Inspection on 26/02/07 for Highdell Nursing Home

This inspection was carried out on 26th February 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.

Other inspections for this house

Highdell Nursing Home 16/05/06

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 Pamela Cunningham Unannounced Inspection 26th February 2007 10:30 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 Highdell Nursing Home DS0000019894.V310926.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. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 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 Stephen Richard Pelkowski Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (22) Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 Brief Description of the Service: Highdell Nursing Home is situated in the village of Idle in Bradford and provides accommodation for up to 22 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. Prospective residents and their relatives can get information about the home from the provider, and the Statement of Purpose and function, and service user guide when they have been updated. Currently they can ask about the facilities and care provided during visits to the home On the day of the visit fees charged for nursing care provided were £380 per week Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit was made on 26th February 2007. The home did not know that the visit was going to take place. Feedback was given to the senior nurse/deputy in charge during and at the end of the visit. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents, and to see if any improvements had been made regarding requirements made at the last inspection of which there were 29. Before visiting the home the inspector asked for information from the manager (the pre inspection questionnaire – PIQ) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. At the time of writing this report eight relatives responses had been returned. One relative also wrote a letter as she thought the tick boxes provided on the comment cards were not sufficient for her to give her view on the good care she thought the home provided. In order to find out how well staff knew residents, care plans were looked at during the visit and residents, visitors and staff were spoken to. Other records in the home were looked at such as accident records, health and safety documentation and complaints received. What the service does well: The home has an atmosphere of calmness. The interaction between staff and residents was good, and there is a good balance of cultural, age and gender mix within the staff team, which benefits the service users. The deputy manager has a good knowledge of each service user and uses her professional experience to relate to the people in her care in a relaxed and friendly manner. Service users are treated as individuals and encouraged to maintain their interests and skills for as long as possible. The home provides a secure environment with less restriction of movement around the building since the installation of the lift in the new part of the building The staff appear to respond appropriately to service users questions and behaviours. These factors increase trust and reduce levels of agitation and aggression for the service users, as was noticed during the visit. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 6 The proprietors, one of whom is the registered manager, take an active interest in the home and the people who live there, and aim to provide a good service. Written comments on comment cards recognised if people are not satisfied with the service, they are willing to listen, investigate and try to put things right. The proprietors are aware of the high level of wear and tear arising from the category of people they are registered to care for and have introduced a programme of redecoration and refurbishment to improve, and maintain, the home to an acceptable standard. What has improved since the last inspection? What they could do better: Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 7 The Statement of Purpose and function of the home still needs amending to include all relevant information, and amended copies to be sent to the CSCI. All staff that prescribe care and update care plans electronically should be provided with appropriate training. This is to make sure that important information is not missed or left out of the care plans because currently there are two sets of records running side by side, and the manager should make sure that the electronic system of care recording in place recognises the need for risk assessments where a risk has been identified by the qualified staff. This is particularly relevant to tissue viability and nutrition. The medication system in use has the potential for mistakes to be made. All medications must be accounted for on arrival to the home and documented on the MAR charts, and all directions must be clearly written in full, and contain the signature of the nurse making the entry. Certain relatives have indicated they are not aware of the complaint procedure. The manager must make sure all relatives are aware of it and have access to a copy of the homes own procedure for handling complaints. The manager must make sure training is on going and that all staff receive training on abuse and Adult Protection. It is also recommended the manager does the two day training on this subject specifically aimed at managers. Staff records are not kept on the premises but can be made available on request. The manager should supply proof of robust recruitment procedures to the Commission. A staff training Matrix needs to be developed so that training needs can be easily identified, and further training planned for. The manager must also make sure all induction training complies with Skills For Care common induction standards. The manager needs to complete the Registered Managers Award, and make sure all care staff receive formal supervision at least 6 times a year. Certain policies and procedures need amending in line with up to date and current legislation, and all care documentation forwarded to relatives should be sent under cover of Post office Special delivery, in accordance with the Data Protection Act 1998. 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. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users or relatives are provided with information to enable them to make an informed choice about the home, however this is not easily available to them as it is currently being updated. EVIDENCE: The Statement of Purpose and Service user Guide were not available to look at, as had not been amended by the owner, and were not on display for easy reference for visitors, as it is currently being update by the manager/provider. Information given in the Pre Inspection Questionnaire (PIQ) sent to the Commission before the inspection made reference to the Statement of Purpose needing amending, however awaiting guidance on this from the CSCI. The Manager should be aware that all information required to complete this document is detailed in the National Minimum Standards and Regulations for Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 10 Older People. Schedule 1. Guidance on writing one is also freely available on the Internet. Evidence was seen of contracts of terms and conditions, with any items identified to be paid for that are not covered by the fees. Pre admission assessments are done by the manager, and no resident is admitted to the home unless the manager is sure they can meet their needs. Numbers of staff on duty and the training the staff have had makes sure the needs of the residents are met. There are certain members of staff however who would benefit from more training, as currently 13 of the residents living at the home have dementia related illnesses, and although this is not the primary reason for their admission to the home, they would benefit from staff having training in this area to make sure all their needs are met Trial visits are encouraged, and can take as long as it takes the service user to settle, and become used to their new surroundings. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 11 Quality in this outcome area is adequate. The home is able to meet the health and personal care needs of service users. The health care needs are identified and monitored; however some medication practices create the opportunity for error. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last random inspection the home was in the process of updating all the care documentation from the old style, to computer-generated records. This is now almost completed, however, during review of some of the records, concerns were identified. At this time only the manager and deputy are competent in using a computer. This means that there are two sets of care records running at the same time, which will, if great care is not taken, result in some important information Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 12 being either missed or left out altogether. If this new system is to be efficient and work for the benefit of the service users health and welfare, then all the qualified staff employed, be it on a full time, bank or part time basis, should have training on how to use a computers and complete care records. Five sets of care plan documentation were chosen for review. All of them contained evidence of planned care preceded by a pre admission assessment of need. There was evidence of involvement with other healthcare professionals, and care plans were reviewed at least monthly, or when there was an identified need. In one set of care documentation reviewed however, there was no evidence of tissue viability assessment or Nutritional risk assessment. On looking at the computer generated records with the deputy manager it was identified by her, that these assessments had been missed because the part of the computerised documentation identifying service users “at risk”, does not allow for the ones who have tissue viability and nutritional problems, and this must be addressed. Certain care plans showed evidence of care plans for acute conditions, and these are also available in a secure place in the service users own rooms. The deputy manager said occasionally, copies of care plans are sent to the next of kin, after attempts to contact them have failed. This is acceptable practice providing the document has been sent under cover of Post Office special delivery to make sure data protection is not compromised. Manual handling risk assessments are also kept in the service users rooms. One service user is nursed in bed. There was evidence of appropriate pressurerelieving equipment in place, and a record was being kept of her food intake, and fluid intake and output. Staff spoken to said they made a point of going to her room regularly to check on her, as there is no key worker system in place. The medication system was looked at. The home uses a system whereby the medications are pre-prepared by the pharmacist using heat sealed blister packs. The system itself is a safe system, however the practices carried out by the home create the opportunity for potential error. Three service users were case tracked. In all three cases the staff had altered the directions on the MAR (Medication Administration Record) charts. There was no written evidence to confirm drugs had been counted on arrival at the home, as they were not marked on the MAR. One entry on the MAR chart only contained the name of the drug. There was no signature of the nurse making the entry, nor was the frequency of administration or amount of medication to be given documented. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 13 During the tour of the premises staff were seen to be very respectful to service users when speaking to them and to knock on their bedroom doors before going in. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social needs of service users are met and they exercise choice in their daily lives. EVIDENCE: I spoke to a number of residents during the inspection. On the whole they were pleased with how they live their lives at the home. They said they could have visitors at any reasonable time, and could go out of the home unescorted to the local shops, as long as they told the staff where they were going. Although there is no activity organiser employed, two of the care staff have attended a training course on activities for the elderly, and arrange the activities between them. At the time of the visit some of the service users were making Easter cards in the dining room. One said it was good to be kept busy as it “passed the time”. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 15 The deputy manager said activities are provided by the staff on a day-to-day basis, and these are service user led. These are documented in the activities book and on a white board in the home. Menus provided before the inspection identified they were four weekly and rotational. Breakfasts are usually a choice of differently prepared eggs, cereal, porridge or toast, with a full cooked breakfast on Sunday. There is quite a good choice of food available with a choice of meal at the main meal of the day, which is lunchtime. There is also quite a substantial tea and supper, but talking to residents in the dining room, they said if they had breakfast and lunch, they were not always ready for tea, so just had supper. I visited the kitchen. The cook was present and showed me all the records he keeps. These were all in order. There was evidence that fresh vegetables and fresh fruit were used. Although the kitchen was clean there was a smell of stale cooking fat/oil. The cook should consider replacing the cooking fat/oil in the deep fat fryer more regularly, as this was the only drawback to the kitchen. He also showed me the record of the last visit by the Environments Health Inspectors. There were no problems highlighted, and no recommendations made, however the Environmental Health Inspector had left a copy of the New Food standards Agency document. “Safer Food Better Business” which he said he was currently reading through. There was evidence in the PIQ that arrangements were being made for one service users to have advocacy involvement. This is good practice. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that any concerns they might have will be listened to, taken seriously and acted upon. EVIDENCE: The homes complaint procedure is in place and is on view in the hallway. It is clear and easy to follow. However information in the returned survey cards indicated certain people, even though they had never had to complain were not aware of the complaint procedure. They did say however they knew who to complaint to and were satisfied their complaints would be dealt with. The deputy manager told me the home had received one complaint, and due to the problem involved, the manager had contacted the Social Worker for advice. As a result a plan has been set up to deal with what looks as if it might be an on going problem. This is evidence the home handles complaints effectively Service users are encouraged to take part in the local and general elections by having postal votes. The deputy manager told me that any unopened letters are returned to the returning officer. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 17 Copies of the homes adult protection procedures and the local authority multi agency adult protection procedures are kept in the manager’s office. Most staff have received training around abuse and adult protection over the last six months and plans are in place to make sure all staff receive it. It is also advisable that the manager applies to do the local authority two-day managers course about adult protection, so that he can then deliver the training to any new staff. Information regarding planned training, and training attended is however present in the PIQ. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable, clean and well-maintained home that is suitable for their needs. EVIDENCE: The manager has recently employed a new member of the domestic staff. The home was clean, tidy and well maintained. It is furnished and decorated in a comfortable style. Since the last inspection the staff toilet has been redecorated, and was very clean. Decoration had also improved the look on the main staircase area, dining room, cellar store, laundry area and the kitchen. The outside of the building has also been decorated. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 19 Other areas such as the ground floor corridor have been recarpetted, and new vinyl floor covering has been provided in the area outside the kitchen. Two of the bedrooms have also been provided with non-slip vinyl floor covering. Two of the lounges and the kitchen have been rewired and redecorated since the last visit. There are 20 single bedrooms, eleven of which have ensuite bathrooms, and one double room with an ensuite facility. There are three lounge areas, one of which is a quiet room. There is also a visitor’s room. Toilets and bathrooms are to be found near to the lounges. A tour of the home identified quite a few of the bedrooms had been nicely personalised by the service users and contained small items of furniture, wall pictures and ornaments. Other rooms however belonging to those service users with no close relatives looked quite bare and uninviting. The management might consider making them look more homely. The assisted bathroom on the top floor of the home in the extension has an over bath hoist. This has been out of action now for quite a while awaiting the delivery of a new cable. A range of creams belonging to three different service users were seen in this bathroom. These should be stored in the service users room to prevent them being used for the resident they were not prescribed for. It goes against infection control procedures and creates the potential for cross infection to occur. A tub of cream was also found being used in one of the bedrooms. This should have been returned to the pharmacy as it had been prescribed for a service user who no longer lives at the home. There was quite a strong odour in one of the bedrooms on the top floor, the cause of which should be sought, and the odour eliminated. The patio is now a safe place for service users to wander onto, and the gardens were in the process of being tidied up after the winter. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager must provide evidence that recruitment procedures are more thorough, and staff are formally supervised to protect residents. EVIDENCE: On the day of the visit there were 21 service users living at the home. Care staff on duty in the home were present in such numbers as to provide the care the service users needed. Other staff such as one domestic, and one cook were there to make sure the service users had sufficient food to eat, and that they lived in a home that was clean. Usually the manager is present at the home and is supernumerary, except for Tuesdays when he works at home on paperwork. This means that on four days of the week, there are two qualified staff on duty to provide any nursing care the service users need and the day-to-day supervision the staff need. Concern was expressed to the deputy manager however, that there is no supernumerary time for her when she covers when the manager is on annual leave. Although the manager has detailed in the Pre Inspection Questionnaire what staff have had what training, this could not be evidenced, as training records Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 21 were not on the premises and available for inspection. It was highlighted at the last inspection that certain documentation required for the purpose of Inspection were not present on the premises, and this included recruitment documentation. The provider must now take steps to provide the Commission with evidence that any new staff have had all the necessary security checks done before starting work at the home. Information given in the PIQ also says: • • • • • • • • All staff had Fire Safety training in January 06. All staff had food hygiene training in September 06. Four staff had First Aid Training in May 06 Two of the care staff attended Activities in the elderly course in June 06. All staff have received manual handling training December 06. One member of care staff has received training in how to handle violence and aggression. One carer has started the NVQ level 2. The deputy and manger have both attended Care planning in the Elderly in February 06. Details of future training planned in the PIQ is: • • • • Fire Safety training, all staff in January 07. Training in mood disorders/schizophrenia – all care staff January/February 07. 2 care staff to commence NVQ Level 2 January/March 07 and 2 carers to commence the commence the National Induction Programme in January 07. From talking to the deputy and the staff, and looking at the information in the PIQ it was clear that the majority of staff are encouraged to attend training sessions. However, one member of staff told me she had been employed at the home 6 yrs and she had not had training on abuse awareness, no training in how the handle difficult situations, and no training in end of life situations. The manager must also look at the induction provided for any new staff to make sure it is to Skills for Care common induction standards. Also talking to the staff it was clear they need training in Dementia related illnesses, as the information in the PIQ states there are 13 service users with Dementia, as opposed to the 8 who have mental health needs, and this needs building into the training plan for the future. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of residents. EVIDENCE: Highdell has two registered providers, the manager being one of them. He is a registered nurse with a mental health qualification. The deputy manager also has appropriate registration. Mr Pelkowski is hands on at the home four days each week, with the fifth day taken up performing administrative duties. The deputy manager and staff spoken to during the inspection said they could approach the manager at any time with any concerns they might have and that he was keen to take their concerns on board. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 23 Service users spoken to also said he was very approachable. Information received before the inspection in the way of survey cards confirmed all the staff always had time for them and were friendly and helpful. The deputy manager said that staff were receiving formal supervision, however out of the four staff interviewed, only one said she had received formal supervision, and only once from the manager in the ten years she had worked at the home. She had however received other training relevant to mental health conditions, but none on Dementia or end of life situations. On the day of the visit the atmosphere in the home was that of calmness, with staff going about their everyday care tasks. Residents meetings are not held, however the home send out surveys to gain the views of the relatives, on how they see the care their relatives are getting. The provider is agent only for two service users. Copies of accounts were seen and were appropriate. The PIQ said that all appropriate policies and procedures are in place, were reviewed between March 06 and March 07, and that staff aware of them and have ready access to them. These were sampled at random for looking at. Certain policies need amending, these are: • • • The meal planning, although excellent and includes much valuable information about what food is best to be provided and why, needs to include reference to Polish diets. The policy on access to client records needs amending to read CSCI, and The Whistle blowing policy needs to include some information on the action to take if the complaint is against the provider. Accident records are kept. These would benefit from additional information about action taken when service users assault staff members. The accident record seen had been reviewed by the manager, but did not contain the details of the resident. Another accident record seen was regarding a squabble between two service users, when one struck the other. This was not witnessed but the documentation did not sate this, so it was not sure who struck whom. The PIQ said that all maintenance and safety checks are carried out and up to date. Since the last inspection the manager has provided written evidence that substantial risk assessments have been done on the interior and exterior of the building. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 2 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 N/A 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 N/A 3 1 3 3 Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 25 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 Requirement The registered provider must ensure the Statement of Purpose and function for the home contains all the information in Schedule 1 National Minimum Standards For Older People, and forward a copy to the CSCI. Timescale for action 01/06/07 2. OP7 15 Previous timescales 22/03/06 and 25/06/06 unmet The registered Provider must 01/02/08 ensure, a. All staff that prescribe care and update care plans electronically, are provided with appropriate training. This is to make sure that important information is not missed or left out of the care plans, because currently there are two sets of records running side by side, and b. Ensure the electronic system of care recording in place recognises the need for risk assessments where a risk has been DS0000019894.V310926.R01.S.doc Version 5.2 Page 26 Highdell Nursing Home identified by the qualified staff, this is particularly relevant to tissue viability and nutrition. Timescale for b, 01/06/07. 3. OP9 13 The registered provider must ensure the medication system is safe, that all medications are accounted for on arrival to the home and documented on the MAR charts, and that all directions are clearly written in full, and contain the signature of the nurse making the entry. The registered provider must make sure all service users and relatives receive a copy of the homes complaint procedure The registered provider must ensure that all staff are provided with training on abuse and Adult Protection. The registered provider must a. provide evidence to the Commission that robust recruitment procedures are in place to protect the service user, and b. Make sure all records that can reasonable be required for the purpose of inspection are made available to the inspector at inspection visits. Timescale for b for the next inspection. Previous timescale from last inspection not met. The registered provider must a. Ensure staff are provided with training in dementia and b. Develop a training matrix so that training needs are easily identified and who the training is given by, and c. Ensure all induction DS0000019894.V310926.R01.S.doc 01/06/07 4. OP16 22 01/06/07 5. OP18 12 01/07/07 6. OP29 RQN 19 Schedule 3 Reg. 17(1)(a) 01/07/07 7. OP30 18 01/07/07 Highdell Nursing Home Version 5.2 Page 27 8. OP31 9 training complies with Skills For Care common induction standards. The registered manager must have a relevant management qualification Last timescales 17/05/06 and 31/08/06 unmet The registered provider must ensure all care staff receive formal supervision at least every 6 weeks and that this is documented. The registered provider must ensure the policies and procedures identified within the main body of the report are amended accordingly. The registered provider must ensure that all care documentation forwarded to relatives is sent under cover of Post office Special delivery, in accordance with the Data Protection Act 1998 and other statutory requirements. 01/12/07 9. OP36 18(2) 01/07/07 10. OP37 17 01/08/07 11. OP37 17 01/06/07 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. Refer to Standard OP18 Good Practice Recommendations Consider providing the local authority two-day training for the manager regarding Adult Protection. Consider cleaning the deep fat fryer more regularly to prevent smells of old fat/oil in the kitchen after the fryer has been used. Consider providing those service users who have no known next of kin, or those who visit very infrequently with DS0000019894.V310926.R01.S.doc Version 5.2 Page 28 2. 3. OP15 OP23 Highdell Nursing Home 4. OP27 homely decorations in their rooms. Consider providing the deputy/senior nurse with supernumerary time at such times as when the manager is on annual leave. Highdell Nursing Home DS0000019894.V310926.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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