Inspection on 16/05/06 for Highdell Nursing Home

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Highdell Nursing Home 26/02/07

Highdell Nursing Home 16/01/06

Highdell Nursing Home 13/07/05

Highdell Nursing Home 26/01/05

Highdell Nursing Home 06/07/04

Highdell Nursing Home 07/01/04

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

CARE HOMES FOR OLDER PEOPLE Highdell Nursing Home 43 Westfield Lane Idle Bradford West Yorkshire BD10 8PY Lead Inspector Valerie Francis Unannounced Inspection 16th May 2006 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 Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 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. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highdell Nursing Home Address 43 Westfield Lane Idle Bradford West Yorkshire BD10 8PY 01274 610442 01274 610442 N/A 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) Mr Stephen Richard Pelkowski Mr Neville Rowe, Mr R Bottomley, Mrs Anna Margaret Johnson Mr Stephen Richard Pelkowski Care Home 25 Category(ies) of Dementia (25), Mental disorder, excluding registration, with number learning disability or dementia (25) of places Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Highdell Nursing Home is situated in the village of Idle, Bradford and provides accommodation for up to 25 people with psychiatric problems. Qualified psychiatric nurses and care staff provide twenty-four hour care. Accommodation at the home is provided on two levels with a recently installed lift offering access to the upper floor. This is in addition to the provision of a stair lift. There are single and double bedrooms, some with en-suite facilities. The home has two lounge areas plus a separate dining room. Parking is available to the front of the home and there are gardens to the rear and side. Although the home is situated in a quiet area the bus routes to Bradford and Shipley are easily accessible. Shops and local amenities are within walking distance. There was no written information in the pre-inspection questionnaire of the current fee charges. The inspection report is available on request from the manager. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on unannounced basis by two inspectors over one day, starting at 9.30am and finishing at 6.35pm. The person in charge of the home was the senior nurse Ms Robinson. The manager was not available in the home. The registered manager did not make himself available for a full feedback of the findings of the inspection. Matters that needed immediate attention were fed back to the person in charge. The inspection gives an overview of the home and for some people what it is like living at Highdell nursing home. The inspectors would like to thank everyone who took the time to talk to us and express their views. Before the visit, recent information about the home was reviewed. This included looking at the pre-inspection questionnaire completed by the registered manager which provided the inspector with information on the working of the home, policies and procedures in place and information regarding staff and residents living at the home. The document was given to the manager at the last inspection to the home and was completed and returned in March. The information given in the document along with other information received from the home was used to plan the inspection visit. During the visit, the inspectors case tracked a number of residents. This method was used to see if people were receiving the care and attention they required and if the care was good. The inspectors spoke to most residents, including residents whose care documents were looked at. Visiting relatives were spoken with; comment survey cards were left at the home for the manager to make available to other visitors. Most residents were spoken to and some of their answers and conversion was confusing because of their level of dementia. There were mixed feeling from others about the care given to them, their comments are in the body of the report. The majority of people feel that they are well cared for. Comment cards were sent to placement officers who had placed people in the home, for their opinions about the quality of services provided at the home. Two relatives and two professionals returned CSCI survey comment cards and gave their view about the home and the experience of the people living at Highdell Nursing Home. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 6 Comments received are included in the body of this report without revealing the identity of those completing them. During the inspection an immediate requirement was made for the repair of the uneven patio area flagged stone and for an improvement in the standard of cleanliness throughout the home. The registered manager was made aware by telephone. This was followed up in writing the following day requesting a plan of action and a timescale to resolve the matters. Comment made by residents and staff at the time of the inspection are also included and quoted in the report. A telephone call was made to the manager requesting him to come to the home and to bring with him the required records that was not available at the home for inspection. The manager declined this request an offer of another day for the inspectors to complete the inspection and to feedback to the manager was agreed. However, a telephone call was received at the CSCI office the day after the inspection informing the inspectors that neither him nor the information would be would at the home and he would not be available for feed back, instead the manager asked the inspectors to put all information in the report. A full feedback of the findings of the inspection was not therefore given to the manager. An action plan was received from the manager indicating how the issues of the standard of cleanliness and the uneven flagged stone patio area would be resolved. What the service does well: What has improved since the last inspection? Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 7 Staff have had first aid training and there is now a member of staff on each shift who has this training and know what to do when the need arises. Yearly electrical tests for small equipment have been carried out. Windows have been fitted with window restrictors that stop the windows opening fully for safety reasons. What they could do better: The registered manager must give prospective residents and others written information of the specialist care given at the home. Consideration must be given to provide people with dementia living at the home with an environment that helps them to maintain their independence. This would include bathrooms, toilets and communal sitting that are clearly marked. An appropriate plan for social activities for all residents in a group setting or individual in their rooms’ show be in place. The manager must make sure that a plan of action is in place to resolve the requirements and recommendations made at the last inspection. All matters relating to infection control and health and safety must be addressed. Residents must have a care plan that provides staff with information on how to meet resident’s needs. The manager must make sure that issues identified in the immediate requirement letter are resolved. Although an acknowledgement for the immediate requirement letter was sent to the CSCI area, a plan of action with a cleaning schedule needs to be in place to address the issues that relate to the standard of cleanliness throughout the building. The manager needs to give due consideration to remove residents personal details from the white board in the office, which is fully visible to any one coming into the home, presently it could compromise confidently and data protection. Additional information is needed to show how the home deals with the cultural and diverse needs of residents and staff where english is not their first language. Staff training on NVQ must continue along with training for the specialist area of care provided at the home relating to mental illnesses. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 8 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. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 9 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 Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 10 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’s written information, that is available to prospective residents and others, is not clear about the service provided at the home, or for whom the home offers care to. EVIDENCE: A copy of the home’s statement of purpose was sent to the Commission for Social Care Inspection (CSCI) local office, along with the pre-inspection questionnaire, which provides the inspectors with information about the daily running of the home. This was given to the manager at the last inspection in January 2006. This document was returned on the 17/03/06 and the information was used at this inspection. Both inspectors assessed the Statement of Purpose before the inspection. It was noted that the document did not give anyone wanting to live at the home enough information for them to make a choice about this. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 11 The document does not clearly provide information about the type of care offered, staff specialist training or how the home will meet their individual care needs whilst still maintaining their value as a person. Information that is given to prospective resident “ the Home’s leaflet “ was looked at, this was found to out of date, because it did not state the name of the Social Care commission. There was evidence on care files that an assessment is carried out of all new residents before their admission to the home, which is good practice. Although there was pre admission assessment information collected, this was seen as scant and did not provide full information about the individual, or that they have been assessed as needing specialist care in a home for people who have a Dementia or a mental health illness. One relative said he had been involved in the assessment process. This relative also said that during the assessment period, he had the opportunity to speak to the manager on several occasions, about his fathers care. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 12 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 Care plans are not clear how needs would be met. The information collected does not translate into a full care plan that gives all the care and social needs of the individual. Medication needs to be managed in a more effective way with a checking system in place for medication coming into the home and the correct use of the drug storage cupboard. EVIDENCE: All residents have a care plan however the information does not clearly give the staff providing the care enough information on how to meet their specialist care needs. Because of the scant information collected at the assessment such as “wandersome at night,“ “ goes into other residents rooms”, “distressed following visits from son” and “occasionally hostile at times” these had not been carried forward into the care plan with details on how to manage and how these would addressed. There was evidence of the Primary Nurse and Key worker involvement in certain care plans and that residents were being weighed on admission but in Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 13 another there was no evidence that these checks were carried out or any further recording. Records also showed the involvement of other health care professionals but no evidence of residents or their relative’s involvement in the care planning process. None of the care plans seen had any information of visit made by General Practitioner at the resident’s point of admission to the home if their own GP was outside the catchment area of the home. There was no evidence to show that care plans are reviewed and have been changed following a review. Records contained subjective statements by staff such as “is lazy at times”. There were no appropriate assessments carried out to assess if residents are at risk of developing pressure sores. There was no evidence to indicate that nutritional assessments had been carried out to see if residents are at risk and if they need any special diet. There was evidence that one resident identified as “having a tendency to put on weight” had had her diet changed by the staff at the home, but there was no written evidence to prove there had been any involvement with either the GP or the dietician or with the resident themselves before changes to the diet had been made. Oral, foot care and fall risk assessments had not been carried out for any residents, with a care plan showing how any identified risks would be minimised. One resident’s daily record of care showed evidence of the resident having fallen from the bed. However there was no recorded follow up of the resident the day after the fall to discover if the resident had either suffered any ill effects, or if any after care was needed. The registered manager had not signed the accidents book other than those he had witnessed. There were inconsistencies in the information seen recorded regarding one resident who “escaped out onto the main road”, and who was found by a passer by badly bruised following a fall and needed hospital treatment. The daily records are mainly a form of note taking or for recording matters not of a care issue, instead of a record of proof of what care has been given. There was very little record of involvement with dental, chiropody or optical services. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 14 The home uses a pre-packed medicine system, which is dispensed by Boots Chemist. The records had been completed properly. There was no system in place to check that the medication coming into the home was accurate when they were delivered. The drug storage cupboard was also found to be used to store cigarettes and wage slips. The controlled drugs cupboard inside the storage cupboard was not correctly fastened to the wall. While the inspectors were looking around the building they saw that residents were being spoken to in a proper manner and were being treated with respect. Many of them were suitably dressed and in clean clothing that fitted them. One visiting relative said the care was “superb in very way”, that the staff were “excellent” and that the place was “a palace”. During the inspector’s conversation with one resident, she noticed that the cardigan worn by the resident had been spoiled during the washing process and looked too big for her to wear. Her hands also smelled of faeces. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 15 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 does not provide all residents with enough stimulation to meet their social needs. Contact with relatives is encouraged. There was no choice of food for the diverse needs of the people living at the home. EVIDENCE: One of the residents, whose first language is not English, told one of the Inspectors that she had not seen a Polish priest since she had lived at the home as she would have liked. There is no information about how residents had lived their lives before either coming to live in England or before coming to live at the home, so that staff have a clear understanding of what they did and pass their life people. There were no recreational activities taking place during the inspection and little or no interaction between staff and residents, apart from moving them from places where they had wandered to, to where staff could keep an eye on them collectively. Residents certainly did not appear to have any kind of constructive stimulation, and routines of the day appeared to be organised for the benefit of the staff routines. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 16 There was an activity book where staff recorded any contact with residents that were seen as activities. One recording was of a resident having his finger nail cut by a member of staff. There were many residents without the capacity to say what they liked or disliked in the way of entertainment, and these were not catered for. Certain residents do have contact with relatives as was seen on the day of the visit. One resident had a visit from his son, who said he could visit any time he liked and that the manager was approachable. One resident who had capacity to go out by himself and buy certain items he wanted said he was happy living at the home. Many of the other residents seen and spoken did not have this capacity. The inspectors did not see any evidence that religious or cultural dietary needs were catered for in the care plans they looked at. Mealtimes were not observed, however the inspectors noticed, the teatime meal being eaten by one of the residents. This was a mix of beans in tomato sauce, cold pork pie, fried potato and fish fingers, and did not look either attractive or appealing, however, there was no indication it was not to his liking. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 17 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 & 18. Clear systems and procedures are needed to protect residents from abuse, and to make sure that people are confident that their complaint would be taken seriously and acted upon. EVIDENCE: The complaint procedure is it now displayed on the wall in the hallway to the entrance to the home making it more accessible to residents and visitors. One visiting relative said he knows how to complain, He not had been given a copy of this and said he did not want one. From previous relatives’ comments they said that they were aware of the procedure, but felt they could speak to the manager if they had any concerns. Two residents said they would speak to the manager if they had any complaints. Staff have access to the home’s “Guidance policy” (the homes adult protection policy procedure). The one seen at the home was last reviewed in 2004, this policy needs to be reviewed regularly to make sure it meets the current guidelines. The policy on adult protection must be clear about the steps to be taken and the involvement of the CSCI and Social Services, should any incident of this nature be identified. Additional information is needed in the whistle blowing policy procedure to make sure staff who alert managers to poor practices, feel they would be protected and supported through out the process. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 18 There is access in the home to the Multi Agency Adult Protection Procedure. Some staff have had abuse awareness training some time ago. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 19 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): There were issues of health and safety and hygiene through out all areas of the home, which needed thorough cleaning and maintenance. There was no evidence that the new extension met building and fire safety standards. EVIDENCE: From discussion with West Yorkshire fire and Building Control services further inspection at the home was required to make sure that the home meet their standards. Very little work appeared to have been carried out on the environment since the last inspection. There were areas of the home that did not meet health and safety regulations or infection control requirements. The ceiling hatch cover in the manager’s office was missing leaving the potential for the spread of flames should there be a fire. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 20 The office, which is also used to store the drug trolley when not in use, was dirty. Some over bed tables used in the, “no smoking” sitting room were clean; others were dirty with food particles present. The flagged patio area on the ground floor, which is freely accessible to residents, is a safety hazard with many of the flags raised and uneven. The garden area next to the patio needs attention. The grass is very long, making the area unsafe and inaccessible to residents who might like to walk around the garden, or sit out. A lounge chair which was fabric covered was out on the patio and was wet, residents could sit on this and wet their clothing. The external woodwork to the dining room windows was rotted and needs attention. The duvet cover on one of the beds on the ground floor was stained with faeces. One of the duvet covers that appeared to have come from the laundry had nasal discharge on it. Faeces staining was seen on the headboard and bottom sheet in one bedroom and the bed base of one bedroom was badly stained. There was an overnight catheter bag on a stand in this room, the end of which was uncovered and trailing on the carpet. An unpleasant odour was present in one room. None of the bedrooms provided staff with dispensed soap or paper towels. Blocks of soap and communal toiletries were seen in bathrooms. Many sinks in rooms did not have plugs. Medicinal creams not containing the name of the occupants of some the rooms were seen stored on open shelves and could be taken and eaten by residents who do not have the capacity to sense danger. Denture cleaning tablets were also seen on open shelves. Bath cleaner was also seen, the container of which did not contain any directions as to what it was. All of these observations reflect poor hygiene control. The curtains to the window in this room were not ironed and were badly creased, some pillows were lumpy and unfit for use. A chair seat in one room was sagging and very worn. Two pressure relieving mattresses were also stored on a bed in a shared room. A pressure-relieving mattress in one room, which was identified to the senior nurse in charge, was set at negative pressure. There were no nurse call leads present in many rooms in the home. (If it is inappropriate to use extension call leads, risk assessments of individual resident should be carried out). Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 21 The nurse call in one bathroom was not only tied up out of reach, but also possibly located in the wrong place. One bedroom door had a large gap under the door, which could compromise fire safety in the home. Door guards, which hold doors open, were seen on many doors. The provider should ensure these are effective in the event of a fire as there were no records to show these had been tested. Fire doors to some of the rooms were faulty and did not close properly making fire safety ineffective. One of the fire doors at the end of the corridor near room 21 was also faulty. Extractor fans through out the building were very dusty and needed cleaning; this is a potential fire hazard. One extraction fan had no back plate and was open to the outside. Many wardrobes were not secured to the wall and could easily be pushed over and some trims were broken which is potential hazard to residents. The type of locks fitted to residents bedrooms, could be used as a restraint to lock them in their rooms, as they cannot be unlocked from the inside. The hot water in from some bedrooms wash hand basins was quite hot. Radiators in rooms were not guarded, nor do they have guaranteed low surface temperatures. Some pipes in en-suites were not lagged. One of the new rooms was a very nice room and contained a double bed for the resident; however there was a large hole in the ensuite wall where work to correct a fault was being investigated. The new bedrooms were found to be cold. The Nurse in charge said these rooms have under floor heating which was sometimes faulty and needing adjusting. It was apparent that this was an ongoing problem and residents had been given extra bedding, and one of the bedrooms had a freestanding radiator, which had trailing plugs, and wires. Several bedrooms were dirty, commode frames were dirty, and cobwebs seen. Floors were sticky in many rooms and needed cleaning. One bath hoist was very dirty, and wet soiled unwrapped laundry was seen in a green fabric laundry bag. The new bathroom bath was dirty, and there was no wash hand basin fitted for staff or residents to wash their hands. One of the window closers was missing and it was very difficult to close the window. At the top of the basement steps was a filthy mop seen stored mop head down in a bucket. (No colour coding obvious) All cleaning mops should be colour Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 22 coded to identify where they should be used and what for, clean, and stored with mop head upwards to dry. The outsides of the freezer and drugs fridge in the basement were very dirty. The staff toilet area in the basement was filthy, there was no liner in the pedal bin and the walls were showing signs of dampness. The laundry floor needs attention as it does not appear to be impermeable, nor do the walls in this area seem suitable for washing down and keeping clean. The ironing room walls also need painting, and the floor needs attention, as it does not seem to be impermeable. There was dust and debris behind the washers. There is a window in this area, which was open to the outside, and with no mesh attached to make it rodent proof. The kitchen was dirty. Many of the metal kitchen trays were seen to contain burned on food, which had not been completely removed after use. The food mixer was filthy and the mixer blades contained remnants of food. Storage containers and open shelves used to store kitchen equipment were dirty. Potatoes and vegetables intended for use at the evening meal on the 17th May 06, were seen stored on an open shelf, under the sink area, in pans of water, one of which was uncovered. The fridge door handle was broken and had remained in this condition for two weeks, food stored in the fridge had no dates of when they were opened. There was evidence of fridge and freezer temperature recordings, and no proof that the temperature of hot food was being checked. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 23 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. There was no evidence at the home to indicate that residents are supported and protected by the home’s recruitment and training policies and practices. EVIDENCE: A copy of the staff rota was sent to the CSCI showing how many and when staff are on each shift during the 24-hour period. The rota does not show the availability of the manager; despite this the inspectors were told that the manager is not available at the home on Tuesdays. Although the rota showed ten trained staff made up of eight first level registered mental health Nurses and two 2nd level Enrolled mental health nurses, only the senior nurse and two others have this as their first employment. Others work at the home covering one or two shifts during the week, on days or nights. Agency staff are frequently used at the home and it was evident from discussion with staff it is sometimes difficult to fit in ongoing training. There is a mixed staff team some of the staff are from different cultural backgrounds to the residents. During the morning there is one nurse in charge and two care staff, one of which is a senior care assistant. The evening shifts are covered by an RMN and two care staff until 9pm,when one trained nurse and care assistants takes over. There was no written evidence available of the on call arrangement for emergency contact with the manager or senior nurse during the day or night. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 24 Although on the whole care staff levels appeared to be adequate for the present resident group during day, the staffing level at nights of two staff could compromise the health and safety of residents and staff because of the size and lay out of the building. The standard of cleanliness through out the building made it obvious that the allocated hours for one domestic staff is not enough to clean the home. There was no staff file or training information available at the home. This matter was the same at the last inspection when the manager had been advised that this information must be in the home. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 25 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): 31.33,35 & 38. The home management team has the qualification to meet the needs of the registered category of the residents. Not all the required records and information was available in the home for inspection The lack of records could cause the finances of residents not to be safeguarded. The health, safety and welfare of residents are compromised and some practices in the kitchen must be reviewed. EVIDENCE: The manager and the senior nurse in charge is a first level Registered Mental Health Nurse (RMN). The management approach of the home encourages residents and their visitors to have access to a senior member to discuss any issue. One visiting relative said, “the food looks good and that he would eat it. He visits on Wednesdays, which is pub night and is given a can of beer at no cost Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 26 to him that he shares with his father. He is kept very well informed about any matters relating to his father. He visits any time as it is open visiting and the home has “nothing to hide”. He said there always seems to be plenty of staff (5 or 6 each time he has visited), and that Mr Pelkowski is always willing to give advice when asked. He also said that although his father has lost a lot of weight since the onset of his Dementia, he was not worried, as he has been told by the home that this usually happens with sufferers of this condition. The manager has no qualification in management. There is a quality audit questionnaire which gives residents and their relatives the opportunity to have their say about the service provided at the home and to give their opinion on matters that affect the running of the home. A copy of the most recent report was sent to the CSCI area office. Due to the absence of the manager the inspectors were not able to discuss any development plan for the home with him. There were no financial records available at the home for inspection in respect of the management of individual residents’ personal allowance, where they cannot look after their finances themselves. There was no evidence available in the home of any staff meetings carried out or individual meeting for staff to discuss with the manager their work, training needs and any other matters. The nurse in charge said since the last inspection staff have had first aide training so that the home has a member of staff on each shift who can administer first aid. There was no evidence that risk assessments have been carried out for the building. Residents have been admitted to the new bedrooms despite these rooms having not yet been passed by building control and the fire service. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 27 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 1 X 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 1 1 3 1 1 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 1 1 X 1 1 Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 28 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 OP7 Regulation 15 Requirement Residents must have a care plan that clearly identifies all their assessed needs and how they would be met. Last and previous timescale 30th August 2005 & 10/03/06 Timescale for action 20/06/06 2. OP7 15 & 13 (4) (b) There must be a plan of action to 20/06/06 be taken to prevent pressure sores occurring and risk assessment in place. Last and previous timescales 30th August 2005 & 15/03/06 A plan of care with an action plan must be in place, in regards to the use of bed safety rails. Last and previous timescales 30th August & 15/03/06 The water temperature checks must be carried out on a monthly basis with records kept of these checks. Last and previous timescales 30th August 2005 & 16/03/06 20/06/06 3. OP7 15 & 13 (4) 4. OP25 23 10/06/06 Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 29 5. OP26 23 The standard of cleanliness of furniture used by residents in communal sitting rooms must continue to improve. Last timescale 15/03/06. A plan with timescale for replacement and redecoration in the home must be sent to the CSCI area office. Last and previous timescale 30th August 2005 & 26/03/06. 10/06/06 6. OP24 23 10/06/06 7. OP28 28 The home must have 50 of 31/10/07 staff with an NVQ qualification by The given timescale. Risk assessments for the building 10/06/06 must be carried out. Last and previous timescale 30/09/05 & 22/03/06. The registered provider must make sure that the home’s statement of purpose clearly outline the service provided at the home and for whom the service is for, and make it is available in the home. The Service User Guide must have the current and the required detail, and is made accessible to residents. Last timescale 22/03/06 The registered person must make sure that care plans are reviewed regularly and any changes are reflected in a new plan of care. Last timescale 22/03/06 Residents and or their representative must be consulted in the care planning process. Last timescale 22/03/06 DS0000019894.V293296.R01.S.doc 8. OP38 23 9. OP1 4 25/06/06 10. OP7 15 (1) (b) 10/06/06 11. OP7 15 (1) (c) 25/06/06 Highdell Nursing Home Version 5.1 Page 30 12. OP8 14 &16(2) (I) The registered person must make sure that all residents have a Nutritional screening assessment. Last timescale 22/03/06. 25/06/06 13. OP9 13 (2) 14. OP12 16(n) The registered person must take 10/06/06 action in accordance with the Royal Pharmaceutical Guideline for the disposal of unwanted medicine. Last timescale 22/03/06 All effort must be made for social 10/06/06 activities to be carried out for all residents. Last timescale 15/03/06. The registered manager must offer and provide residents from a different background with food that meets their cultural and diverse needs. The registered provider must make sure that residents have access to the nurse call system at all times. Extension cords must be in place for all. All matter relating to health and safety must be resolved. All electrical ventilation must be cleaned. The hot water temperature to outlet identified must be resolved. Regular hot water checks must be made and a record kept. Last timescale 15/03/06. The registered manager must have a relevant management qualification Last timescale 17/05/06 Staff must have training on mental health illnesses, that would enable them to meet the needs of the people living in the home. DS0000019894.V293296.R01.S.doc 15. OP15 16. OP22 Schedule 4. Regulation 17 (2) (13). 12 (a) 10/06/06 10/06/06 17. OP38 23 (1)(c) (4) 10/06/06 18. OP31 9 31/08/06 19. OP30 18 31/07/06 Highdell Nursing Home Version 5.1 Page 31 20. OP38 23 Last timescale 12/04/06 The registered person must 16/06/06 make sure that there are certificates from Building control and the West Yorkshire fire authority to confirm that the building meet their standards and can be used by service users. A copy of theses must be sent to the CSCI local office by the given timescale. Last timescale 06/03/06. 30/05/06 21. OP25 22. OP21 23 OP38 24. OP25 25. *RQN 26. OP38 Portable heaters must only be used in an emergency, a risk assessment must be made with an action plan how to minimise the any potential risk. 23 (2) (j) The registered provider must provide a wash hand basin in the new bathroom (An action plan to be sent to the CSCI area office) Liquid soap and paper towel 13 (3) must be available in all and wc’s, in communal bathrooms and in residents rooms. 23 The problem with the heating in the new extension must be repaired. To eradicate the use of portable heaters. Schedule All records that is a requirement 3 to be kept in the home and Regulation made available for inspection. 17(1)(a) 23 & 12 The registered provider must make sure that all infection control and health and safety issues raised in the body of this report that relates to the premises is resolved. An action of plan with timescales of how and when these matters will be resolved, must be sent to the CSCI local office within the given timescale. DS0000019894.V293296.R01.S.doc 23 (2) (P) 10/06/06 25/06/06 10/06/06 Immediately 10/06/06 Highdell Nursing Home Version 5.1 Page 32 27. OP4 14 (2) Additional information is needed 28/06/06 in the home’s written information and in each resident care file, to show how the home deals with the cultural and diverse needs of residents for whom English is not their first language. 28. OP10 12 (4) (a) Residents personal details on the white board in the managers office is visible to any one coming into the home and compromises confidently and data protection. The health and safety issue regarding the uneven flagged stone patio area. Must be made safe. 10/06/06 29. OP38 23 (2) (b) 13 (2) (b) 21/05/06 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. 2. 3. Refer to Standard OP7 *RCN *RCN Good Practice Recommendations Resident/ relatives should sign an agreement to indicate Their consent for bed safety rail in place. Some consideration should be given for the manager to provide a care plan that is person centred. The manager should provide the CSCI with a plan of the redecoration and replacement through out the home. Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 33 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Highdell Nursing Home DS0000019894.V293296.R01.S.doc Version 5.1 Page 34 - 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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