Inspection on 19/05/08 for Highfield

This inspection was carried out on 19th May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Highfield Dunns Lane Dordon Nr Tamworth Staffordshire B78 1RS Lead Inspector Mandy Brassington Unannounced Inspection 19th May 2008 09:45 Highfield DS0000071230.V364495.R01.S.doc Version 5.2 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 Highfield DS0000071230.V364495.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 Adults 18-65. 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. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Address Dunns Lane Dordon Nr Tamworth Staffordshire B78 1RS 01827 892882 01827 892500 stewartharrison2@aol.com 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) Polesworth Group Homes Limited Stewart John Harrison Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of care only: Care Home (Code PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 5 of the following age range: The minimum age on admission will be from 40 years of age 2. The maximum number of service users to be accommodated is 5. Date of last inspection New Service Brief Description of the Service: Highfields is a purpose built bungalow towards the end of a quiet lane leading to rural surroundings. The house was designed to be able to support people as they matured, so the home could accommodate mobility equipment if required. The bungalow is deceptively large. There is an office and sleep in room off the entrance hall, which leads to a spacious corridor. All five bedrooms have full en-suite facilities. There is a separate utility room, a guest toilet, a well-equipped modern kitchen, and a large lounge leading to a spacious conservatory with dining facilities. There are French doors opening onto a large garden, which is mainly grassed with a patio area and garden furniture, and external lighting. The home is close to local shops and amenities and has good access to public transport. The home is able to provide accommodation to five people with a learning disability. People are supported by a small team of staff, and assisted to Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 5 participate in community activities. The organisation has some day care provision within the local area and people participate in craft activities and learning living skills. Each day, activities are organised flexibly according to the needs and desires of people in the home. The Service User Guide on 19 May 2008 recorded that the weekly fee level for the home was £633.16. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. This visit was an unannounced key inspection and therefore covered the core standards. This was the first inspection of the service, which was registered in January 2008. The inspection took place over 7.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. There were questionnaires sent to people who use the service, professionals and staff members. Three completed surveys were retuned by people who used the service and one survey from staff. On the day of the inspection, the home was accommodating five people. We, the commission examined records, carried out indirect observation of five people who used the service, and four staff on duty. Three care plans and three staff records were examined and observation of daily events took place. A tour of the home was undertaken. Inspection of the storage system and medication procedures was inspected. What the service does well: The home has been built to a very high standard, with large rooms and modern facilities. Two people were already living in another home in the organisation, and their needs and support were considered when designing the home, so it was built around how they could be supported. The home is a bungalow and the service hopes to be able to change and adapt to people’s needs as they grow older, to enable individuals to continue to live there. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 7 When moving into the home people are able to choose how they would like their room and have been making craft items, buying a television, a stereo and tapes and putting pictures and photographs around the home. Each bedroom is different but all have an en-suite toilet and shower facilities. The organisation has other homes within the area and provides some day activities for people to attend. There is a craft centre and a home where people can choose to learn living skills. People like going to the craft activities so the service provider is arranging for more sessions to be provided. Individuals are able to choose how to spend their days. This can be listening to music, watching television, playing football in the garden or going out shopping, bowling or the cinema. People are able to meet up with friends and family for social activities. In the home, individuals are supported to join in all household activities. This includes cooking and cleaning, planning meals and preparing the table. Individuals decide what they want to eat at each meal time, and if they need some food items they go to local shops so the meal can be cooked. Everybody eats together including staff, and meal times are a social event. Staff at the home support people sensitively with personal care. Everybody wore smart clean clothes, and had a range of clothes to choose from including accessories to match outfits. Staff helped people to apply make up and nail varnish. Staff at the home have received training so they can support people and help them to achieve additional skills. Staff were seen to work closely with people and give individuals a lot of support and encouragement to do things independently. What has improved since the last inspection? This was the first inspection of the service. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 8 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. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions only take place after a comprehensive assessment has been completed, so the home can make a decision about how it is able to support people. Individuals are able to spend time in the home and visit on many occasions before deciding whether they would like to move in. EVIDENCE: The home was registered in January 2008 and two people had been identified to move to the home from another service within the Organisation. A large number of staff also transferred across with individuals to provide continuity of care. People had a copy of the Statement of Purpose and Service user Guide, which had been developed with pictorial support and photographs. The Guide included details of the terms and conditions of occupancy and fee level. The manager reported that when additional information about the persons likes and daily routines had been established, the guide would be personalised to reflect Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 11 this information. One Guide contained photographs of activities the person preferred to participate in, and information about his daily routine. Individuals were able to visit the home prior to opening and were supported to choose a room to meet their needs. Family members had been included in the introduction to the home. We examined three personal files, which demonstrated that each person had a contract, and a community care assessment had been completed for people moving from the community. It was agreed that for two people moving from another home within the organisation, the placing authority would oversee the transfer process. The home provides day care for one individual; the person also receives a service from the small domiciliary service managed by the organisation. Two people who moved from another home had an existing relationship with this individual. Information regarding day care provision needs to be included within the Statement of Purpose and reflect how support is provided within the staffing of the home. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plan is individual to the person and focuses on strengths and personal preferences. With support, the person is helped to understand the information, which is regularly reviewed so it is up to date. EVIDENCE: Each person has a detailed person centred plan, which includes information about personal history and family, the person’s usual routine, and a personal profile. There is a daily plan for usual activities, which is also included in some Service User Guide. The plan includes photographs of activities and pictorial support. One person may exhibit complex behaviour and discussion with the manager and staff demonstrated that people were aware of the behaviour and how to Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 13 manage this. It is recommended that behavioural management guidelines be recorded and included within the plan of care, to ensure consistency and to support monitoring the management strategy. Personal risk assessments records the level of risk and how to support the person. The assessments cover Epilepsy, mobility, health, night time assistance and mobility. Discussion with staff revealed that people were aware of risks within the home and the community and were supported to take responsible risks under supervision. People were supported to make decisions about all aspects of their life. The manager reported within the AQAA that where major decisions were made, people were supported by professionals and had access to an advocacy service. One person received support for communicating with significant people and a record of the decision-making process and possible implications was maintained in the home. Throughout the visit, staff were observed providing people with opportunities to make choices about daily activities. Upon arrival a trip had been planned ten pin bowling, one person had chosen to not to participate and this was respected. The AQAA recorded that people who used the service are encouraged to be actively involved in the running of the home. Two people like to lay and clear the table, and staff ensure that each person is given every opportunity to do so. During lunch people were supported to particpate in preparation and clearing away. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can make choices in all areas of their life and have opportunities to join in with social and recreational activities. Personal relationships are encouraged and people are can develop and maintain existing relationships. EVIDENCE: The manager reported within the AQAA that the home provides a variety of activites throughout the week suited to individual needs, including the use of local facilities. The home provides its own day care programme, which includes bowling, swimming, meals, shopping and cinema. On the day of the visit, three people went bowling and met with other people from homes within the organisation. Staff reported that social events for all homes are organised Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 15 on a regular basis, to enable people to maintain existing friendships. The manager reported that people who use the service access craft sessions, which are held at the craft room located within another of the homes. People spoke enthusiastically regarding the craft sessions, and one person showed a jewel box that had been made. Staff stated that where possible local facilities are used. One person has started to use a local hairdressors. The managers encourages people to buy fresh produce from farm shops and local butchers. Within the AQAA the manager reported that ‘as a company, we place a very high emphasis on the quality and varity of meals prepared. All our meat, for example, is purchased directly from a high quality butcher. We actively encourage staff to access local farm shops for fresh fruit and vegetables’. Meals are chosen on a daily basis. On the day of the visit, lunch was served in the dining room and people had chosen sanwiches or a jacket potatoe. A range of yoghurts and puddings were displayed on the table for people to choose from. After the meal two people helped to clear away. Throughout the meal everybody was included in conversation and where people required support this was sensitively given. People are supported to maintain relationships with family and friends. The organisation has several homes within the area, and staff reported that people have good reationships with others, therefore some activities are organised jointly to enable people to retain these friendships. Family members are encouraged to continue to play an important role in the person’s life, and there are no restrictions on visiting. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to access healthcare services, and are encouraged to have regular appointments and visit local health care services, to ensure their wellbeing. EVIDENCE: Plans of care recorded health care needs and how people were to be supported. Four people receive support from health care professionals for issues relating to dementia and complex behaviour. Upon arrival at the home most of the staff team were receiving training from a health care specialist, to help staff support one person with a specific diagnosed condition. Each person is registered with a local General Practitioner. The manager reported within the AQAA that upon admission, the new service users received Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 17 a health check before being formally registered with the local GP practice. Plans of care included details of all appointments and reviews with health care professionals and details of outcomes of any intervention or meeting. Observations of practices demonstrated that staff supported people in a manner to which they were comfortable. Discussion with staff revealed that they had an in-depth knowledge of how to support each individual. Staff were seen to be sensitive to individual’s needs. Discussion with staff revealed people were aware of how to support people with different faiths, and would enable people to develop personal relationships with a companion of their choice, irrespective of gender. People using the service were able to dress in a style of their choosing. Everybody was clean and well presented. One person said ‘ I like to look nice’ and was enthusiastic to show her co-ordinating clothes, jewellery, make up and nail care. Medicines are stored in a locked cupboard and the Monitored Dosage System is used. The Medication Administration Records (MAR) include a photograph of each person. The MAR Folder also contains details of each medicine, what it is used for and any possible side effects. There are details of staff who have received training for safe administration of medication, along with their signature and initials. A small number of entries on the MAR sheets were handwritten. It is reccommended that where there are any hand written entries, two people sign to ensure accuracy. One tablet was signed for prior to observing the medicine being administered; it is reccommended that the principles of safe practices of administration be reviewed to ensure that an entry is recorded after administration. Each person receiving a service signs an agreement for consent to adminsiter medication; this is contained in their personal file. Where people have complex needs and may need ‘as required’ (p.r.n.) medication, there is a protocol in place to guide staff. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure that is clearly written and is available with picture symbols, and everyone living at the home has a copy. The staff understand the procedures for Safeguarding Adults and have a good knowledge of how to respond to an alert to protect people. EVIDENCE: The Complaints procedure is written with the support of pictorial symbols and a copy was available in the Service User Guide. The form also included the names of the person’s Key worker and the Director of the organisation along with a photograph, who they may prefer to make aware of any concerns. Discussion with people who use the service revealed that everybody felt safe in the home and knew they could speak to somebody if they weren’t happy. People also have access to an advocacy service. There have been no complaints received by us, since the home opened in January 2008. Staff have received training for safeguarding people, which staff stated included types of abuse and how to respond to any alert. The home has a Whistle blowing Policy which staff were aware of. One staff said ‘ I wouldn’t Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 19 have a problem dealing with something I knew was wrong, and I know I’d be supported.’ Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are encouraged to see the home as their own. The home is a very pleasant, safe place to live. EVIDENCE: Highfields is a purpose built bungalow towards the end of a quiet lane leading to rural surroundings. The house was designed to be able to support people as they matured, so the home could accommodate mobility equipment if required. The bungalow is deceptively large. There is an office and sleep in room off the entrance hall, which leads to a spacious corridor. All five bedrooms have full en-suite facilities. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 21 There is a separate utility room, a guest toilet, a well-equipped modern kitchen, a large leading to a spacious conservatory with dining facilities. There are French doors leading to a large garden, which is mainly grassed. There is a patio with garden furniture and external lighting. The home is close to local shops and amenities and has good access to public transport. The home has been furnished and decorated to a high standard. People are able to personalise their rooms and the manager reported that there are plans to put photographs of people, family and events in the home and more pictures. At the six-month review people will have an opportunity to discuss the home including personalising their room and redecorating. Discussion with people revealed they liked their new home and one person firmly stated, ‘this is my home and I’m going to stay here for ever’. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment procedure to protect people living in the home. Staff receive a thorough induction to the home and on-going training to enable them to support people who use the service. EVIDENCE: The home operates two day shifts and a night shift. During the day two staff are on duty on each shift and the manager works flexibly across the shifts. At night time one member of staff sleeps in. Domestic staff provide support each week day in the home, and also work as carers. The manager confirmed that this was the usual pattern of shifts; staff from within the home covered any additional shifts to ensure continuity of care. Where a specific activity had been planned, additional staffing could be provided in line with any assessment of risk. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 23 Three staff records were examined which demonstrated that the organisation has robust recruitment practices. All records included a photograph, an application form, two written references, a Protection of Vulnerable Adults (PoVA first) check and a Criminal Records Bureau Check (CRB). Staff receive an induction to the home and are able to work in a supervised capacity. Staff reported, ‘this gives you the confidence to be able to do your job.’ Many of the staff working at the home have transferred from an existing home where two of the people who use the service lived. Staff stated, ‘this is better for people as it means we already knew them, and could help with the move.’ On the day of the visit, most of the staff were receiving training for a specific diagnosis of one person. Upon their return, staff reported that the training had provided them with the knowledge about the condition, and how to support the person, including how sentences should be phrased and words used to support communication. Staff reported that they were able to attend regular training updates including safe administration of medicines, health and safety, moving and handling, fire training, and food hygiene. Responses in the completed surveys demonstrated that people who use the service have confidence in the staff who care for them, as staff are responsive and always available. People know whom they can talk to if they are not happy and people reported that staff always treat them well. Discussion with staff and from observation of daily events revealed that people were sensitively supported and given opportunities to be involved in the general running of the home and provided with everyday choices. People reported they felt safe with staff and one person demonstrated how they would summons staff support if they needed help. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear understanding of the principles and focus of the service and manages the home to support people’s individuals’ needs. EVIDENCE: Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 25 It is evident from observation and discussion with staff, that the manager is extremely enthusiastic and committed to promoting people’s rights and providing a quality service. The manager is person-centred in his approach and open and transparent in all areas of managing the home. Staff commented they felt valued and part of a supportive team and would have no hesitation approaching the manager. The manager is experienced, and is also the registered manager of other homes within the organisation including a small domiciliary service. Staff reported they felt they were valued within the organisation and recognition of obtaining a National Vocational Qualification resulted in a review of contract, and after a period of five years, staff were entitled to additional days leave. Prior to the Inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. The AQAA contained clear, relevant information that was supported by a wide range of evidence. The AQAA identified the changes they have made since opening, and where they still need to make improvements. Evidence within the AQAA was sampled and found to be accurate. The organisation has an Annual General Meeting and carers are invited to attend. The manager reported that people are able to speak openly and it is used as an opportunity to discuss the quality of the service. There are quality surveys for each person, relatives and professionals to complete on an annual basis. The manager stated that as this is a new service, people would be given this opportunity over the next few months. All environmental work and testing was completed as part of the registration process and checked by us prior to the registration the home. This will be reviewed on the next visit to ensure the property is suitably maintained. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 4 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA1 YA6 YA20 YA20 YA24 Good Practice Recommendations To include information relating to Day Care Provision within the Statement of Purpose To record management support guidelines within the plan of care, to enable staff to provide a consistent approach to managing complex behaviour All hand written entries to be recorded and signed for by two people to ensure accuracy Medicines to be signed for after administration to demonstrate these have been administered To continue to personalise and decorate areas of the home including people’s bedrooms in a style of their choosing. Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Highfield DS0000071230.V364495.R01.S.doc Version 5.2 Page 29 - 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. 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