Inspection on 15/05/06 for Highfield Manor

This inspection was carried out on 15th May 2006.

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 Manor 20/04/07

Highfield Manor 25/01/07

Highfield Manor 05/01/06

Highfield Manor 08/08/05

Highfield Manor 13/07/04

Highfield Manor 28/05/04

Highfield Manor 16/01/04

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

CARE HOMES FOR OLDER PEOPLE Highfield Manor 44 Branksome Wood Road Bournemouth Dorset BH4 9LA Lead Inspector Trevor Julian Unannounced Inspection 15th May 2006 9:00 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 Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Manor Address 44 Branksome Wood Road Bournemouth Dorset BH4 9LA 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) 01202 769429 01202 769429 RYSA Ltd Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (27) Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Highfield Manor is registered to provide care for up to 27 older people with dementia and mental disorders. The home is owned by Mr and Mrs R. Koussa, trading as RYSA Ltd. Mr and Mrs Koussa also own another care home which is in Poole. The registered persons have decided to run the home without a manager for the present time with Mrs Koussa assuming the main responsibility for the day-to-day running of Highfield Manor. Highfield Manor is a large detached property, set back from the road and situated in a quiet residential area. It is within easy travelling distance of all the amenities to be found in the centre of Bournemouth and also Westbourne. Attractive walks are available to the nearby Coy Pond and Upper Gardens. The area at the front of the home offers car parking for visitors and further parking is always available on the road outside. To the rear of the property, the garden is laid mainly to lawn and is sheltered by shrubs and mature trees. The patio provides an enclosed sitting area. The grounds are well maintained and accessible to service users. Accommodation is provided on the ground and first floors in 19 single bedrooms (11 en-suite) and 4 doubles (2 en-suite). Communal areas, comprising a lounge, separate dining room and a large conservatory, are all situated together on the ground floor. A five persons passenger lift is available to assist residents between floors. Fees range between £461 - £505 per week. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 15th May 2006. The inspector was accompanied by Penny Spurr from Bournemouth Social Services. The visit took place between 09:00 – 17:00. The purpose of the visit was to review the home against the key standards and to monitor progress made with requirements and recommendations made during previous inspections. Information was gathered through discussion and observation with the residents, staff, visitors and the owners. Further evidence was gained through a tour of the premises and examination of records and policies. During the visit the inspector spoke to 6 residents, 4 members of staff and two visitors to the home. Before the visit some information had been provided by the home in the form of pre- inspection survey and comment cards. Comment cards were received from: 13 residents although 12 were completed by family or friends. 16 relatives or friends of the residents. 4 visiting healthcare workers. The report included the findings of a pharmacy inspection carried out on 26th May 2006 by Christine Main, CSCI Pharmacy Inspector. Since the last inspection, there had been one visit to the home in response to an Adult Protection referral. A further two Adult protection referrals had also been received. What the service does well: What has improved since the last inspection? Since the last inspection there had been one new admission. Records showed that an assessment had been completed before being offered a place. None of the residents had moved rooms. Care records had been improved and contained details of risk assessments the files seen had bee reviewed and there was evidence that the representative of the resident had agreed the care plan. The care plans included social histories and their preferred activities. A number of activities were taking place during Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 6 the visit. The files seen had copies of photographs to aid identification for medication etc. Three of five requirements, relating to medication, made following the last inspection were met and one partly met and the two recommendations had been partly addressed. Storage of medicines needing refrigeration had improved. An improvement was also seen in the medicines policy and record keeping. The food provided on the day of the visit was wholesome and appealing. There was plenty of fruit which the residents were encouraged to eat. Food was appropriately stored and were needed had been labelled and dated. Some residents were being assisted with their meal this was sensitively carried out. The kitchen fridge has been replaced. The complaints procedure was available around the home however, the policy needed to be updated as previously reported. The adult protection procedure had been updated, however the policy file contained both updated and previous versions which could lead to confusion for people referring to the documentation. The building had been redecorated in some areas and this had improved the overall environment. Some unsuitable side tables had been replaced. The damaged bath had been replaced and the tiling reinstated. Lighting in one bedroom had been replaced with domestic style fittings. Recruitment of two recent members of staff had the required levels of documentation and clearances. A training programme had been introduced and certification of completed staff training was seen on the individual files. Two members of staff were in the process of completing their NVQ level 2 in care. Staff supervision had been started and was on target to achieve 6 meetings per year. What they could do better: Care plans showed some improvement in records in the home. It was noted that there was some duplication of information. The records should be reviewed to simplify the recording process. Recording changes to resident’s medication following discussion with the GP could be improved and having evidence of ongoing monitoring of medicines administration and the records to ensure that they are given as prescribed and accurately recorded. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 7 Staff must be very clear about respecting residents’ dignity. Staff should be reminded about the use of appropriate language when communicating with the residents. The home’s complaint and adult protection procedure must be revised and previous versions should be removed. Senior staff and management need to ensure that they undertake specialist training in Dementia care. The home had not achieved 50 of staff with NVQ 2 in Care. Advice was given to assist the owners identify the equivalence of qualifications of overseas staff. The owners need to develop their Quality Assurance systems to seek the views of all stakeholders. Those views need to be included in the home’s Business Development plan. The home must provide a clear audit trail of any service users’ money that they handle. Service users’ money must be kept in a bank account in the service users’ name or at the home. 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 Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Standard 6 Intermediate Care is not offered in the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home admitted people only after a full assessment had been completed to ensure that their needs can be met. EVIDENCE: Only one person had been admitted since the last inspection. The file showed that an assessment had been carried out before a placement was offered. None of the residents could recall the assessment process. Visitor said that they had been provided with sufficient information about the home to help them decide on the suitability of the placement; the comment cards returned also confirmed this. At the last inspection it was found that residents had been moved between rooms and their terms and conditions had not been amended. Nor was the reason for the move recorded; since the last inspection no person had been moved between rooms. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were in place to inform the staff how needs were to be met. The home makes referrals to healthcare professionals to ensure the wellbeing of the residents. The home has systems in place for administering resident’s medication and checks confirmed that most were given as prescribed and recorded. Evidence of the registered person monitoring this and recording the outcome and action taken to address any problems would provide more reassurance that residents’ health is safeguarded. EVIDENCE: Records showed that the care needs and risk assessments were reviewed by the staff and that the care plans were developed with the involvement of the service users representative. Specialist equipment, including bed rails, were in use for some residents, risk assessments were seen for their use. The care Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 11 records seen did contain some elements of duplication it was recommended that the care recording system be reviewed to simplify the recording process. One resident said that if people were unwell then the staff called for the GP to visit. One file seen showed a GP being called and the outcome of the visit. During the visit several people said they were well treated by the staff and felt their dignity was respected. However, during a tour of the property a member was overheard talking to a resident and the form of words was inappropriate and there was a lack of dignity, the matter was drawn to Mrs Koussa’s attention. Mr Koussa arrived to check on the medication just after we arrived and before the inspection started but there was no evidence of other checks done, the outcome and any follow up action to show that medication was regularly monitored to ensure that staff followed correct procedures and gave residents medicines as prescribed. Advice on how this could be done was provided. The MAR charts were signed to indicate that medicines were given as prescribed apart from a few cases, one where one dose was still in the pack but signed as given and another, which was not signed, but was missing from the pack. One medicine due on the night of the inspection was already signed as given, presumably in error. When a choice of dose was prescribed for one tablet for pain, which I checked, staff had recorded the dose given and the number remaining confirmed that the doses given were correctly recorded. The dose given of a liquid medicine with a choice of dose was not recorded. The GP had recently prescribed a second dose of a sedative medicine for one resident “when required” but there was nothing in the care plan or on the MAR chart to indicate to staff when the extra dose should be given and every dose had been given. There were copies of the prescriptions for this medicine confirming the dose prescribed by the doctor. The number of tablets remaining was two less that it should have been from the records of receipt and administration. I was told that two residents’ laxative medication had been reviewed and changed at staff’s suggestion but this was not well recorded in their notes. Prescription directions should be updated as soon as possible. The medication policy had been updated with most of the recommendations but more detailed instructions are needed to ensure that staff are aware of correct procedures to follow when checking and recording a new resident’s medication to ensure that staff correctly record and administer it. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 12 The maximum and minimum temperature of the medicines fridge was monitored and recorded daily and temperatures were in the recommended range. A trolley had been obtained to transport medicines around the home but there was no means of securing it so it wasn’t being used yet. The date of opening eye drops in use had been recorded so that they could be replaced after 4 weeks use to reduce the risk of infection. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s activities provided the residents with meaningful pastimes to create stimulation. There were links with the local community; relatives and friends were welcomed into the home. The meal served was appetising and well presented. EVIDENCE: During the inspection staff were seen playing skittles and other games with the residents. Some people were watching an old movie during the afternoon. One person in the lounge had an album of family photographs provided by her family. Hairdressing was offered in the home. Some of the residents recalled a recent trip out with Mrs Koussa, she also commented that sometimes residents would be escorted on walks in the locality. There was also an attractive garden at the rear of the premises which was used by the residents. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 14 The care plan for the newest resident showed her religious preference and how that preference was being met. The care records gave information on social activities. Visitors to the home said they could call in at any time and were offered refreshments. There were regular church visitors to the home, and the piano was played for the residents by one of the visitors. Food stocks were good and there were fresh vegetables and fruit available. One person preferred not to have lunch and was offered fruit as an alternative. Two of the fridges had been replaced since the last visit. During the morning hot drinks were served at 10:15 and a selection of prepared fresh fruit was given to the residents. The cooked lunch was served at 12:30. There was a choice of dishes and the meals seen were presented well and looked appetising. Staff were seen assisting some residents with their meal, this was carried out in a sensitive manner. The evening meal was due to be served at 17:15 with sandwiches and hot drinks available at 19:30. Mrs Koussa said residents went to bed between 18:30 and 23:00 at their own preference. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had procedures for responding to complaints and allegations of abuse. However, there was a need to ensure that staff are trained in adult protection matters. EVIDENCE: Information on the complaint procedure was available in the residents’ contracts and on display in the entrance hall. The complaints log was not viewed on this occasion. Since the last inspection the Commission had received two adult protection referrals relating to the home. Adult protection was discussed and two members of staff were booked for adult protection training. However, it was recommended that the owners also attended the training to ensure they were up to date with current practice. The procedures were checked and there were two versions of the document on file this could lead staff to follow the wrong advice. The policy and procedure manual needs to be reviewed to ensure it contains only the current versions of all documents. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment had been improved for the benefit of the residents, although there were ongoing issues to be addressed. EVIDENCE: Since the last inspection there was evidence of ongoing improvements to the fabric of the building. Bedrooms seen during the visit had personal items belonging to the residents. There were call alarms with extension cords. Mrs Koussa had ordered pressure mats to link into the alarm system. The en-suite in room 12 had been modified and this meant there was no ventilation/extraction in the room. The owners need to seek advice from building control to ensure the regulations are complied with. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 17 It was noted that some of the en-suite rooms had bare lamps; the rooms would appear more homely if shades were fitted. There were privacy screens in the shared bedrooms. Pipework and radiators were covered in the rooms visited. One bath had been replaced and tiling repaired. Side tables had been replaced with a more suitable design. The laundry area was sited away from the food storage and preparation areas and contained commercial washers and dryers. One person said sometimes the clean laundry was not always returned to the correct owners. Several people commented that the home had been kept warm throughout the winter months. During the visit the home was clean and warm. There was an odour in one part of the home during the first part of the visit but was attended to and not noticeable by mid-morning. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At the time of the visit staffing was appropriate to the needs of the residents. Staff training showed improvement but still required further development in order to ensure that staff have relevant specialist knowledge. EVIDENCE: There were several vacancies in the home at the time of the visit. Staff said the shifts were busy but manageable, they explained that there were three carers on duty between 07:00 – 19:00 reducing to 2 carers overnight. This was in addition to the owners, the deputy manager and domestic staff. The carers also said that they enjoyed the work and sometimes felt that the regulatory authorities were undermining their confidence. Mr Koussa said that staffing levels had been increased to help meet the needs of the residents. The home employed several overseas staff, a check of four files showed each had correct documentation including references, and clearances. The files showed that new staff complete an induction programme. The owners need to ensure that the initial training programme conforms to the Skill for Care standards. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 19 Two members of staff were working on their NVQ 2 in care. Mr Koussa explained that the staff recruited from overseas had equivalent qualification to NVQ 3 in care although there was no documentary evidence to support this. Advice was given to ensure that the owners verify qualifications claimed by staff from overseas to determine their equivalency to UK National Training Organisation (NTO) training standards for care staff. Verification can be obtained from the National Recognition Information Centre for the UK on www.uknrp.org.uk The files seen showed that training was provided in a range of topics. Ongoing training included local adult protection procedures. None of the files seen had nominations for specialist training e.g. Dementia etc. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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): 31, 33, 36, 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home did not have a registered manager which could result in the residents being placed at risk. The home needs to develop a system for seeking the views of those involved in the home to ensure the home is run in the best interest of the residents. The home had introduced a system of staff supervision to ensure the staff were working within the ethos of the home and that their training was up to date. Service users finances are not safeguarded, as there were no clear systems in the home to ensure accountability. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since changing ownership to a limited company, the home has not had a registered manager. Mrs Koussa’s application to be registered manager had been considered by the Commission and refused, pending appeal. As a result the owners must ensure that a manager with suitable qualifications and experience is appointed. It is important that for homes specialising in Dementia Care that the management of the home keep abreast of training and best practice initiatives. The home needs to develop a quality assurance system based on feedback from all stakeholders, this should then be used to develop an annual business development plan. Pre – inspection questionnaires completed by Mr Koussa stated that the home had no involvement in service users finances. However, it was found during the course of an Adult Protection investigation that a large sum of money belonging to a resident was being kept at the provider’s own home; here there was no audit trail or record of how or why this was being done. The staff files seen showed there had been supervision started and on track to achieve the target of 6 sessions during the year. Accident reports were not fully assessed but the need for effective analysis was discussed with Mr Koussa. This will allow trends to be identified and acted upon sooner. Fire safety checks and training were up to date. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X 3 X 2 Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 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. Standard OP9 Regulation 13 (2) Requirement All medicines administered in the home must be accurately recorded, including the dose if a choice is prescribed, so that there is a clear audit trail that accounts for all medication. The person responsible must sign records. There should be evidence of regular monitoring of this and the medicine records to ensure that medicines are given as prescribed. This requirement was first made with a timescale of 01/03/06 and was partly met. Appropriate language must be 01/08/06 used at all times in order that residents are always treated with respect and dignity and as adults. (previous timescale 01/06/06) The complaints procedure must 01/08/06 be updated to be in line with the regulation and standards. All copies of the procedures available in the home must be updated so that they are DS0000046663.V295449.R01.S.doc Version 5.2 Page 24 Timescale for action 30/06/06 2. OP10 12 3 OP16 22 Highfield Manor 3. OP18 13 4. OP31 10 consistent with the main policy. (previously timescale 01/02/06 The adult protection / abuse 01/08/06 policy must be updated in order that it is in line with the Department of Health - No Secrets and local guidance. Once updated the registered person must make sure that staff understand the homes adult protection policy and what they need to do if they have any concerns about abuse. (previous timescale 1/12/05 and 1/4/06) The person in control of the day 01/08/06 to day running of the home must undertake an accredited specialist training course such as person centred care or dementia care mapping to ensure that they are up to date with current good practice in the provision of care to residents with dementia. They must ensure that they undertake such training as is appropriate to ensure that they have the skills necessary for managing the home in order that policies, procedures and training are put into practice by staff. (Previous timescale 1/4/06) A system for reviewing and improving the quality of care provided at the care home must be established and maintained and a report of the review be submitted to the Commission. Policies and procedures must be kept up to date in order to promote and make proper provision for the health and welfare of residents. (Previous timescale 1/4/06) 01/08/06 5. OP33 24 Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 25 6. OP38 17 7. OP9 13 The home must keep a full 01/09/06 record of all accidents to inform the accident analysis that should be carried out and documented at the home. (Previous timescale for action 1.3.05 not met) Any changes to medication must 31/05/06 be authorised by the doctor or other prescriber. The manager or other member of staff who takes a spoken direction from a doctor or other prescriber to change a resident’s medication must record the details clearly, including the name of the doctor, and sign the record. Changes to the MAR chart should be checked and countersigned. Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations The care recording should be revised to reduce the risk of duplication. The medicines policy should be reviewed and updated with the recommended additions and amendments. The home should have written confirmation of a resident’s medication on admission (e.g. hospital discharge summary or copy of their prescription. For ‘when required’ medicines the reason for use should be included on the medicine record chart and / or in the care plan (e.g. for sedative medicines). The home should have a laundry policy in order that staff know how to deal with laundry in the home. 50 of care staff should have NVQ level 2 in care or equivalent by 2005. Any asserted equivalence should be confirmed by appropriate NVQ assessors. The home’s recruitment policy should be updated to reflect legal requirements. The registered person should have an NVQ level 4 or equivalent in care and management. 4. 5. OP26 OP28 6. 7. OP29 OP31 Highfield Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Manor DS0000046663.V295449.R01.S.doc Version 5.2 Page 28 - 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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