Inspection on 04/10/05 for Highfield House Residential Home

This inspection was carried out on 4th 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 House Residential Home 12/02/10

Highfield House Residential Home 09/09/09

Highfield House Residential Home 04/09/08

Highfield House Residential Home 13/06/07

Highfield House Residential Home 28/06/06

Highfield House Residential Home 02/02/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Highfield House Residential Home 67-69 Sudell Road Darwen Lancs BB3 3HW Lead Inspector Jennifer M Turner Unannounced Inspection 10:00 4 and 7 October 2005 th th 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 House Residential Home DS0000064296.V254762.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 House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highfield House Residential Home Address 67-69 Sudell Road Darwen Lancs BB3 3HW Telephone number Fax number Email address Responsible individual 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) 01254 701273 01254 701273 Dhillon Financial UK Limited Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 31st January 2005 Date of last inspection Brief Description of the Service: Highfield House is a detached property set in its own grounds. It has a small garden at the front, a car parking area at the side and a small-enclosed garden area to the rear. At the time of the inspection the home was registered for 18 older people requiring personal care. Accommodation is provided in single rooms, one of which has an ensuite facility, (W.C. and wash hand basin). There are bedrooms on both the ground and first floors. A passenger lift connects the two floors. The home has two bathing facilities and one shower facility. There is a Loop system that is available for those service users who wear a hearing aid. The home is on a bus route into Darwen Town Centre, and the home is approximately half a mile from the main shopping centre. People moving into Highfield House are encouraged to take some personal possessions with them, including small pieces of furniture, ornaments and pictures. At the time of the inspection the home had occupancy of 13 residents. The home was reregistered on 05.07.05 when the registered responsible individual changed. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 4th October 2005 with the acting manager and on the 7th October 2005 to meet with the responsible individual. Information was obtained by talking with the acting manager, five staff members and seven residents, by examining a variety of records and walking around the home. Views were obtained from residents and staff members on a variety of topics and information was also obtained by case tracking. Since the inspection five comment cards have been received from residents and two from relatives. Views have been recorded collectively where the answers obtained were similar. Any specific or differing comments have been recorded in the main body of the report. The inspectors’ notes have been retained as evidence of the inspection. Following the registration of the home to a new responsible individual on 05.07.05 a monitoring visit was made to the home on 12.07.05 as the registered manager was threatening to resign. On the 14.07.05 the new responsible individual visited the CSCI office to discuss with the inspector the situation in the home and the progress in registering a new manager as the registered manager had tendered her resignation. A monitoring visit was made on 27.07.05. On 18.08.05 the inspector visited the home to discuss with the responsible individual and the acting manager, future plans for the home. During this inspection an Immediate Requirement Notice was handed to the responsible individual on 07.10.05. The following areas were covered and have been dealt with in the main body of the report. 1. To restore hot water flow to rooms 14; 15; 16 (Ensuite) 8 and bathroom 7. No hot water flow in bath or wash hand basin; no hot water from shower (only cold). 2. Room 16 – Ensuite. W.C. leaking and not being used – needs repair. 3. Room 14 – nurse call system not working – cover missing. 4. Downstairs W.C./shower – door does not close into frame; extractor does not work. 5. Light bulbs need to be replaced on the upstairs landing by Room 11; in the W.C. by room 12; on small flight of stairs by room 16. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 6 6. Doors designated as fire doors should not be wedged open but fitted with an appropriate device with a self-release mechanism connected into the fire alarm system. Door restraints need to be adjusted. 7. Ceiling in front green lounge requires repair and made habitable. The none use of this room only provides enough communal space for 13 residents. What the service does well: What has improved since the last inspection? What they could do better: The acting manager must be given enough “managerial” hours to fulfil her managerial duties. This will ensure that the home is being properly managed and that the residents and staff receive the support they require. The Statement of Purpose and Service Users Guide must be reviewed and brought up to date. At the present time residents and their relatives have no up to date information in respect of the management structure of the home. Following an assessment, prospective residents (or their representative) must receive written confirmation that staff at the home can meet their assessed needs. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 7 All staff who administer medication must receive the appropriate accredited training. Residents said “staff had little time to do anything”. Residents should be given the opportunity to discuss their preferences in respect of social activity and a meaningful programme of activities should be arranged on their behalf by the care staff. Information relating to social activities should be included in the residents care plan. This will alert staff to monitor and prevent social isolation. Comments on comment cards from residents stated that they “did not” or “sometimes” enjoyed the food. Residents said that they did not know until mealtime what was available and said “it was a surprise”. When one resident was asked why she was not having fish she commented, “he” (the responsible individual) “doesn’t buy batter free fish”. All residents should have a nutritional assessment carried out in order for their likes and dislikes to be known. The complaints procedure must be updated to reflect the present management structure in the home. The home should continue to be maintained. A maintenance book should be made available for staff to record any areas within the home and grounds that require attention to either the structure or the fabric. This will ensure that residents live, and staff work, in a clean and safe environment. All offensive odours must be eradicated. This will ensure that the environment smells pleasant for both residents and staff. A safe, hot water supply must be maintained within residents bedrooms and in bathing and W.C. areas, to ensure that residents personal needs are met. The nurse call alarm system should operate in all areas of the home accessible to residents. Residents then know that they are living in a safe environment. Staffing levels should be at a level to meet the dependency needs of the residents. This will ensure that all residents receive the appropriate care to meet their assessed health and welfare needs. Robust recruitment practices must be carried out in order to recruit competent staff. This will ensure that residents are protected from possible abuse. The responsible individual must ensure that visits under Regulation 26 are carried out at least once a month, and the appropriate reports written, in order to meet the legal requirements. Staff must be offered the required amount of formal supervision. This will ensure that they feel competent to carry out their duties and assist with their own personal development. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 8 Quality Assurance systems must be put in place. benchmark for improvement within the home. This will provide a Fire procedures must be up to date and the fire panel repaired to ensure that staff are competent when dealing with possible emergency situations. Cleaning materials must be stored securely and safely to prevent possible harm to residents or staff. 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 House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1;3; The home does not provide Intermediate Care. Documentation about the home did not reflect the current management structure therefore not providing residents or families with correct information. An assessment procedure was carried out prior to people moving into the home. This meant that their needs were known and met. EVIDENCE: The Statement of Purpose was reviewed in May 2005. The Service Users Guide was reviewed in January 2005. Neither have been reviewed since the home was re registered to a new responsible individual in July 2005. Areas relating to the Proprietors, registered manager, details in the complaints procedure, all need attention. Once these have been attended to a copy of the Statement of Purpose must be made available in the home to residents and relatives/visitors. A copy must also be forwarded to the CSCI. The reviewed Service Users Guide must be given to each resident and a copy forwarded to the CSCI. The acting manager indicated that there was no facility in the home to amend policies and procedures. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 11 Referring social workers provided written assessments to the home in respect of prospective residents. The acting manager or a senior carer visited the prospective resident in order to ascertain whether the home was able to provide the appropriate care. Prospective residents were informed verbally whether the home could meet their needs or not. It is required that this information is followed up in writing. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7;8;9;10 Whilst most of the residents’ healthcare needs were identified further risk assessments are needed. Medication policies need to be reviewed to ensure that residents are protected from careless practice. To ensure complete privacy for residents some door locks required attention. EVIDENCE: Four residents case files were examined. Information obtained during the admission process was recorded in a summary. Residents spoken with confirmed that they were included in the review of their care plan and were asked to sign decisions reached by their key worker. One relative commented in the comment card that they were consulted about their relatives care if the resident was unable to make a decision. Another relative indicated that they were not consulted. A mobility risk assessment, to include a “Falls Risk assessment” was to be completed and included in the care plan. A record of health professional visits was kept in the care plans. The acting manager reported that district nurses’ monitored residents who had pressure areas. Continence advice was provided for residents and records of assessments and interventions were up to date and detailed. It was Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 13 recommended that pressure care assessments and nutritional assessments were included in the overall care plan and reviewed accordingly. The majority of the requirements and recommendations raised during the previous inspection relating to the administration of medication have been addressed. The acting manager has forwarded the names of staff to a training consultancy in respect of training relating to “the managing and safe handling of medicine”. It was recommended that relatives be asked to sign documentation relating to medication leaving and being returned to the Highfield House prior to and following visits by residents to relatives homes. The acting manager was to ask the District Nurse to discuss protocols and provide training for staff in respect of the testing of residents “blood sugar”. Locks were provided on bedroom doors and on the doors of bathing and W.C. facilities. The door of the downstairs shower/W.C. room was prevented from closing due to the carpet. As a result the door could not be locked and the extractor fan did not activate. Residents were unable to use this facility in private. There was evidence that some residents had private telephone lines in their rooms. The main telephone for residents was situated in the hall. The office telephone was used for private conversations. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12;13;15 Residents were not completely satisfied that their social requirements were being met. Although a balanced menu was provided some residents were not happy with the food offered. EVIDENCE: Residents said that the provision of social activities “was sparse”. A member of staff was carrying out manicures to some residents during the second day of the inspection. Two residents said that they enjoyed reading and “the mobile library visited every other Wednesday”. The acting manager was advised to record any social activities that residents took part in, into their care notes and care plans. Only one resident commented on the comment card that the “home provided suitable activities”. The other four stated either “no suitable activities were provided” or “sometimes suitable activities were provided”. One resident said that she attended services and meetings at the local Church. Some residents said they taken out weekly by their relatives. The Statement of Purpose and Service Users Guide provided advice in respect of visiting. It was noted that there was no restrictions on visiting. Residents told the inspector that they could see their relatives at any time. Comments on the relatives comment cards indicated that they were able to visit their Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 15 relatives in private. Members of local Churches visited residents to offer the Holy Sacrament. Comments from residents relating to the food was mixed. Those spoken with said that they enjoyed the meals although they did not know what they were going to have at meal times. It was recommended that a wipe board be displayed in the dining room showing what was available at mealtimes. Although the acting manager said that staff were available to assist residents at mealtimes, one relative commented in the comment card that “residents don’t have enough help at mealtimes”. The acting manager confirmed that some residents refused constant attention wishing to retain their own independence. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16;18 Residents were protected from abuse and had access to the homes complaints procedure, although the management details required to be updated. EVIDENCE: Residents spoken with said that they knew who to complain to if they had any concerns although the relatives had commented that they were unaware of the homes complaints procedure. The complaints procedure required the information to be updated. There was a copy of the Blackburn with Darwen “Prevention of Adult Abuse” procedures, and a copy of procedures for staff to follow in the home. The acting manager was provided with contact details for making referrals to the Protection of Vulnerable Adults register. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 17 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;22;25;26. As a result of there being no ongoing maintenance record, the environmental standard of the home was deteriorating. Problems with the hot water system meant that one bathroom was “out of commission”. Failure to control odour problems in some areas of the home meant that residents were not living in a pleasant environment. EVIDENCE: Whilst walking around the home the inspector noted a number of structural and environmental items that required attention. These were brought to the notice of the responsible individual, the acting manager and via an Immediate Requirement Notice. There was no maintenance book where staff could record maintenance or refurbishment requirements. There was a lot of loose rubbish in the gardens, which made the environment look unsightly. The “green lounge” was not being used by residents, as there was a hole in the ceiling in the bay window area. The acting manager was told that this room needed to be locked until repairs had been completed, to prevent residents walking in. The curtains in the “pink lounge” needed to be re-hung as they were sliding off Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 18 the rail. One of the windows in the porch door required replacing as it was broken. The dining room carpet was unsightly and unsafe where sections were joined and requires replacing. The Immediate Requirement Notice stated that light bulbs required to be replaced in communal areas. There was only one useable bathroom in the home. Although the W.C. in the downstairs W.C./shower was being used, the door would not close securely or lock because the carpet was preventing closure. Consequently the extractor fan did not activate, as the door was not being closed properly. Staff indicated that they did not use the shower facility as it was unsuitable and they were unable to assist residents into the shower cubicle. In bathroom 7 there was no hot water flow in either the wash hand basin or the bath. Only cold water was available in the shower. Staff indicated that the Ensuite W.C. in Bedroom 16 had been leaking for some time and the resident was unable to use it. The Immediate Requirement Notice that had been issued showed that there was no water flow from the hot taps in some bedrooms. The nurse call system was randomly tested and found to be working. However, the nurse call facility in Room 14 was not working as the cover was missing. This room was unoccupied and it was suggested that the room be kept locked until the cover was replaced and the system was in working order. The window in Room 26 did not close properly and requires attention. There was no light in the dry storeroom in the basement; the nite light in Room 24 required to be replaced and the lighting in Room 22 needed to be stronger. A new floor covering was required in the laundry as the seal was broken in the linoleum where water had seeped underneath from the washing machine. The washing machine did not reach the required temperature and both the washing machine and dryer were replaced during the second day of the inspection. Floorboards required to be replaced in Bedroom 1 before a new carpet was laid, as there was a strong odour from the floorboards in the room. The carpet required to be cleaned in Room 12 as there was an odour problem. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27;28;29 The skill mix of care staff met residents’ needs. The absence of a maintenance person meant that a clean and safe environment was not being provided for the residents. Not enough senior care hours meant that the acting manager was covering these instead of her own duties. Not all the required records/information were available on staff files. This could lead to residents’ welfare not being fully protected. EVIDENCE: The staff rotas showed that in addition to the acting manager, 1 Senior Carer, 1 Care Assistant, a domestic and the cook were on duty. The acting manager said that she was only allocated two days a week to carry out her managerial duties and the rest of the time the responsible individual expected her to carry out the duties of a senior carer. Comments received in the relatives comments cards were mixed. One comment was that the relative “was satisfied with the overall care provided” whilst the other relative wasn’t. Domestic staff were finding it difficult to complete the required cleaning duties in the time allocated to them. It was noted that some areas of cleaning were being neglected e.g. door tracks in the lift, heavy cleaning of rooms. Staff training records showed that of the 18 care staff employed in the home, 10 had obtained the National Vocational Qualification at level 2, and two had obtained level 3. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 20 The file of the most recently employed member of staff was examined. Not all the requirements of the regulations or the standard were met. Although CRB and POVA checks had been carried out there was no record of when the member of staff commenced work. She had not been given a contract or a job description. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31;33;34;35;36;38 The lack of managerial hours available for the acting manager meant that staff were not receiving full managerial support. There is little positive dialogue between the responsible individual and the acting manager resulting in staff being unhappy in their jobs and some residents feeling unsettled. EVIDENCE: The acting manager has commenced the NVQ at level 4 and has registered for the Registered Managers Award. She told the inspector that she does not have enough time to fulfil her managerial duties as the responsible individual only allows her two days a week for managerial duties. The inspector has discussed this with both the acting manager and the responsible individual. Although the responsible individual visits the home on a weekly basis no reports have been submitted to the CSC! under Regulation 26 of the Care Homes Regulations 2001. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 22 The acting manager indicated that Highfield House had “lost the Blackburn with Darwen Q.A. recognition”. Although the home had previously been awarded the Investors In People Award, the acting manager thought that it was also due to be reviewed. There was no evidence that active feedback was being obtained from residents, stakeholders or family members in order to monitor the homes performance. The acting manager told the inspector that she was not in possession of any petty cash funds and both herself and staff had to buy day-to-day items for the home out of their own money and claim it back from the responsible individual. The acting manager indicated that residents paid their fees directly by Standing Order or cheque to the Proprietor. Family members or solicitors dealt with residents’ personal allowances. The acting manager indicated that she did not provide staff with the required formal supervision as she was only allocated two days a week for managerial duties. Some cleaning materials/chemicals were stored in the garage in the back garden but were not kept securely. The acting manager was advised to contact the Fire Brigade for advice in respect of the lock on the side gate. Staff indicated that the fire panel was faulty and could not be reset without the Fire Brigade being in attendance. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 2 x x 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 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 1 1 2 X X 2 2 STAFFING Standard No Score 27 1 28 4 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 2 3 1 X 2 Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 24 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 responsible individual/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Responsible individual(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4; 5; Schedule 1 Timescale for action The registered responsible 01/11/05 individual must ensure that the Statement of Purpose and Service Users Guide are reviewed to reflect the changes in the management structure of the home. Once these have been attended to, a copy of the Statement of Purpose must be made available in the home to residents and relatives/visitors. A copy must also be forwarded to the CSCI. The reviewed Service Users Guide must be given to each resident and a copy forwarded to the CSCI. The registered responsible 01/11/05 individual must confirm in writing to the prospective resident, that having regard to the assessment, the care home is suitable for the purpose of meeting the residents needs in respect of their health and welfare. The registered responsible 31/12/05 individual must ensure that all members of staff with responsibility for the DS0000064296.V254762.R01.S.doc Version 5.0 Page 25 Requirement 2 OP3 14 (1) (b) 3 OP9 13 (2) Highfield House Residential Home 4 OP9 18 (1) (a)(c) administration of medication complete an accredited medicines management-training course. (Previous timescale of 01/05/05 not met) The registered responsible 31/12/05 individual must ensure that staff are competent in the testing of residents “blood sugar” and receive the appropriate training. The registered responsible individual must consult with residents about the programme of activities arranged on their behalf by care staff, and provide facilities for recreation, having regard to the needs of the residents. The registered responsible individual must ensure that those residents who require, are offered assistance at mealtimes in a manner, which respects their dignity. The registered responsible individual must ensure that the complaints procedure is up to date and gives clear information relating to who complaints must be made to. Upon amendment a copy must be provided to every resident (and/or their representative) and the CSCI. The registered responsible individual must ensure that there is a book available for staff to record any maintenance or fabric requirements in the home. This should be dated and signed off when the items are attended to. Ongoing refurbishment must appear in the programme of routine maintenance. The registered responsible individual must ensure that the grounds of the home are kept DS0000064296.V254762.R01.S.doc 5 OP12 16 (2) (n) 31/10/05 6 OP15 12 (4) (a) 07/10/05 7 OP16 22 31/10/05 8 OP19 23 (2)(b)(c)( d) 31/10/05 9 OP19 23 (2)(o) 31/10/05 Highfield House Residential Home Version 5.0 Page 26 10 OP19 23 (2)(b)(g) 11 OP20 23(2)(p) 12 OP21 23 (2)(j) 13 OP21 23 (2)(j) 14 OP22 23 (2) (n) 15 OP25 23 (2) (p) 16 OP27 18 (1) (a) 17 OP29 19 Schedule 2 18 OP31 18 (1) (a)(c) tidy and free from litter. The registered responsible individual must ensure that repairs are carried out to the “green lounge” in order for it to be used by residents. The registered responsible individual must ensure that working lights are maintained on communal corridors in order to provide a safe environment for residents. The registered responsible individual must ensure that all W.C. and bathing facilities can be used safely and privately. The registered responsible individual must ensure that a hot water supply is provided in each resident’s bedroom. The registered responsible individual must ensure that a call system with an accessible alarm facility is provided in every room. The registered responsible individual must ensure that lighting, suitable for residents, is available in their rooms. The registered responsible individual must ensure that at all times there are suitably qualified, competent and experienced people working in the care home in such numbers that are appropriate for the health and welfare of the residents. The registered responsible individual must ensure that robust recruitment practices are carried out and that new members of staff are not employed until all the requirements of this standard and Schedule are completed. The registered responsible individual must ensure that the DS0000064296.V254762.R01.S.doc 31/10/05 07/10/05 31/10/05 31/10/05 30/11/05 07/10/05 07/10/05 07/10/05 31/12/06 Page 27 Highfield House Residential Home Version 5.0 19 OP31 26 (2)(3)(4)( 5) 24 (1)(2)(3) 20 OP33 21 OP36 18 (2) 22 OP38 13 (4) 23 OP38 Schedule 4 (14) acting manager becomes suitably qualified, is competent and has the required knowledge to manage the home. The registered responsible individual must ensure that visits under this regulation are carried out, and reported, at least once a month. The registered responsible individual must ensure that quality assurance systems are in place, as detailed within this standard. The registered responsible individual must ensure that staff receive appropriate formal supervision The registered responsible individual must ensure that all cleaning materials/chemicals are stored safely and securely. The registered responsible individual must ensure that the fire procedures are updated and that the fire panel is repaired to ensure the correct resetting of the fire panel. 31/10/05 31/12/05 30/11/05 07/10/05 07/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Responsible individual/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP1 OP7 OP7 OP8 Good Practice Recommendations In order for the acting manager to carry out her duties in respect of updating policies and procedures, the appropriate equipment should be made available to her. Information relating to the health and welfare of residents should be recorded in the care plan. A “Falls risk assessment” should be included in the residents care plan. Pressure care assessments and nutritional assessments DS0000064296.V254762.R01.S.doc Version 5.0 Page 28 Highfield House Residential Home 5 OP9 6 OP10 7 8 9 10 11 12 13 14 15 16 OP12 OP15 OP19 OP19 OP19 OP25 OP26 OP26 OP26 OP34 should be included in the residents care plan. Policies and procedures should be reviewed in line with the Royal Pharmaceutical Society of Great Britain Guidelines to address all aspects of medication management including the provision of medication for administration outside the home. Attention should be given to enable the door of the downstairs WC/shower to be closed and locked which should enable the extractor fan to activate and for residents to use the facilities in private. A record should be made on residents’ files of any activity they take part in whether it be inside or outside of the home. The daily menu should be displayed on a board in the dining room in order for residents to know before meal times what was on offer. The curtains in the “pink lounge” require to be re-hung. One of the broken window panels requires to be replaced in the outside porch door. The carpet in the dining room is unsightly and unsafe and should be replaced. The window in Room 26 should receive attention in order for it to close securely. The covering on the laundry floor requires replacing as water has seeped under the existing covering. Some of the floorboards in bedroom 1 should be replaced before the new carpet is fitted. This should eradicate some of the odour problem in this room. The carpet in Bedroom 12 required to be cleaned, as there was an odour in the room. It is recommended that the acting manager be given petty cash in respect of purchasing any day-to-day items. Highfield House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 House Residential Home DS0000064296.V254762.R01.S.doc Version 5.0 Page 30 - 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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