Inspection on 28/10/05 for Highfield Care Home

This inspection was carried out on 28th October 2005.

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

Highfield Care Home 24/05/07

Highfield Care Home 19/07/06

Highfield Care Home 20/02/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Highfield Care Home Bekesbourne Lane Bekesbourne Canterbury Kent CT4 5DX Lead Inspector Wendy Gabriel and Tina Thomas Announced Inspection 28th October 2005 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 Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 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. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highfield Care Home Address Bekesbourne Lane Bekesbourne Canterbury Kent CT4 5DX 01227 831941 01227 832400 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) Ashbourne (Eton) Limited Mario Taherian Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (4) of places Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disability is restricted to those persons whose dates of birth are 17.06.1945, 18.12.1951, 17.01.1945 and 17.04.1950 15.02.05 Date of last inspection Brief Description of the Service: Highfield Care Home is registered to offer nursing and residential care for up to 34 residents. The home is situated on the outskirts of the rural village of Bekesbourne and is within 10 minutes drive of the City of Canterbury. The Acting Manager stated that the four double bedrooms are currently used as single accommodation. The surrounding gardens are well maintained and there is plentiful parking to the side of the premises. Access to the grounds is suitable for wheelchair use. Public transport is limited to the mainline railway station within approximately 15 minutes walking distance. The two storey building has the benefit of a shaft lift to the 3 bedrooms on the first floor. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection and interviews with staff and some residents and a family member was undertaken over two days. The two inspectors met the Deputy Manager, Acting Manager and Regional Manager and discussed recent Adult protection issues concerning the home. The Inspectors were pleased to be informed that the company had taken note of the issues raised and were methodically undertaking the necessary changes that had been identified then as necessary to meet the National Minimum Standards. A number of requirements and recommendations were made and were agreed on. Some involved the ongoing maintenance of the home and the Inspectors noted from records seen, that the home had previously identified certain electrical concerns and hot water concerns and had sought appropriate engineers to remedy these. Although checks and work had been recently undertaken, the problems were still occurring. The kitchen management is subcontracted by Ashbourne (Eaton) Ltd the new company that now owns Highfields. Some residents had made comments that the meals were sometimes late and not thoroughly enjoyed, however, they stated that there had been some improvements to the meals since the comments were made. The Acting Manager is reviewing the subcontracting procedure. The laundry system has been improved by the employment of a dedicated laundry person. The Acting Manager said that further hours had been made available and another person will also be employed to ensure the laundry shifts are covered over 7 days. The Regional Manager confirmed that the company had taken very seriously the issues raised at the adult protection meeting including mistakes and lack of regular reviews in care plans. Some work is still to be done on these as identified in the report, but the home is methodically reviewing all the care plans. The Acting Manager stated that the staff files did not all contain the appropriate information required by the National Minimum Standards and that the home was currently in the process of obtaining the missing documents. Staff confirmed that training is ongoing and there was evidence of notices to staff for training courses. The new company has a human resources department and the Acting Manager said that recruitment and training is now undertaken through them and is much more vigorous than the previous system. The home has the benefit of an activities person for five days a week from 10am to 4pm. Residents were undertaking a variety of activities when the Inspectors toured the premises and some residents confirmed to the Inspector that they enjoyed the various occupations offered. A Halloween party had also been arranged for the afternoon. A relative told the Inspectors that staff were always friendly and welcoming. The Inspectors were also told there was a book where maintenance messages could be left and that if he wrote anything in there it would have been sorted out by the following day. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 6 Written comments to the Inspector from some residents and families stated that sometimes there was not enough staff on duty. One member of staff said that the home would always try to cover any vacant shifts. Staff said that the management were supportive and one said that the new Deputy Manager was ‘lovely’. Water temperatures in a sluice room and a bathroom were tested and found to be excessively high and an immediate requirement was made for this to be made safe. The Regional manager actioned this at the time. During the inspection it was noted that the rapport between staff and residents was friendly and comfortable. Residents were dressed appropriately for the time of year and were seen freely accessing various communal areas of the home. One resident said that she preferred to take her meals in her room and that this was no problem for the staff. The home was clean, warm and free from unpleasant odours. The Inspectors would like to thank the management and staff for their hospitality during the inspection. What the service does well: What has improved since the last inspection? The laundry system as indicated above has improved. Meals have improved and are expected to improve further when discussions have taken place regarding the subcontracting of the kitchen. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 7 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. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 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 Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2.3.4.5 Residents receive a written contract or statement of terms and conditions. Pre-admission assessments ensure residents know their needs can be met. Residents may visit the home to assess the facilities prior to admission. EVIDENCE: Although the statement of purpose and service users guide were not inspected at this time the Inspectors remind the Registered Provider to ensure these are kept up to date with any changes made to the home. Residents receive a written statement of terms and conditions or contract. Pre-admission assessments are undertaken by the home and care managers for prospective residents. Wherever possible, prospective residents and their families are invited to visit the home prior to admission to assess the home and its facilities. Some residents occasionally stay in the home for short-term care, but an Inspector at a previous inspection has been informed that intermediate care is not undertaken. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. People who live in the home have a plan of care which sets out their health, personal and social care needs. Service users physical health care needs are fully met, their psychological needs are not. The home has policies and procedures pertaining to safe practice in the administration of medication. People that are able to, are encouraged to be responsible for their own medication, however this is not within a safe risk management framework. Residents’ privacy is compromised by not having locks on bedroom doors, or lockable facilities within. EVIDENCE: The home has well formatted care plans. The home has worked with a primary care trust nurse advisor (Judith Rawlings) to improve care plans and to improve staff understanding and ability to be involved in effective care planning. Recently it was identified that there were deficits in the quality, recording and reviewing of some care plans. The group have actively ensured, these care Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 11 plans have now all been reviewed. The group are pleased that this was identified as a part of a wider quality assurance measure. The inspector/s viewed the care plans of five people that live in the home and found them to be generally of good quality. One persons care plan indicates that there has been a decline in their cognitive ability. Their manual handling risk assessment states ‘ confused, disoriented, forgetful and aggressive at times.’ Their cognitive decline has not been suitably investigated or monitored. A requirement has been made that the psychological health of people living in the home is monitored regularly and preventative and restorative care provided. It came to the attention of the inspector/s that another person was admitted with the knowledge that they had dementia. The home is not registered to deliver care to people with dementia, neither is it described in their statement of purpose. Whilst this person also has nursing needs, these do not ‘outweigh’ their mental health needs. Regardless of their nursing needs their mental health needs continue to exist and therefore the home must seek a variation for this service user and any others out of the homes category of registration. Requirement made regarding this matter (Requirement 2 Part A) The inspector also viewed a care plan for a service user with a known learning disability; once again the home must seek a variation to its registration, to show that they are able to best meet this persons needs. Both service users mentioned above, and the home, were receiving suitable support and clinical guidance from outside agencies regarding these peoples needs. There was no evidence to show that people living in the home had been involved with their care planning. A good practice recommendation that people sign agreement of their care plans has been made. (Recommendation 1 part A) The inspector/s viewed a number of suitable risk assessments that are in place to ensure as far as reasonably practicable the safety of people living in the home. However, the inspector/s found that manual handling risk assessments did not fully describe to staff how to safely move people that live in the home. For example: one risk assessment described that 2 carers were needed to use a hoist. It did not describe which type of hoist, which sling to use with it, or any specific way to approach the person being hoisted. The inspector/s also noted that although the home has a good nutritional screening tool one of the five viewed was incorrectly completed. The body mass index of an obese person was recorded as being within normal limits. This effects the overall scoring. When cross referenced with the persons ‘Index of problems and needs’ obesity is not highlighted. Requirement made regarding this matter. (Requirement 3 Part A.). Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 12 The inspector/s also observed that one person who used their own kettle did not have a risk assessment regarding this. The inspector/s observed that all the people living in the home were appropriately dressed. Oral and personal hygiene had been addressed. The inspector/s were told that there were two people in the home that had pressure sores. These sores did not originate at the home. Care plans showed good evidence, written and pictorial, of the care given and success in the gradual healing of these sores. Service users are assessed, by a person trained to do so, to identify those service users who have developed, or are at risk of developing, pressure sores and appropriate intervention is recorded in the plan of care. Equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is provided. The registered person ensures that there is a policy and staff adhere to procedures, for the receipt, recording, storage, handling, administration and disposal of medicines. Only qualified staff administer medication. The home receives its medication mostly pre- packed in monitored dosage systems. The inspector/s viewed the controlled drugs books and cross-referenced it to medication returned to the pharmacy and found that the quantities tallied. Service users are able to take responsibility for their own medication if they wish; however the inspectors found no risk management framework within the care plan of one person who self medicated. Requirement made regarding this matter (Requirement 4 Part A) Not all bedroom doors had locks and the Acting Manager said residents had been asked about this at a meeting and had chosen not to have them provided. A recommendation was made for locks to be put on the doors or that when a bedroom became vacant a requirement would be made for a lock to be put on the door. The Inspectors required that lockable facilities be provided in bedrooms. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 13 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): 12.13.15. Residents are enabled to exercise choice and control over their lives. Family and community contact is maintained as appropriate. The home has made progress in providing nourishing meals at a time to suit residents. EVIDENCE: A range of activities is made available to residents and both residents and staff confirmed that some outings are undertaken. Families are welcomed into the home and invited to join in various events. A Halloween party took place during the afternoon of the inspection and staff had decorated the lounge where it took place. A sign inviting non residents to join an ‘outreach clinic’ in the home and to join in meals and activities was seen and the Inspectors required that this be removed as it would compromise the registration of the home and be intrusive in the lives of the residents. The Acting Manager said that this had never been taken up to the best of her knowledge and agreed to remove the notices. The company has a quality assurance programme to audit different aspects of the home. A resident confirmed that monthly residents meetings take place. It has previously been reported that there was little response by residents to questionnaires given to them by the home. The Acting Manager stated she is to have a meeting with the company that is subcontracted to manage the kitchen as, although menus and meals provided Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 14 have improved recently according to residents who commented on this to the Inspectors. The Acting Manager wishes to ensure services provided are of the very best quality for the residents. The Inspectors saw a very good variety of fresh vegetables and fruit, fresh meat, frozen and dried food stored appropriately in the home. Fridge and freezer temperatures were maintained. The kitchen door is locked via a numbered system to ensure health and safety of residents. The dining room is light, attractive and welcoming and tables set for dinner included linen cloths and napkins. The Acting Manager confirmed this is always maintained. The dining room did not have enough tables for all the residents but the Acting Manager said that many residents wished to always take their meals in their rooms. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 15 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. Residents know their complaints will be listened to. Company procedures are in place to protect residents from abuse. EVIDENCE: Staff who spoke to the Inspector were able to confirm they understood adult abuse and what actions they should take if they had any concerns or complaints to make. The home operates an adult protection procedure. Understanding abuse training is included in the NVQ undertaken by some staff. The home operates a complaints procedure that identifies actions to be taken if a complaint is made. Staff also told the Inspector that they would have no hesitation in ‘whistle blowing’ should the need arise. A resident said she would know who to speak to if she had a concern and a family member said he had had no complaints but would feel confident talking to the staff or Deputy Manager if he had a complaint to make. The Acting Manager said that the company has a computerised system for recording complaints and for dealing with any concerns raised including a time scale. The Deputy Manager agreed to display a complaint procedure notice in the entrance hall. During the year the home had reported instances of theft to the police and the CSCI. To the best of their knowledge the Acting Manager and the Regional manager believed this was now resolved. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.23.24.25.26. Residents live in an environment where although there is some ongoing maintenance work to be completed, routine maintenance is identified and undertaken. Communal indoor and outdoor facilities are easily accessible by residents. There are sufficient lavatories and washing facilities. Residents’ bedrooms are comfortable and contain their personal possessions. The home is clean and hygienic. EVIDENCE: Although there was written evidence that the home had identified and reported maintenance concerns and had had work undertaken by appropriate engineers; there were still ongoing problems with the temperature of hot water in some areas and with emergency lighting. The Regional Manager and the Acting Manager said they were arranging for the engineers to return to identify and remedy the problems. A requirement was made for this work to be undertaken satisfactorily. Evidence was seen of a forthcoming visit by a suitably qualified electrician to undertake a maintenance check of the premises on the 1st November 2005. A requirement was made for maintenance work to Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 17 be undertaken as identified by a recent lift and hoist engineers report. A hoist in the upstairs bathroom is not to be used unless re-sited, as it is unsuitable for safe use. A member of staff later stated that that bathroom is not used. Eighteen bedrooms have en-suite toilets and washbasins. One bathroom and a sluice had excessively high water temperature and an immediate requirement was made for this to be made safe and the Regional Manager actioned this. There are 3 bathrooms and a shower room in the home, however, on the day of the inspection one bathroom had a large amount of boxed storage in making it unusable and another had portable hoists stored in making access to a sink and grab rail by the toilet difficult for any resident to use without having to move the hoists. A requirement was made for both of these to be made free of storage for resident ease of access and safety. The laundry room was clean and had suitable machines for washing at high temperatures and the new laundry assistant has solved the associated problems previously commented on by residents. A resident commented that the laundry assistant was very friendly and took time to speak to them individually, for example to check where they wished their clean and aired laundry to be stored in their bedrooms. This was welcomed by the home as good practice. The home has comfortable communal facilities and the garden is accessible for wheelchair users. Some bedrooms were seen during the inspection and were noted to contain residents’ personal possessions that made them individual and homely. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.29. Recruitment practices require attention to provide protection and support to residents. Residents will benefit from staffing needs being regularly assessed. EVIDENCE: Some comments were received by the Inspector from residents and some family members that they considered there were not always enough staff on duty. Some staff said as many of the residents now needed two members of staff to manage their needs appropriately; they felt that an extra member of staff would be a benefit. The rota included at the weekends 1 RGN, 6 carers, 1 domestic cleaner and 1 cook. The Deputy Manager stated she is on call at the weekends and the Inspector advised that she ensures when she is off duty she has free time from being on call. During the week there are 3 RGNs, 2 senior carers and 3 carers on duty plus 2 domestic cleaners, cook and maintenance man and activities person. There is 1 RGN and 2 carers on duty at night. A gardener is also employed part time by the home. The Inspector recommends that the home continually assess the residents to ensure enough qualified and unqualified staff is available to meet their changing needs. Recruitment was not inspected at this time as the Acting Manager said they had discovered that staff files did not contain all the pertinent documents indicated by the National Minimum Standards. The Acting Manager confirmed that the Companies Human Resources department was dealing with this and actively obtaining the paperwork needed. A requirement was made for this to Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 19 be completed and for new staff to have the documents in place prior to being employed. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32.33.36.37.38. Resident’s benefit from the ethos and leadership of the home. Residents know the home is run in their best interests. Residents’ benefit from staff being regularly supervised. Record keeping does not safeguard the residents’ best interests. Residents’ health safety and welfare is compromised by ongoing maintenance needs. EVIDENCE: The Regional Manager, Acting Manager and Deputy Manager discussed current changes taking place in the home with the Inspectors and indicated their commitment to the management of the home during this time. All three managers have a good understanding of the areas that the home needs to improve. This was supported by comments from staff, residents and a visitor. The management have sought advice from suitable professionals to improve care plans in response to recent Adult Protection findings and these are being methodically reviewed. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 21 The Acting Manager stated that the home does not undertake advocacy for any resident and that cash held for some residents was for minimal amounts. Access to electrical and water tanks situated above the ceiling in a down stairs corridor is limited and with little space for work to be undertaken. The attic has a ½ size ladder to attach to the fixed stair to the attic entrance but blocks a fire exit when in use. The Inspectors appreciate that this is part of the building inherited by the Company but make a requirement for the Company to seek safe working practises for these areas. The outside steps from the fire exit to the ground floor require maintenance to stop them being slippery. The maintenance man confirmed he had planned for this and has the appropriate items ready to undertake this. There is an annual maintenance diary in operation that identifies work to be undertaken and when it was completed. The fire book was in date. The most recent fire drill was undertaken on 27th October 2005. The fire risk assessment was out of date by 8 months and the Inspectors made a requirement for this to be reviewed. Staff confirmed they receive regular supervision. The home has an up to date insurance policy. There are some windows in the home that have slatted sections. Although they are attractive and offer restricted openings for safety, the Inspectors recommend they be assessed for security as there may be a possibility of them being removed from the outside. There are fire notices in each bedroom and the Acting Manager agreed to put them in a simple format for residents to read and understand. Not all doors in the home had auto closers, a requirement was made for this for fire safety. Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x 2 x 3 3 2 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 x 3 x 3 2 2 Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 6 7 8 9 10 11 Standard OP38 OP38 OP38 OP25 OP29 OP21 OP21 OP19 OP13 OP10 OP9 Regulation 23 23 23 23 19 23 23 23 12 10 12. 2 13. 7 13 4b 4c Requirement Fire risk assessment to be updated. Outside fire exit steps to be maintained. Safe working practices to be identified for areas discussed. Water temperatures to be made safe in identified areas. Recruitment practices to meet National Minimum Standards. Hoist in upstairs bathroom not to be used unless appropriately resited. Bathrooms as identified, to be cleared of storage for safe access. Maintenance work as identified by engineers to be complied with. Outreach clinic facility to cease with immediate effect. Lockable facilities to be provided in bedrooms. Service users are able to take responsibility for their own medication if they wish, within a risk management framework. Information in risk assessments should be accurately recorded. A DS0000065782.V258968.R01.S.doc Timescale for action 01/01/06 01/01/06 01/01/06 28/11/05 01/12/05 28/11/05 01/12/05 01/12/05 28/10/05 01/12/05 21/11/05 12 OP7 21/11/05 Highfield Care Home Version 5.0 Page 24 13 OP8 12 1a 14 OP8 12 1a 13b safe system of work should be identified. All Service users must be within 21/11/05 the homes registered category and Statement of Purpose. Variations must be sought for those that are not, and the statement of purpose amended to reflect any changes The psychological health of 21/11/05 people living in the home is monitored regularly and preventative and restorative care provided. 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 Refer to Standard 38 27 10 7 Good Practice Recommendations Slatted windows to be assessed for security. Numbers of staff on duty to be regularly assessed to meet needs of residents. Locks be put on the doors where possible and this would become a requirement as rooms became vacant. Service users should sign agreement of their care plans Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Highfield Care Home DS0000065782.V258968.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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