes and puddings and pies. All residents can have a cooked breakfast if they wish, with breakfast being available from 7am –10am. Residents can have their breakfast in their rooms or in the dining room. Menus are reviewed fortnightly to prevent residents getting bored and the cook stated that the provider ‘never skimps on food’. This was evident at a previous inspection when one resident stated that ‘all the vegetables do not leave room for meat’, to which the provider stated he must have more meat. The resident identified that this is happening, but that sometimes he gets ‘too much food’. All residents spoke highly of the food. The meal on this day was sausage plait, sautéed potatoes or mashed potatoes, sprouts and carrots, followed by chocolate pudding, rhubarb and custard or ice cream. Homemade cakes were provided for afternoon tea. All records relating to food and fridge and freezer temperatures were in place. Both the cook and the kitchen assistant need to renew their food hygiene course and are awaiting a place on this course. Comments about the food were very positive with residents stating that the food was plentiful and good. Care assistants were seen to be assisting resident with their meals in a courteous and caring manner, almost all residents coming to the dining room for meals. However those in the lounge who were unable to come to the dining room were seen to be left unattended after they had finished their meal whilst staff went to the dining room to help. For safety reasons one member of staff must be present in the lounge at all times. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home takes complains seriously and acts in a robust and open manner to safeguard residents. Staff training and pre employment checks show that the provider and manager are aware of their role in the protection of residents living in the home. EVIDENCE: The home has a complaints policy, which is displayed both in the main entrance hall and the service users guide and meets this standard. Residents spoken with were aware that if they wished to make a complaint they could speak to the manager. The home has had very few complaints although during the inspection minor complaints regarding the laundry were received; the complainant stated that they had not mentioned this to the manager. This was discussed with the provider who will address this. Previous complaints have been dealt with in a fair and robust manner by the provider and issues raised addressed. The provider and manager are aware of how to access solicitors and advocates for residents and have applied for postal votes for those wishing to take part in the electoral process. All staff have undertaken training in the ‘Protection of the Vulnerable Adult’, this mostly takes place ‘ in house’ and it is recommended that senior staff attend the training provided by social services. Staff spoken with appeared aware of their responsibilities towards those in their care. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24.25.26 The home has had some refurbishment and redecoration, including new carpets, curtains and furniture. This coupled with the improved standard of maintenance, tidiness and cleanliness within the home has provided a pleasant place for residents to live. EVIDENCE: Highbury house has benefited greatly from a recent programme of refurbishment and redecoration. New carpets have been laid in some areas and some redecoration has taken place, new curtains and furniture have been brought into some rooms. This has improved these areas and both staff and residents have commented on this. The gardens are well maintained and accessible to wheelchair users and have bird feeders within sight of the windows. Residents have previously said how they enjoy watching the birds. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 18 Communal space includes two dining areas, a large lounge and a smaller lounge area; residents were using all these rooms. There has been a great improvement in the tidiness and maintenance around all areas of the home and a positive difference in the cleanliness of the home was noted. The provider states that she recently has employed a new handyman and now employs her own cleaners instead of contract cleaners. The home provides three assisted bathrooms and an assisted shower room, with the majority of rooms having ensuite facilities consisting of a w.c. and wash hand basin. An occupational therapist has assessed the home and there are handrails along most corridors and in the w.c’s. There are adequate hoists, ramps and moving and handling equipment. Staff were seen to be using lifting belts when transferring residents. There is a storage problem, and hoists and wheelchairs have to be stored in the bathrooms when these are not in use, likewise incontinence products have to be stored in a ground floor bathroom. Staff stated that the storage of hoists etc in the bathrooms makes it difficult when they need to bathe or shower residents, as they have to move these into a corridor, thus creating a hazard in the corridor. The storage of incontinence products in the bathrooms, which are not moved out when a resident is bathed, does not help to achieve the feeling of relaxation in a pleasant bath, that should accompany the experience of bathing. The provided must try to identify some storage space within the home, and this was discussed with her. The majority of rooms meet the size as detailed in the standards, one resident’s room is below 10 sq m, but the resident has stated that this does not worry him. All residents’ rooms are pleasantly furnished with residents having lockable facilities and being able to bring in their own possessions. Variable height beds are provided for those with nursing needs. Although water temperatures for the bathrooms were seen to be recorded regularly, there was no evidence provided of what action is taken when temperatures fall below or above recommended parameters. There was no evidence seen that water temperatures for individual room outlets were being checked and these must be checked regularly and records kept. The standard of cleanliness within the home was good, apart from some areas in the kitchen, which were identified to the provider. All bathrooms were clean Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 19 but there was some old block soap left in the shower room and this must be removed. Dried food within the kitchen must be kept in containers and not left in its packet in order to prevent contamination. Staff within the home stated that they felt that the overall maintenance and cleanliness had improved in the past few months. A verbal complaint relating to wet clothes being put back in one residents room and other peoples laundry being taken to this resident, was made at the inspection. The provider was made aware of this and is addressing it. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The home is committed to providing a sufficient number of staff and ensuring that these staff receive adequate and ongoing training to meet the needs of the residents in their care. EVIDENCE: There is a good staff to resident ratio with the manager being able to bring in extra staff if required. There are two registered nurses supported by six care staff from the hours of 8am-8pm and one registered nurse and two care staff on at night. Staff stated that they felt there were sufficient staff on duty to meet the assessed needs of the residents. Residents stated that there were always staff around and that their call bells were answered promptly. The home has a very low staff turnover, many of the staff having worked within the home for several years. The home shows a commitment to staff training with care staff studying for NVQ2 and registered nurses undertaking training to expand or update their skills. On the day of this visit one of the registered nurses was on a course for male catheterisation and she also stated that she was undertaking venepuncture and a further wound care training. The home provides an induction course, which is in line with nationally Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 21 approved training, and all staff undertake this on commencement of employment. Personnel files belonging to recently employed staff were examined and these had all necessary documentation to comply with the regulations. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.33.34.35.36.37.38 Residents were positive about and felt that they benefited from, the open and transparent atmosphere within the home. The home takes the necessary precautions to ensure the safety of residents. EVIDENCE: The acting manager, Ms Benitha Siziba, has been in post for seven months. She is a registered nurse and the CSCI has recently received her application to be registered as manager. Her working week consists of some time spent nursing and some spent in managing the home, this split enables her to be aware of any problems with staff or residents. She was not present at this inspection. Ms Sibiza is aware of the need to undertake a management course.
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 23 Residents and staff spoke positively about their relationship with both the provider and the manager. It was evident on the day of the visit, that Mrs Nanji, the provider was familiar with all the residents and many visitors. They appeared to be comfortable in discussion with her. Staff also stated that they felt able to talk to the provider and that she facilitates some of the staff and resident meetings. Staff also stated that the recent change of manager was good and that they thought that the atmosphere within the home was comfortable with the emphasis always been placed on what was right for the resident. Residents stated that staff “were friendly”, “very helpful”, “are always polite” and “ will talk to you about normal every day things”. This latter comment emphasises the importance of talking about outside, daily life, to people in a care home and it is good that this appears to be recognised by the staff. Resident meetings, to which relatives are invited, take place on a six or eight weekly basis and minutes are kept of these and are on view in the entrance hall. Staff meetings take place on a monthly basis. At the last inspection one completed questionnaire received from resident stated that it would be good to hold combined staff, residents and visitors meetings. At the time the provider and manager thought that this would be a good thing to do, however it was unclear as to whether this has been followed through. The provider uses quality monitoring to test the strengths and weaknesses of the home and acts on these. Regulation 26 visits take place on a monthly basis and the CSCI receives reports on these. Staff supervision is taking place at intervals dictated by the standard. The financial accounts for the home and the business plan have been seen this year and appear to be in order. The home has robust procedures for dealing with resident’s money given in for safekeeping, and records are kept of this. The review of policies is ongoing and many of these have been reviewed this year. All certificates relating to the servicing of utilities and equipment were in place and in date. Staff attend mandatory training, and the provider is now a trainer for moving and handling. Several members of staff were booked to attend a
Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 24 first aid training course in the next week and also for a food handler’s course in the New Year. Both the cook and the kitchen assistant require their food hygiene certificate and the cleaners and the handyman are due to attend a moving and handling course. Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 4 3 3 3 3 3 Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation Reg 13(2) Requirement That all medication is signed for on administration, and that all medication is disposed of on its date of expiry. That the manager ensures that staff are allowing all service users to make choices around activities of daily living, as stated in the homes statement of purpose. That all water temperatures of outlets used by service users have their temperature tested and recorded on a regular basis along with an action plan for under or over heating. Areas in the kitchen identified with the provider are kept clean (This was a previous requirement July 2005) That dry food is kept in airtight containers. That block soap is removed from the shower room. That kitchen staff undertake the food hygiene training. That staff do not leave service users in the lounge without supervision.
DS0000013999.V268771.R01.S.doc Timescale for action 12/12/05 2 OP14 Reg 12(2) 20/12/05 3 OP25 Reg 13(4) 12/12/05 4 OP26 Reg 13(3) 20/12/05 5 6 7 OP26 OP26 OP38 Reg 13(3) Reg 13(3) Reg 13(4) 07/12/05 30/01/06 07/12/05 Highbury House Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP1 OP7 OP8 OP9 OP12 OP18 OP22 Good Practice Recommendations That the assessing person takes a copy of the service users guide to show those service users unable to visit the home. That care plans are reformatted for ease of use and that risk assessments and evidence of choice relating to the provision of room keys are in place That the labels from the catheter pack are kept in the care plan following recatheterisation to identify catheters used in case of reaction. That controlled drugs are counted and checked on a regular basis. That registered nurses ensure that senior carers add social plans to all care plans. That staff involve residents in for personal care in the activities and spend time with them. That senior staff attend the updating on adult protection protocols provided by social services. That the provider attempts to solve the storage problems identified in the main body of the report Highbury House DS0000013999.V268771.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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