Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 27/11/07 for Highcliffe House Nursing Home

Also see our care home review for Highcliffe House Nursing Home for more information

This inspection was carried out on 27th November 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Highcliffe House offers a friendly and welcoming atmosphere with a homely environment. Friends and family of the residents are encouraged to visit when they can and are welcomed by staff. Meals are prepared to a high standard and offer alternative dishes at each meal with a vegetarian option always available. The staff team is stable and committed. The registered manager is supportive but clear in their expectations of the team. There are adequate numbers of staff to meet residents` needs and staff spend time socialising with the residents.

What has improved since the last inspection?

Some work has been done on ensuring correct documentation is in place so the statement of purpose has been updated and now contains current information. No fire doors seen were wedged open and the fire exits were clearly indicated and free of obstructions. One lounge has had an extension built that includes patio doors to lead to the front garden. The laundry has been re-sited within the main building in part of the new build. A new call bell system has been installed that has a printout of calls with the response time so they can be monitored. Staff training in the protection of vulnerable adults (POVA) has taken place for most staff in the last few months. The service is preparing to commence a quality assurance survey of residents and families and has produced the questionnaire it intends to distribute.

What the care home could do better:

The named individual who was receiving terminal care has died so the registration certificate is incorrect. Application needs to be made to the registration team for a new certificate. Not all the residents` files looked at had evidence that a pre-admission assessment of need had been carried out prior to admission. The residents` files seen contained care plans but they were variable in quality of information and in some cases lacked important details. Some were not signed or dated and the frequency of reviews varied. Two of the new staff files seen only contained evidence of one reference for the person. On one landing of the home a cleaning trolley with products covered by the control of substances hazardous to health (COSHH) regulations was left unattended for a period of time with the products accessible. Some areas of the home look cluttered, as there is limited storage space for equipment. The bedroom window in one resident`s room has a faulty double-glazing seal.

CARE HOMES FOR OLDER PEOPLE Highcliffe House Nursing Home 10 Cobbold Road Felixstowe Suffolk IP11 7HQ Lead Inspector Jane Offord Unannounced Inspection 27th November 2007 09:30 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 Highcliffe House Nursing Home DS0000024414.V355756.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. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highcliffe House Nursing Home Address 10 Cobbold Road Felixstowe Suffolk IP11 7HQ 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) 01394 671114 01394 671298 alison@highcliffehouse.com www.highcliffehouse.com Highcliffe House Limited Mrs Bridget Bone Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (32), Terminally ill (1) of places Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named resident who is terminally ill Date of last inspection 5th June 2007 Brief Description of the Service: Highcliffe House is registered as a care home with nursing, providing care for a maximum of 27 older people. The home was registered to provide general nursing care to one individual service user falling within the registration category of terminal illness however the named person has now died and the registration certificate needs to be altered. The home is privately owned by Highcliffe House Limited and is managed by Mrs Bridget Bone. Highcliffe House is a large Edwardian building situated in a residential area of Felixstowe within walking distance of the sea front and local amenities. It is a detached building with gardens to the front of the property and parking at the rear. Accommodation is over three floors with communal rooms located on the ground floor. Access to the upper floors is by stairs or passenger lift. Fees range from £625.00 to £700.00 per week depending on the level of dependency and the accommodation occupied. The fees do not include the cost of toiletries, hairdressing, chiropody or newspapers. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.30 and 14.30. The registered manager and the director were both present and available during the day and assisted with providing documents and information. This report has been compiled using information available prior to the inspection, including a completed annual quality assurance assessment (AQAA), and evidence found on the day. During the day all areas of the home were visited and the new extension was seen. A number of residents and staff were spoken with and care practice was observed. Four new residents’ files and care plans and three new staff files were looked at. A wide selection of policies, maintenance records, service certificates and staff training records were seen. The kitchen was visited and the lunchtime meal serving was observed. Medication practice was not inspected on this occasion as a pharmacy inspector had recently undertaken a random inspection and given the service a statutory enforcement notice to improve practice. The notice had not expired by the date of this inspection but the requirements made are included in this report. Requirements 1-6 are made from evidence found at this inspection, requirements 7-13 are the requirements from the pharmacy inspection. On the day of inspection the home was clean and tidy with residents making use of the two lounges or remaining in their rooms as they chose. No unpleasant odours were noted. Residents looked comfortable and well dressed. Interactions between residents and staff were friendly and appropriate. Residents spoken with talked highly of the care received in the home. Staff members spoke of good teamwork and a supportive manager. The meal at lunch was nicely served and looked appetising. What the service does well: Highcliffe House offers a friendly and welcoming atmosphere with a homely environment. Friends and family of the residents are encouraged to visit when they can and are welcomed by staff. Meals are prepared to a high standard and offer alternative dishes at each meal with a vegetarian option always available. The staff team is stable and committed. The registered manager is supportive but clear in their expectations of the team. There are adequate numbers of staff to meet residents’ needs and staff spend time socialising with the residents. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Highcliffe House Nursing Home DS0000024414.V355756.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 Highcliffe House Nursing Home DS0000024414.V355756.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6. Quality in this outcome area is adequate. People who use this service can expect to have sufficient information to make an informed decision but cannot be assured they will have an assessment of need prior to being offered a place in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide were both seen and contained all the information required about the service offered by Highcliffe House. Details of the registered manager had been updated. The files for four recently admitted residents were seen and only two contained documentary evidence that staff from the home had undertaken a preadmission assessment of need. The manager explained that in one case the resident was the spouse of an existing resident and only came for a short stay but agreed the assessment should have been done. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 9 The assessments seen covered areas of support required for the activities of daily living such as communication, eating and drinking, personal hygiene, continence, mobility and night needs. There were also details about social interests, religion and family involvement. The registration certificate has one named person receiving terminal care as a condition of registration of the home. That person has died so an application for a variation to the certificate to remove that condition needs to be sent to the registration team of CSCI. This service does not offer intermediate care. Highcliffe House Nursing Home DS0000024414.V355756.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is poor. People who use this service can expect to have their health needs met and be treated with respect but they cannot be assured that their care plan will reflect all their care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An assessment on admission in each file seen included the reason for the need to be admitted, a past medical history, current medication, any known allergies and a little social history. There was a tick list to show the level of support required in walking, standing, sight, hearing, skin integrity and mental state. The four residents’ files seen all contained records of visits to and by health care professionals such as the GP, dietician, physiotherapist and chiropodist. One file contained a complete urinary catheter history and another had instructions for managing a feeding tube. Wound care was clearly documented with the size and description of the wound recorded. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 11 Three of the four files contained a care plan in relation to the support the resident needed in day-to-day living. The fourth person had only been admitted two days earlier and the registered manager said it was in their diary as a job for the day and they commenced writing the care plan during the inspection. The care plans seen had basic information and limited interventions under headings such as maintaining safety, eating and drinking, mobility, personal hygiene and communication. Some care plans were not signed or dated by the person compiling them. The home’s statement of purpose says that all care plans will be reviewed monthly but the evidence seen showed this was inconsistent. Some had evidence of monthly reviews but others had not been reviewed for several months. One resident with insulin dependent diabetes had no interventions in relation to the management and monitoring of the condition in their care plan, although there was a record of regular blood sugar readings in the file. Another resident with a pressure ulcer had an intervention under personal hygiene that said, ‘ensure XXXX has a bath weekly’. There was no record that the resident had had a general bath since admission. The manager said a bath was not appropriate until the pressure ulcer was healed and agreed the care plan was incorrect. A resident who had been in the home for a number of months had made good progress and their physical condition was much improved. Plans were being made to discharge them home where there was family to help support them, prior to Christmas. Their file contained evidence of forward planning by commencing a programme of self-medication teaching with the resident. Since the last key inspection in June 2007 a CSCI pharmacy inspector has undertaken two random inspections concentrating on the practice around medication storage, administration and recording. The findings from these inspections are written up in separate reports, which are available on request. As a result of the findings a statutory enforcement notice has been issued to the home. The notice had not expired by the date of this inspection so medication practice was not looked at during the day however the requirements from the second pharmacy inspection are incorporated in this report. Care practice observed was caring and respectful. Carers made eye contact with residents they were speaking to and spent time listening to residents. People were observed knocking on doors prior to entering bedrooms and bathrooms. Help was offered sensitively during mealtimes and residents were given choice about what they wanted to eat or where they wished to be sitting. Residents spoken with were happy with the care they were given. One said, ‘the carers are lovely, nothing is too much trouble’. Another said, ‘I love it here’. Highcliffe House Nursing Home DS0000024414.V355756.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service can expect to be offered meaningful pastimes, be encouraged to maintain contact with family and friends and have a well balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the files seen contained some details of the resident’s social needs, some were more complete than others. One had a full life history written by the resident and one had the resident’s previous occupation. Contact details of the next of kin and anyone important to the resident were recorded. Daily records showed when residents had had visitors. Visitors were seen to come and go during the day and were welcomed by staff. Many thank you cards on the notice board made comments about how welcoming the staff had always been. The home employs a part time activities co-ordinator who has been on a longterm absence for a period, which has had an effect on the amount of organised pastimes available for the residents. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 13 There have been no formal arrangements put in place to cover the absence of the activities co-ordinator but the manager said that carers try to spend time with residents and often do manicures for them or read newspapers with them. When the weather is good the seafront is a short walk away and carers will take residents down to the beach. There are some booked events such as entertainers, a carol singing service, a Christmas party and a magician. There is a weekly church service held in the home for residents who wish to participate. Residents spoken with said they were happy with the level of activity and occupation available. The kitchen was visited and a discussion was held with the cook about the choices available for residents’ meals on a daily basis. They said that for breakfast a resident could choose from cereals, a continental breakfast or a cooked breakfast. Fresh fruit, fruit juice and yoghurts were also available. Records seen of residents’ breakfast choices confirmed that a variety of meals were served. The lunchtime meal on the day of inspection was fish pie and vegetables; the alternative was sausages, either meat or a vegetarian choice of quorn. Dessert was upside down pineapple pudding and custard. The meal was plated individually, covered and transported to the temporary dining room or the resident’s own room if they chose. The meals looked hot and appetising. One resident spoken with said they were hungry but that, ‘food here is always worth waiting for!’. The planned menus were seen and showed that a fish dish is served each Friday and a roast every Sunday. Supper menus offered soup and sandwiches with a hot snack alternative such as ham and pasta bake. There was also a light dessert available, like chocolate mousse. The food stores were kept in the cellar, which is dry and spacious. The recorded temperatures of the refrigerators and freezers showed they were functioning within safe limits for food storage. Food was stored on washable shelves and there was a wide selection of ingredients and fresh produce. Highcliffe House Nursing Home DS0000024414.V355756.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. People who use this service can expect to have complaints taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy was seen and is included in the statement of purpose. It has been updated to include new details of the local CSCI office. Neither the home nor CSCI have received a complaint about this service since before the last inspection although there were a large number of complimentary thank you cards on display in the entrance hall. People spoken with were clear about the procedure for raising any concerns. The POVA policy has been amended since the last visit and contains details of the referral route if abuse is suspected. The policy folder contains a policy on whistle blowing to protect staff who may raise issues. Staff spoken with were clear about their duty of care and were able to identify hypothetical instances of even subtle areas of abuse. They said they had received updated POVA training within the last year. Training records confirmed training had been given. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. People who use this service can expect to live in a clean, homely environment that has a programme of ongoing maintenance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were visited during the day and the manager gave a tour of the new extension and explained some of the other changes proposed. The present clinic room is to be moved further back in the house to a larger room with the facility to use for wound care as well as store medication. One toilet is being refurbished and made wheelchair accessible. There is a large conservatory that is nearly ready for use and the quiet lounge has had an extension added with patio doors leading onto the front garden. The quiet lounge is doubling as a dining room at present as there are new window frames being fitted in the existing dining room. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 16 On the day of inspection the home was clean and tidy although in places felt cluttered by equipment storage in bathrooms, corridors and under the stairs. The manager said there were plans to utilise some external storage cabins when the workmen had completed the present extension. A number of residents’ bedrooms were seen and were attractively decorated and personalised with small items of furniture, pictures, photographs and ornaments. One shared room that was visited was unoccupied at the time but there was evidence it was being used for equipment storage. The doubleglazing unit in the window was faulty and the window was completely misted obscuring any view outside. The laundry is in a new purpose built room within the main building. It is light, clean and spacious compared with the previous accommodation. The washing machines have sluicing and hot wash programmes. The infection control policy is that soiled linen is transported and washed in alginate bags with dispersible seams. The policy gives clear guidance on hand washing techniques and the use of protective clothing. Staff spoken with identified situations when protective clothing should be used and the correct disposal of gloves and aprons afterwards. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of suitably trained staff but cannot be assured that documentary evidence that all recruitment checks have been made is available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that there is a trained nurse on duty throughout the twenty-four hours. Six carers in the morning shift, four carers during the afternoon and evening and two carers overnight support them. There is a cook and breakfast assistant in the kitchen and the manager has a number of supernumerary days each week. The home employs laundry workers, a maintenance person and a part time activities co-ordinator. A physiotherapist attends the home weekly for assessments and routine exercise work with the residents. The completed AQAA states that there are sixteen carers working in the home with a further two with bank contracts. Five carers have achieved an NVQ level 2 or above with seven more working towards the award. When the training is completed the percentage of carers with the qualification will be 66 , which exceeds the recommended 50 of standard 28 of the national minimum standards (NMS). Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 18 The files for three newly recruited members of staff were seen and showed that a POVA 1st check had been undertaken prior to them commencing in post and a criminal records bureau (CRB) check done as soon as possible. Each file contained evidence that the person’s identity had been verified with the use of official documents such as a birth certificate or passport. Only one of the three files had evidence that the required two references had been obtained, the others only had one reference. Staff spoken with talked about the induction they had received that included fire awareness, moving and handling, recognition of abuse and health and safety. The nurses are responsible for the care plans with each trained nurse named for a group of residents. Carers have access to the care plans but work under instruction from the trained nurses. All the staff spoken with said there were enough staff to meet residents’ needs and that the team was very supportive, working well together. The training records showed that POVA training had been updated for nearly all staff since the last inspection to comply with one of the requirements. The AQAA states that POVA training updates are planned for annually in future. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is adequate. People who use this service can expect it to be managed by a responsible person but cannot be assured that all practice will protect their welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The present manager has been in the post two years having achieved a promotion within the service. They are a trained nurse and have a number of years experience in caring for older people. They hold an ENB skills assessor and an NVQ assessor awards. In discussion with them it is clear they understand the roots of problems within the service and are determined to achieve better standards. Staff spoken with said the manager was approachable but clear in their expectations. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 20 Previously the home did not manage any personal monies for residents. The director confirmed that the situation remained the same. Lockable drawers were provided if requested for residents’ rooms and their own personal use. Minutes of staff meetings were seen and it was evident that wide discussions took place on a variety of aspects of the home. Items ranged from the new extension to health and safety, the last CSCI report and new staff. The home has developed a questionnaire to ascertain the level of satisfaction of the service among residents. This has not yet been distributed so QA results were not available at this inspection. A number of service certificates and maintenance records were seen. External consultants had examined fire-fighting equipment in July 2007 and fire training had been given in October 2007. There had been an environmental health inspection in April 2007 and a gas inspection in the same month. The lift was serviced in November 2007 and the bi-annual service and loler tests on the hoists were recorded for January and October 2007. Risk assessments for fire in all areas of the home were seen. The fire log showed checks on fire alarms and extinguishers were done weekly and emergency lighting monthly. Fire doors seen were not wedged open and fire exit routes were free of obstruction. Since the last inspection a lockable box has been attached to cleaning trolleys so products that fall under the control of substances hazardous to health (COSHH) regulations can be secured when the trolley is unattended. During the visit it was noted that one trolley was unattended for a period of time with a range of products not locked away and accessible to people passing in that corridor. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4 (1) (c) Sch 1 Requirement Application must be made to correct the registration certificate so prospective residents are properly informed of the range of care offered by the service. All prospective residents, even those proposed for short term care, must have a pre-admission assessment of need undertaken to ensure the home can meet their care needs and is a suitable place for the person to be. All the care needs of each resident must be addressed in their care plan, which must be reviewed on a regular basis to ensure resident receive the care they need in the way they would wish. Timescale for action 31/12/07 3. OP3 14 (1) 27/11/07 4. OP7 15 (1) (2) 31/12/07 5. OP29 19 (1) (b) (i) Sch 2 Two references must be obtained 27/11/07 and the evidence retained in staff files for all new staff employed to ensure residents are protected from unsuitable workers. DS0000024414.V355756.R01.S.doc Version 5.2 Page 23 Highcliffe House Nursing Home 6. OP38 13 (4) (c) Staff must observe the requirements of the COSHH regulations to protect residents. 27/11/07 7. OP9 13 (2) 13 (4) This is a repeat requirement. People who use the service must 27/11/07 have their medicines safely secured by staff who ensure they cannot be accessed by unauthorised persons. People who use the service must have their medicines given to them by staff who follow safe procedures for their administration. A review of medicine administration must be conducted to ensure this. People who use the service must have their medicines promptly obtained at all times and given to them continuously as scheduled. Repeat requirement from inspection of 04/09/07. People who use the service must have records of medicines given to them fully and accurately completed by staff at all times. Repeat requirement from inspection of 04/09/07. People who use the service must have records of medicines received at the home on their behalf fully and accurately recorded at all times. Repeat requirement from inspection of 04/09/07. People who use the service must have accurate records of medicines and their prescribed doses so that staff can safely prepare them for administration. DS0000024414.V355756.R01.S.doc 8. OP9 13 (2) 13 (4) 27/11/07 9. OP9 12 (1) 13 (2) 13 (4) 27/11/07 10. OP9 13 (2) 13 (4) 17 (1) sch 3 27/11/07 11. OP9 13 (2) 13 (4) 17 (1) sch 3 27/11/07 12. OP9 13 (2) 13 (4) 27/11/07 Highcliffe House Nursing Home Version 5.2 Page 24 13. OP9 13 (2) 13 (4) People who use the service must have medicines given to them in line with prescribed instructions at all times. This must be demonstrated by the home’s record keeping practice. Repeat requirement from inspection of 04/09/07. 27/11/07 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. Refer to Standard OP19 OP19 Good Practice Recommendations Consideration should be given to the arrangements for storing equipment in more suitable areas to make sure the home is safe and attractive for residents. Faulty double-glazing units should be replaced to make sure the windows function correctly and residents can benefit from views outside. Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Highcliffe House Nursing Home DS0000024414.V355756.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!