Inspection on 29/04/05 for Highfield Grange

This inspection was carried out on 29th April 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 Grange 14/01/08

Highfield Grange 16/01/07

Highfield Grange 27/07/06

Highfield Grange 29/11/05

Highfield Grange 04/01/05

Highfield Grange 19/05/04

Highfield Grange 09/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Highfield Grange John Street Wombwell Barnsley S73 8LW Lead Inspector Jayne White Unannounced 29 April, 2005 08:30am 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 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 Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highfield Grange Address John Street Wombwell Barnsley S73 8LW 01226 341123 01226 756986 None Barnsley Primary Care Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Christine Thickett PC Care Home Only 40 Category(ies) of OP Old age (40) registration, with number of places Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The ten single bedrooms with a partition screen must be used as double bedrooms. The occupants of these double rooms must be given the option to move to single bedrooms when available. 2. Flats 1, 2 & 5 must be used for intermediate care only. 3. Flats 3 & 4 must be used for long-term care/short stay only. 4. Staffing levels must be maintained at, at least, the minimum levels required by the April 2002 published `Residential Forum, Care Staffing in Care Homes for Older People` by 1/5/2003. These levels do not include managerial, nursing, administrative or ancillary hours which must be over and above these levels. 5. The area used for day care must be available for use by the home`s service users from 1600hrs to 0700hrs, Monday to Friday and at all times Saturdays and Sundays. 6. The registered manager works 5 days (37 hours) per week as the registered manager. Date of last inspection 4th January 2005 Brief Description of the Service: Highfield Grange is a care home providing personal care and accommodation for 40 older people. Sixteen of those places are registered for long and short stay residents and twenty four for intermediate care, however, the philosophy of the home is now such that all admissions are for intermediate or short stay residents. The homes registered provider is Barnsley Primary Care Trust. Highfield Grange is situated off John Street, Wombwell, Barnsley. Wombwell town centre has various shops and is a short distance from the home. Main bus services run close to the home. The home is all on one level. The home is registered for thirty single and five double bedrooms. The home stands in its own grounds and has a garden area that is accessible to service users. There are car-parking facilities. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven and a quarter hours from 8:30 to 15:45. Opportunity was taken to make a partial tour of the premises, inspect a sample of records, observe care practices and talk to residents and staff. The manager was available for parts of the inspection; therefore some standards were either not inspected or partially inspected. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to two of the staff on duty about their knowledge, skills and experiences of working at the home and seven of the twenty nine residents about their views on aspects of living at the home. It was noted that residents’ were being admitted to the home that were outside the home’s registration category. This was discussed with Amanda Lindley, regulation manager at the CSCI who was aware of the admission and discussions were taking place between the CSCI and PCT. Some previous requirements have been reviewed and removed in further discussions within the CSCI in consideration of the homes philosophy of admitting only intermediate and short stay residents. What the service does well: All residents that were spoken to said their needs were met and they were happy with the care offered to them. Residents who were admitted to the home for intermediate care were helped to maximise their independence and return home. All residents’ spoken to said that staff were very good, kind and considerate and that their privacy and dignity was observed and their personal care needs were met. Residents’ said the food served was of a good quality and this was served in a pleasant dining area. The home was clean and on the whole well maintained and the residents’ that were spoken to were happy with their living environment. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Information contained in the statement of purpose/service user guide continues to require amendment to ensure residents are provided with details about the home that are correct. This must be provided to residents prior to their admission so that they have information about the home. Their admission would also be better managed if they were able to meet a member of staff from the home prior to their admission to discuss the daily routines of the home, for example, that a different choice at meal times will be offered if required. The care plans contained a range of required information and more detail had been added on the action to be taken by care staff to ensure residents’ needs were met, however, the daily report did not consistently demonstrate that the action taken correlated with the action required and there were gaps in information that had been identified in the care plan that needed recording. In addition there was inconsistency in the provision of risk assessments and lack of detail in regard to residents wishes for death and dying, religion and social/leisure needs. More care is required to ensure the medication record demonstrates medication is administered as required, medication received into the home is recorded accurately and supplement drinks are treated as medication and recorded and stored as such. Although no resident had any complaints and said they would complain if necessary the procedure to explain the process for doing so still did not include details of the CSCI. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 7 The record maintained to demonstrate the water temperatures needs expanding to include the action taken to maintain the safety of residents’ in regard to water temperatures. To demonstrate residents’ needs are met by sufficient staffing levels using the residential staffing forum, this needs to be completed at required intervals to ensure it is up to date, fully completed and that the care staff hours provided are calculated to demonstrate compliance with the identified figure. The training plan needs reassessing to identify how the recommended number of staff who hold NVQ Level 2 or equivalent is to be achieved. There had been no improvements in visits to the home made by the registered provider. Although staff said they were supervised it was not at the frequency recommended in the standards (6 months). 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 Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 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 standard(s) 1, 3, 5 & 6 Information contained in the statement of purpose/service user guide continues to require amendment. The information of the assessed needs of the residents had improved, however, the residents did not receive information about the home prior to admission and no staff at the home met the resident before their admission. Residents who were admitted to the home for intermediate care were helped to maximise their independence and return home. EVIDENCE: The statement of purpose/service user guide still required amendment in regard to a clear description of the double bedrooms provided and that they are not first and foremost single rooms. The action plan received from the last inspection stated there was only one manager acting as manager of the home. This continues to require amendment in the statement of purpose/service user guide. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 10 The nature of the intermediate care and rapid response service that was offered by the home, for admission at any point of the day, meant that there was no opportunity for residents to visit the home. There was no contact between prospective residents and the home’s staff prior to admission, neither were residents given information about the home and were therefore unable to make an informed decision about their admission. The information provided on the admission assessment for residents had improved since the last inspection and staff that were spoken to confirmed there was now more detail provided when residents were admitted. Rehabilitation facilities were sited in dedicated space. There were specialised facilities, equipment and staff to deliver this service to enable residents to return home. Care plans seen did specify in the action to be taken regarding the rehabilitation of residents and provision of specialist facilities and equipment to enable this rehabilitation and return home. This rehabilitation was enhanced by the services of the occupational therapists, physiotherapists and other specialist workers. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Residents had an individual plan of care that identified health and personal care needs but not social care needs. The daily recording against the plan of care did not confirm that all identified health needs were met. There were residents responsible for their own medication, however, consistency was not maintained in that this was within a risk management framework. The procedures for dealing with medication were inconsistent and the recording poor. Residents felt they were treated with respect and dignity. EVIDENCE: One care plan was checked in detail. There had been improvement in the quality of information provided and the files were much more organised. The files contained a range of required information and more detail had been added on the action to be taken by care staff to ensure residents’ needs were met. The daily report did not consistently demonstrate that the action taken correlated with the action required and there were gaps in information that had been identified in the care plan that needed recording. A nutritional risk assessment had not been completed. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 12 Consistency was not maintained in the documentation in regard to risk assessments for self-administration of medication, the position of the bed and keys. Risk assessments for moving and handling were in place. There was evidence of resident involvement in parts of the care plan regarding risk assessment but not for activities of daily living within the individual plan of care. There was evidence of reviews taking place. The care plan did not contain details of resident’s wishes on death and dying, social/leisure and religious requirements. This had been discussed prior to the inspection with Linda Barker. She stated that this would not be information that was completed via their assessment as it was not relevant. Discussions were held and it was identified to Linda that as a registered care home this information was required and discussions were required as to who was going to assess and complete the appropriate documentation in the assessment and subsequent care plan. Discussions with staff identified two assistant resource centre managers had received record keeping training. Residents that were spoken to confirmed that they were satisfied with the health care they received. Staff could clearly state what assistance service users needed with their personal care and residents said staff offered this appropriately as and when needed. Observations during the inspection together with inspecting resident’s care plans identified residents had appointments with a range of healthcare professionals. The medication record of one resident was checked. Records of medication received into the home were incorrect and the record did not confirm medication was administered as required. Supplement drinks were not recorded as medication even though discussions with the assistant resource centre manager (ARCM) confirmed they should be. In addition the drinks were insecurely stored in a refrigerator in one of the flats. The record of medication did not confirm medication was administered as required and the recording of medication received into the home was inaccurate. Staff had received medication training. It was positive to note that some care staff that were not responsible for medication had also received training to heighten their awareness when caring for residents’. The storage and recording of controlled drugs was satisfactory. Medication requiring refrigeration was stored appropriately, however, temperatures were not recorded. All residents’ spoken to said that staff were very good, kind and considerate and that their privacy and dignity was observed and their personal care needs were met. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 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 standard(s) 15 Residents’ said the food served was of a good quality in a pleasant dining area. EVIDENCE: On 2 December 2004 the environmental health department visited the home and their requirements impacted on meals being served on individual flats and therefore impacted on residents’ preparing meals on the flats to maintain/increase their independence in readiness for their discharge home. The manager had liaised with the environmental health department and the PCT are in the process of installing separate hand washing sinks on each flat to resolve the issue. Residents’ that were spoken to said the food served was of good quality and that there was a good choice of food. They confirmed that three full meals a day were served and drinks were served in between meals. Not all residents’ were aware that alternative choices would be served even though there were notices describing this on the individual flats and the cook said they introduced themselves to new residents and said they only needed to ask if they wanted anything any different. The cook was aware of special diets and the communication between the care and the kitchen staff was good to make sure meals were served to the appropriate resident. The mealtime was unhurried and residents had plenty of time to eat their meal. Those needing assistance were helped in an appropriate manner. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Discussions with residents identified they had no complaints, however, the complaints procedures required more detail. EVIDENCE: The home did keep a record of complaints. No complaints have been received either by the home or CSCI since the last inspection. The home did have a number of compliments and complaints procedures available in the entrance to the home. All were very comprehensive, however, they did not contain details of the CSCI. The compliments and complaints procedure stated that the procedure was also available in large print and audio tape. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,25 & 26 The home was clean and on the whole well maintained and the residents spoken with found the home comfortable. EVIDENCE: Residents’ that were spoken to were happy with their living environment. In general, the home was well maintained and suited to residents’ needs. The home was divided into five flats each with a lounge and dining area. There was also a large dining room that could accommodate all residents’ and another large room was available on an evening during the week and all the time at weekends for residents to use. The grounds presented very well and were pleasant areas for residents’ to sit. Refurbishment work had and was still taking place. The refrigerator had been replaced on flat 1 and the manager said measurements had been taken to replace the smoking lounge doorway. The building was clean and free from offensive odours. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 16 Residents’ could not control the heating in their own rooms; this was done centrally. This had resulted on previous inspections either residents’ being too hot or too cold. Discussions had been held at the CSCI and relayed to the manager that records of room temperatures must be maintained at different parts of the day to assess whether that arrangement continued to be satisfactory. The manager was also now recording water temperatures, however, the record did not confirm that when temperatures exceeded forty three degrees centigrade she was notified and corrective action was taken. To maintain the control of infection the laundry was sited away from food preparation and cooking areas. The home had appropriate sluicing facilities and washing machines. Care staff were able to describe procedures that were in place to control the spread of infection. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 Insufficient information was provided to determine whether resident needs had been met as agreed, by using the residential staffing forum calculation. The recommended percentage of care staff with NVQ Level 2 or equivalent had not been met. EVIDENCE: A condition of registration is that ratios of care staff to residents’ must be determined according to the assessed needs of the service users in accordance with guidance recommended by the Department of Health. The manager gave the inspector the last staffing forum calculation. This was out of date and not fully completed. The manager said staffing levels on flat three and four had not improved and there continued to be only one member of staff allocated to those flats with the carers allocated linking together if there were residents’ that needed the assistance of two. The manager provided information to determine that four of the twenty six staff (15.38 per cent) had achieved their NVQ level 2 in Care or equivalent. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 37 & 38 There had been no improvement to regulation 26 visits made to the home by the registered provider. Staff were receiving supervision albeit not at the intervals recommended by the standard. Improvements were required with some of the records kept by the home to ensure residents’ were sufficiently safeguarded by the home’s record keeping policies and procedures. The health and safety of residents’ and staff were on the whole promoted and protected. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 19 EVIDENCE: A comments/suggestions box and service users questionnaires were available in the entrance to the home. The last inspection report was available at various points within the home including the entrance hall, the notice board in each flat and in residents’ bedrooms. Regulation 26 visits were not being undertaken as required by the regulations. Discussions with staff identified they were now receiving supervision, however, it was not at the recommended intervals identified in the standard. This requirement has therefore been transferred to a recommendation. A sample of the records that the home was required to keep was inspected. These have been commented upon throughout the report and where necessary requirements made including the statement of purpose, individual care plans, medication, complaints, recruitment and regulation 26 visits. Staff were now vigilant about records been stored in a secure way and the care plans and fire records were much more organised. Notifiable incidents were reported as required. Discussions with staff identified they were receiving comprehensive training. The home had a health and safety policy. Safety posters were on display. No fire exits were blocked and hazardous substances were securely stored. The fire officer had completed an inspection at the home on 15 July 2004. Weekly checks were in place of the fire alarm and emergency lighting. Although there had been a service of fire extinguishers on 18 April 2005 there was no record to demonstrate these were checked as required on a monthly basis. The assistant resource centre managers confirmed these were not completed. The main entrance had a keypad in situ to ensure the security of the premises and prevent intruders. There was a member of staff on shift qualified in first aid. Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x 2 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x 2 3 STAFFING Standard No Score 27 2 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 2 x 2 2 2 2 Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 21 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 1 Regulation 6 Requirement The statement of purpose must accurately describe the condition of registration that the ten single bedrooms with a partition screen must be used as double bedrooms and occupants of those double rooms must be given the option to move to single bedrooms when available. Previous timescale of 31 March 2005 not met. Care plan training must be arranged for all staff with responsibility for recording in residents files. Previous timescales of 31March 2004 & 31 December 2004 not met. The recording against the care plan must correlate between the actions staff must take to ensure the service user’s health, personal and social care needs are met and what actions they have taken. Previous timescales of 31 March 2004, 31 July 2004 & 31 March 2005 not met. Residents and/or their relatives/advocates must be involved in the formulation of their care plans. Previous Highfield Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 22 Timescale for action 30 June 2005 2. 7 18 31 August 2005 3. 7&8 15 30 June 2005 4. 7&8 15 5. 7 15 6. 9 13 7. 9 13 8. 9. 10. 9 9 16 13 13 22 11. 25 13 12. 27 18 timescales of 31 March 2004, 31 July 2004 & 31 March 2005 not met. Consistency must be maintained in the completion of a nutritional risk assessment for all residents. Previous timescale of 31 March 2005 not met. Consistency must be maintained in recording in all care plans the residents needs in regard to their wishes on death and dying, religion and social/leisure needs. Previous timescale of 31 March 2005 not met. Consistency must be maintained in that all residents responsible for their own medication do so as part of a risk management framework. Systems must be implemented to ensure that medication records accurately reflect the amount of medication received into the home. The medication record must demonstrate that medication is administered as prescribed. Supplement drinks must be treated as medication and recorded and stored as such. All compliments and complaints procedures used by the home must include the name, address and telephone number of the CSCI. Previous timescale of 31 March 2005 not met. The record of water temperatures must demonstrate assistance is sought when temperatures exceed forty three degrees centigrade and what action is taken to maintain the water temperature at a safe level. The residential staffing forum calculation must be completed as J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 Page 23 Highfield Grange Version 1.30 13. 29 19 14. 30 18 15. 33 26 16. 33 24 required to ensure it is up to date and appropriate staffing levels are maintained at all times. The calculation must be fully completed and the figure for the grand total of care hours required used to determine staffing hours. To demonstrate the staffing hours as required by the residential staffing forum have been met the total of care hours provided from the staff rota must be calculated. The manager must retain responsibility for the recruitment of all staff that are to commence work at the care home and provide evidence that a thorough recruitment procedure has been followed in accordance with the documentation required in the regulations and NMS. Previous timescales of 31 March 2004 & 31 December 2004 not met. All new members of staff must received induction training to National training Organisation specification within the first six weeks of employment. Previous timescale of 31 December 2004 not met. Consistency must be maintained for regulation 26 visits and for the report to be submitted to the CSCI. Previous timescales of 31 July 2004 & 31 March 2005 not met. A system must be established and maintained to review the quality of care provided at the home including individual care plans and ensuring delegated tasks required by the regulations and standards are met. Previous timescale of 31 J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc 31 March 2005 Not checked on this inspection. 31 March 2005 Not checked on this inspection. 30 June 2005 31 August 2005 Highfield Grange Version 1.30 Page 24 December 2004 not met. 17. 35 & 37 12, 17 & 25 Residents records must identify the fee to be paid, personal allowances paid to the service user and how this amount is arrived at.Service user records must demonstrate how their financial arrangements are to be dealt with and that the service user and/or their advocate confirms this arrangement. Records required by the regulations must be kept up to date and accurate. Records must be maintained of monthly checks of fire extinguishers. Previous timescales of 31 March 2004, 31 December 2004 & 31 March 2005 not met. 31 March 2005 Not checked on this inspection. 18. 19. 37 38 17 23 30 June 2005 30 June 2005 20. 21. 22. 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 2 5 27 28 Good Practice Recommendations Service users should know at the point of moving into the home the fee that is payable and by whom. That someone from the home sees the service user prior to them being admitted to the home to enable any questions about the home and their stay to be clarified. That two care staff are deployed on both 3 and 4 flats to maintain appropriate supervision of service users. The training plan needs to identify how the home intends to continue staff training to NVQ Level 2 or equivalent so that by 2005 there is a minimum of 50 staff trained to this level. That supervision takes place at intervals recommended in the standard. J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 25 5. 36 Highfield Grange Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Grange J51 S38647 Highfield Grange V223564 29.04.05 UI Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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