Inspection on 08/08/06 for Highbury Nursing Home

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highbury Nursing Home 29/07/08

Highbury Nursing Home 08/08/07

Highbury Nursing Home 01/02/06

Highbury Nursing Home 04/10/05

Highbury Nursing Home 17/03/05

Highbury Nursing Home 04/09/04

Highbury Nursing Home 03/08/04

Highbury Nursing Home 11/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Highbury Nursing Home 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX Lead Inspector Kath Strong Announced Inspection 8th August 2006 08:30 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 Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbury Nursing Home Address 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX 0121 442 4885 0121 449 7855 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) Flintvaleltd@btconnect.com Flintvale Limited Bernadette Farrell Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Terminally ill over 65 years of age (38) Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing home for the elderly, old age, dementia and terminally ill That Mrs Farrell undertakes further training in the area of Dementia Care and notifies CSCI of the details. Date of last inspection Brief Description of the Service: Highbury Nursing Home is purpose built and is located on the outskirts of Moseley Village, a suburb of Birmingham. The home provides residential and nursing care for up to 38 persons who are aged 65 years or above who may suffer from dementia. Bedroom accommodation includes both single and shared rooms, some of which have en-suite facilities. Bedrooms are situated on three floors; these are accessible via stairs or a shaft lift. The communal areas are situated on the ground floor and have recently been extended. All of the communal rooms are linked by well glazed partitions, which facilitates staff ability in observing residents and the nurses’ office is adjacently situated. The main lounge leads on to a smaller lounge, which leads onto the main dining area. There are two smaller rooms within close proximity one is used as a lounge and the other as an extra dining area. Communal toilets and bathrooms are within easy access of all areas of the home. The home has adequate quantities of specialist equipment and hoists to assist with the care needs of residents. During clement weather residents frequent a secluded and well laid out garden and patio area. A large unused grassed area is situated to the side of the garden and a generous sized car park is also located at the rear of the premises. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out the fieldwork visit to the home over a period of 8.25 hours. The registered manager and administrator provided assistance throughout the day. All key standards were assessed and progress made on the requirements generated during the previous visit. Care plans were reviewed and the care of the latest admission was case tracked to ensure that all the identified needs were being met. Discussions were held with residents, a visiting relative and staff. Observations of staff practices were carried out throughout the day. Relevant documents were assessed and a partial tour of the premises carried out including the bedrooms of those whose care plans were examined. At the conclusion verbal feedback was given to the registered manager by both inspectors, she was advised that the outcome of the visit is positive. What the service does well: What has improved since the last inspection? Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 6 Some bedroom furniture has been replaced and there is a phased plan to continue this process for all bedrooms. The new furniture includes a lockable facility so that residents can securely store their financial and personal belongings. One bedroom has been fitted with new flooring. Some rooms have been redecorated, this always carried out rooms are vacated to reduce disruption to the occupants. A dedicated room has been established for the visiting hairdresser to improve the arrangements for resident’s comfort and privacy. Two bathrooms have had window blinds fitted. Curtains have been purchased and hung at the windows of the new lounge extension to improve the appearance. A new flat screen television, DVD and fish tank have been purchased for the lounge. A karaoke machine has been bought to increase recreations within the home. A gazebo has been purchased for the garden to provide a shady place for residents to enjoy the garden. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 Residents and external professionals are provided with good information to enable them to make a decision about he home. Pre-admission assessments are carried out to ensure that the home is able to meet all needs at the point of admission. Lack of staff training in dementia care fails to demonstrate to homes ability to meet residents long term needs. EVIDENCE: The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose, service user guide and the last three inspection reports are on display in the reception area. The registered manager advised that a copy of the service user guide is given to each resident on admission. To give residents complete information the complaint section of the document needs to include the timescale for resolution. The contract of terms and conditions of residency provided to each resident requires further development to give residents the required information. It Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 9 needs to include a description of the services that are not included in the fee rate and the room occupied. Care plans examined included the pre-admission assessments, these were found to include good information for the home to determine individual’s needs and personal preferences. It was noted that the pre-admission assessment tool had not been signed in respect of the latest admission. The home is registered to provide care for people who suffer form dementia but staff have not received training in this aspect of care and should do so to ensure that they are competent to carry out their roles. The home does not provide intermediate care. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 10 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 and 10 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well documented and give staff guidance about how the majority of care needs should be provided. There is ample evidence that health needs are being monitored and met using the involvement of external professionals. The medication arrangements are good preventing residents from harm. Observations of staff practices indicated that the dignity and privacy of residents is maintained. EVIDENCE: Each resident has a care plan, which provides all care staff with information regarding assessments, care needs, monitoring and reviews to ensure that changes of needs are up to date. Those care plans reviewed are logically presented to ensure ease of access to relevant sections. The pre-admission assessment is used as the framework for the more detailed assessments and collation of care plans. They include detailed information about mental and physical health needs and personal preferences. The care plan seen for a resident who displays difficult to manage behaviour was noted to be well Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 11 documented and included staff instructions. The personal and communication needs of persons of ethnic minorities are recorded and include clear staff instructions. Pressure ulcer records are descriptive and the advice provided by external professionals of varying disciplines is carried out. Regular reviews are carried out and the resident/relatives are invited to attend. The files indicate that residents are well cared for to maximise their well being. The registered manager was complimented for the overall standard of the care plans. Some shortfalls were noted: • The signed form giving permission for restraint must be renewed annually • The sling size and type of hoist needs to be included for those residents who require mechanical assistance to mobilise • A nursing assessment had not been dated, it is not possible to determine when a review is required • The home is advised to develop a care plan the psychological effects for any residents who are experiencing terminal illness. These were brought to the attention of the registered manager who advised that the shortfalls would be addressed. Comments received from residents included, “I feel safe and well looked after here, I have no complaints, its very good here, I’ve lived here for five years and I love it”. All aspects of the administration of medications was examined and found to be satisfactory with documentation being fully carried out. It was noted that an investigation was being carried out for one controlled drug (tablet) discrepancy found. Relevant observations are carried out prior to administration of a medication. Receipt of medications from the pharmacy are audited and returns are well documented. Observations of the delivery of care and staff interactions with residents were respectful and supportive. Staff used the preferred term of reference; these are also recorded in the care plans, which ensure that the dignity of residents is adhered to. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Due to insufficient recreations residents are not sufficiently stimulated. Residents are enabled to influence the day to day running of the home. The meals provided offer variation, choices and a balanced diet but cultural needs must be explored and provided. EVIDENCE: The activities organiser is shared with the sister home resulting in lack of adequate time being dedicated to recreation. The registered manager advised that the programme is currently being developed. The individual records suggest that more time needs to be provided for the physical and mental stimulation of residents. The activities organiser advised that the life history and personal diary of residents is currently being re-developed. The outings currently are scant but records confirm that a number of residents went to a pub recently. Another resident regularly goes to her brother’s house for the afternoon, and another had gone to her sister’s home for two weeks. A resident advised that she was going out by bus to her brother’s house to have tea and cake. A notice is on display regarding the planned trip to Cannon Hill Park and Nature Centre. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 13 Regular resident and relative meetings are held with the minutes distributed accordingly. The agenda items indicate that that residents are encouraged to suggest changes and ‘have a voice’ about the way the home is run. The reception area has a Family and Residents notice board where a variety of information is supplied and messages can be left. One resident said, ”I get myself up in the morning and come down for breakfast whatever time I like”. A resident who speaks very little English is visited daily by relatives who act as interpreters for staff. The care plan asks staff to speak slowly, clearly and if necessary to repeat the dialogue because the resident may understand what is being said. This is viewed as being good practice. The registered manager advised that the pay phone had to be moved to the ground floor corridor, however this does not afford adequate privacy for residents. The six week cyclical food menu provides details of four meals per day and the type of soft diets provided every lunchtime. The menu for normal diets appeared to be varied, provide choices and consists of a nutritious and balanced diet. It was noted that for soft diets weeks 3 to 6 offer a lunch that includes meat 3 to 4 times per week but only twice during weeks 1 and 2. This was discussed with the registered manager regarding the infrequency of meat on those weeks for older persons who are more prone to anaemia. There was no evidence to support that the residents of ethnic minorities have been offered culturally appropriate meals. The care plan of one resident states that she enjoys curries, however verbal feedback received was that she enjoys English food. Advice was given that the menu is currently being reviewed and that residents have been consulted during residents/relatives meetings. Breakfast includes scrambled eggs, lunch consists of two courses (main meal of the day) with omelette, jacket potatoes, or pies available as alternatives, tea consists of various items and sandwiches, cake and hot drinks are served at supper time. Specialist diets are catered for. A record of resident’s preferences are recorded the previous evening. Lunch was observed being served and was noted that the chicken and vegetable pie had been home made. Staff wore blue aprons and where assistance was required staff sat next to the resident and were observed providing respectful assistance. The meals were attractively presented and of ample sized portions. Comments received form residents include, “The food is very good here, you get a choice of food but sometimes you get something you don’t like, I have grapefruit for breakfast, food is lovely”. A relative also said, “I can have a meal here if I want to”. This is viewed as being good practice in encouraging mealtimes to be a social event for residents. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 14 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 and 18 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are given information on how to make a complaint and how it will be dealt with but a timescale for resolution is not included. The adult protection arrangements largely protect residents from harm but needs further minor development. EVIDENCE: The complaints procedure within the service user guide is on display in reception, a copy is given to each resident on admission to the home. It was brought to the attention of the registered manager that it requires further development to include the timescale for resolution of the complaint. No complaints have been received since the last inspection and the home has a history of having few complaints made. This indicates that residents are receiving good standards of services and care. The registered manager was also advised to commence a logging system to include details of the complaint, investigation, outcome and action and if monitoring is required. It was noted that there are lots of complimentary cards within the reception area. The written policy in respect of adult protection requires further development, although in practice of previous and current allegation it has been evidenced that the home responds appropriately. The policy does not include the Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 15 Birmingham multi-agency guidelines or that Social Care and Health are the lead agency and must be informed. The document should also include staff instructions that they must not carry out any interviews or investigations but should document events witnessed and any actions taken. The registered manager provides staff training in this aspect of care. The two staff who were interviewed demonstrated that they would respond appropriately if an allegation of abuse is made or suspected. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant, comfortable and safe environment. EVIDENCE: The extended communal sitting and dining rooms are light and airy and homely in appearance. They are fully utilised by residents and the dining areas are also used for activities. Residents are able to choose which lounge and dining table they prefer to sit at. The rooms are located directly adjacent to each other and have large glazed partitions to improve staff’s ability to provide discreet observations. The furniture fixtures and fittings are of a good standard. The garden offers seating for residents and visitor to frequent during clement weather. One of the assisted baths was in need of repair restricting current bathing to one bath and three assisted showers. The assisted element of a shower room Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 17 was not working and a quotation has been obtained for the repair. Bedrooms include en-suite facilities or a wash hand basin. A communal toilet was noted to have the seat missing and another the cistern lid missing. The registered manager said these would be dealt with without delay. Those bedrooms where new furniture has been replaced include a lockable facility for the safe storage of personal and financial items. Rooms vary in size and layout and those seen were personalised to the extent preferred by the occupant. There is a rolling programme of decoration of rooms and replacement of furniture. All rooms have suited door locks and residents may be given a key providing they have been assessed as being safe to hold the key. Information given by residents included, “I love my room, they clean my room every morning, my room is nice and clean”. Rooms and corridors are light, warm and uncluttered for the safe access of residents. Random testing and recording of hot water outlets are carried out of those accessible to residents in order to prevent the risk of scalds. A company carries out other water testing. The home was found to be tidy and hygienic in all areas. Two housekeeping staff are on duty every morning and three at weekends when deep cleaning is carried out. Both the kitchen and laundry rooms were hygienic and respective procedures carried out for the prevention of infection. Practices observed of housekeeping staff and care staff indicates that there are good infection control measures in place for the continued well being of residents. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 18 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 and 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels are sufficient to ensure the care needs are fully met for the current client group. Recruitment practices are robust, preventing residents from harm. Lack of evidence prevented assessment of staff training resulting in a workforce who are not competent to carry out their role. EVIDENCE: The home supplied four weeks of the staff rota of all shifts shortly prior to the inspection. This was assessed against the numbers and dependency levels of residents and was determined to be satisfactory to adequate standards of care to be delivered. There is a full complement of ancillary staff permitting care staff to concentrate on the health care of residents. The kitchen and laundry rooms are staffed every day and the home has a maintenance operative in post. A sample of staff files was examined including the latest recruit. They were found to be in good order and all necessary checks as well as CRB/POVA are carried out before a vacancy is filled. The outcome is that the home appears to operate a safe recruitment system. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 19 Although there was a good amount of evidence that staff have received mandatory, relevant refresher courses and other training to meet the needs of residents it was not possible to determine if all staff have been captured. This was due to the training matrix not being up to date. The registered manager said she had been providing assistance at the sister home and completion of the matrix had slipped. She advised that she will up date the records shortly. CSCI received the matrix 24th August but due to ticks and/or year only being recorded it was not possible to verify the actual dates of completion. It was also noted that gaps persist in training for all aspects of mandatory, abuse and dementia care. Training in Moving and Handling, Health and Safety, Food Hygiene, Fire Safety and Adult Abuse must be provided to all care staff. Other courses the home have provided for some staff are Infection control, Wound care, Administration of Medications, Care of the Dying, Parkinson’s Disease, Continence, Diabetes, Oral and Eye care, first Aid, Adult Protection, Nutrition, Dealing With Complaints, Reminiscence and Negligence and the Law. These were found to be relevant to resident’s needs and delivery of comprehensive care. As discussed within standard 4, the registered manager and all care staff need to undertake training in dementia care in order to meet the registration category of the home. The home needs to ensure that the induction programme for care staff reflects the contents of the Skills for Care package. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear vision for the development of the home and has leadership skills to ensure that staff deliver a good service. The quality assurance process needs to be further developed. Some slippage in the frequency of formal staff supervisions fails to ensure that they possess the knowledge and skills to carry out their roles. Health and safety arrangements are robust and protect residents from the risk of injury or harm. EVIDENCE: The registered manager has the skills and a wealth of management experience in the care sector. A condition of registration for the home is that she undertakes a training course in dementia care. A deputy manager also provides management support. Staff are able to obtain out of hours advice if Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 21 required. The staff who were interviewed said that the registered manager and other senior staff are supportive and helpful towards them. Resident and relative questionnaires are distributed regularly as part of the quality assurance process. The premises are audited every six months and includes infection control, documentation and the kitchen. Information was supplied to the registered manager about the increased level of quality assurance in that an annual report should be compiled and where shortfalls are identified and action plan with timescales incorporated. The document needs to be shared with residents and staff. The responsible individual visits the home every week, this does not fully comply with Regulation 26 that states a monthly unannounced visit should be made and report developed and given to the manager, which is also available for inspection. Shortly prior to the fieldwork visit four comment cards were received from residents and six from relatives, all made positive comments. One health care professional also responded and stated, “Staff do not always demonstrate a clear understanding of care needs”. The arrangements for the safe storage and financial transactions of personal monies held on behalf of residents are robust in ensuring prevention of irregularities. Although formal staff supervisions are being carried out the frequency must be increased to at least six times per annum to monitor staff knowledge and practices. All elements of health and safety arrangements appeared to be met. Regular checks and servicing of equipment are carried out. The fire alarms are tested weekly and the emergency lighting monthly and recorded. Fire drills are carried out at regular intervals and those staff who participated are recorded. The home should be commended for including the visiting GP in the latest fire drill. A monthly audit of accidents is carried out to monitor trends and take appropriate action if necessary to reduce the incidences to ensure residents well being is promoted. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 22 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 2 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 3 Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1)(b) Requirement The contract of terms of residency must be further developed to include details of the services not included in the fee rate and the room occupied. The registered manager and all care staff must comply with the homes registration by undertaking training in dementia care. The home must increase the amount and variety of internal and external activities. A programme must be developed to give residents prior notice of the options available to them. Resident’s choices of food must include consideration of cultural needs and requests catered for. The written complaints procedure must be further developed to include a timescale for the resolution and the registered manager must develop and introduce a system DS0000024854.V306629.R01.S.doc Timescale for action 31/10/06 2. OP4 OP31 18(1)(a) 10/12/06 3. OP12 OP13 16(2)(n) 30/11/06 4. OP15 12(4)(b) 16(2)(i) 22(4) 31/10/06 5. OP16 31/10/06 Highbury Nursing Home Version 5.2 Page 24 for logging complaints received. 6. OP18 13(6) The written procedure in respect of adult protection must be further developed to include notifying Social Care & Health and that they also take the lead role. Staff must also be advised to document any findings and actions taken but not to commence an investigation. The registered person must make arrangements for the repairs to be carried out for the assisted bathing facilities. N.B. Quotation has been received for the shower. 31/10/06 7. OP21 23(2)© 31/10/06 8. OP22 23(2)n The registered person must 31/12/06 demonstrate that an assessment of the premises has been carried out by a suitably qualified person to ensure that sufficient disability equipment is provided to meet the residents needs. N.B. Not assessed on this occasion therefore carried forward. N.B. This remains outstanding from the previous three inspections. The registered manager must provide CSCI with documentary evidence that all staff have received all mandatory and respective refresher courses. The registered person must complete and introduce the already commenced quality assurance system. N.B. This remains outstanding from the previous two inspections. The responsible individual must 31/10/06 9. OP30 18(1)(a) 10. OP33 24(1&2) 30/11/06 Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 25 carry out unannounced monthly visits to the home, collate a report and supply a copy to the registered manager who must make it available for inspection. 11. OP36 18(1)c The registered person must ensure that newly recruited care staff receive a comprehensive induction programme that is compliant with Skills for Care standards. N.B. This remains outstanding form the three previous inspections. The registered manager must ensure that all care staff receive formal supervisory meetings at least six times per annum. 30/11/06 12. OP36 18(2) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The registered manager should give consideration to production of the service user guide and complaints procedure in large print and/or taped for the convenience of those people who have sight or hearing impairment. Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Highbury Nursing Home DS0000024854.V306629.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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