Inspection on 07/06/07 for Highfield Nursing Home

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Nursing Home 30/08/06

Highfield Nursing Home 27/03/06

Highfield Nursing Home 26/08/05

Highfield Nursing Home 23/03/05

Highfield Nursing Home 30/09/04

Highfield Nursing Home 29/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Highfield Nursing Home 36-38 Bromley Road Catford London SE6 2TP Lead Inspector Ornella Cavuoto Unannounced Inspection 7th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000007027.V341517.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. DS0000007027.V341517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Nursing Home Address 36-38 Bromley Road Catford London SE6 2TP 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) 020 8488 3970 F/P 020 8488 3970 lorna.lang@excelcareholdings.com Highfield Healthcare Ltd Mrs Yvette Elizabeth Owens Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places DS0000007027.V341517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 45 patients, frail elderly persons aged 60 years and above (female) and 65 years and above (male) 30th August 2006 Date of last inspection Brief Description of the Service: Highfield is a care home with nursing for a maximum of 25 older residents, who are physically frail. The overall stated aim, shared with other homes run by the same provider, is that of offering care in a home from home setting, recognising and meeting individual needs. To this end, Highfield says that they strive to offer sensitive and conscientious nursing and personal care in a comfortable and safe environment. The home aims to deliver a service based on a thorough assessment of need, in collaboration with the appropriate health professionals and involving the residents and their families. Recruitment and training would be targeted to ensure that staff are competent and committed. The registered provider is Highfield Healthcare, a company associated to an organisation called ‘Excelcare’, who runs over thirty homes in England. A director, to whom all the staff are ultimately accountable, directs the service. The day-to-day running of the home is delegated to a care manager, who works full time at the home and who leads a team of staff. Accommodation is provided in a large building, divided into three smaller units, one on each floor. There is a lift. Bathrooms and toilets are located on each floor. None of the bedrooms have en-suite facilities. Over 50 of places had been in shared (double) bedrooms, but this is changing with double rooms being used as single when vacancies arise. There is a large back garden, mostly laid to lawn, with raised flowerbeds and a rockery. The front of the premises is paved to allow parking for visitors and staff. The front and back doors are accessible to people in wheelchairs, with ramps being provided to enable access to the garden. The premises are located on a main road close to the centre of Catford. The area is served by public transport and has a selection of shops and a supermarket. The home will issue a brochure about the home to prospective residents if the admission is carried out as an emergency and provide a copy of the service user guide and statement of purpose on admission. If it is a planned admission a service user guide and statement of purpose are sent to prospective residents and /or their relatives. The home keeps a copy of CSCI reports in the main reception of the home making it accessible to prospective residents and relatives. The fees of the home vary depending on needs and if nursing care is required. Frail residential costs are £494.24p weekly, Frail Nursing costs are £ 608.69- £725.00 weekly. Additional charges are made for hairdressing, toiletries, magazines, newspapers and holidays. This information was provided DS0000007027.V341517.R01.S.doc Version 5.2 Page 5 to CSCI June 2007. DS0000007027.V341517.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present for the duration of the inspection and the regional operations manager was in attendance for part of it. Two care workers were spoken to, three residents and a relative during the inspection. Case tracking methods were used. In addition, prior to the inspection the home was asked to complete a pre-inspection questionnaire and surveys were sent out for completion by relatives. Fifteen surveys were returned with two being filled in by residents. The surveys and information included within the preinspection questionnaire will be used to inform the findings of the report. Other inspection methods used included looking at records and a partial tour of the premises. The inspection found the home had made good progress with seven of the eight previous requirements having been met and only two new requirements being specified. What the service does well: Feedback from surveys completed by relatives were all very positive about the home. Comments included; “We are reasonably content with the level of service” and regarding the staff “ They are doing all they can”, “The care home is able to meet my mum’s needs such that she has improved her general health”, “ All the staff are helpful and considerate to both the residents and their relatives.” “Staff spend time talking/reading to residents. They are encouraged to join in activities, entertainment, making it as much as home from home as possible” Residents spoken to on the day of the inspection said; “I don’t find much fault with it (in reference to the home), its clean, staff are nice”. Regarding staff, “The are all nice”. Residents’ needs are fully assessed prior to their admission ensuring the home can meet all their individual needs. Care plans are drawn up with the involvement of residents and relatives where appropriate and comprehensively address all residents’ individual needs. Health care needs of residents had been well met. The home has an effective medication system that ensures residents receive all their medication as prescribed. Visitors are welcomed by the home and they can visit at any time. The home supports residents to maintain links with the local community by having regular local entertainers coming into the home and also that their spiritual needs are met with a local priest and vicar visiting the home. Although some improvement needs to be made regarding the home meeting the specific cultural needs of residents, the home offers a choice of meals and the diet is varied. DS0000007027.V341517.R01.S.doc Version 5.2 Page 7 The home addresses complaints thoroughly and relatives and residents are aware of whom to bring their complaints. The home is generally well maintained and is clean and hygienic. Staff are supported to obtain relevant qualifications to ensure they can meet the needs of residents and staff receive regular training opportunities. Generally the home’s recruitment practices protect residents. The home is overall well run and managed with an experienced and qualified manager in post. Residents, relatives and professionals are asked for feedback by the home to ensure it is being run in their best interests. The health, safety and welfare of residents are well promoted and protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. DS0000007027.V341517.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000007027.V341517.R01.S.doc Version 5.2 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 DS0000007027.V341517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The fees of the home had been included in the service user guide as required by regulation. The needs of residents had been fully assessed prior to being accepted and moving into the home. EVIDENCE: The home’s statement of purpose was not inspected on this occasion. However, with regards to the new regulation, which came into force in September 2006 that information regarding fees for the home should be included in the service user guide this had been addressed. In addition, there was a statement made about the fees charged by the home providing a breakdown of charges that was attached to the statement of terms and conditions. The personal files of five residents were looked at, two of which belonged to residents that had recently been admitted and one that had been admitted to DS0000007027.V341517.R01.S.doc Version 5.2 Page 11 the home since the last inspection. There was evidence in place that a full needs assessment had been carried out with them prior to their admissions and also that an assessment had been carried out by the home to fully ensure the individual needs of residents could be met. DS0000007027.V341517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had a comprehensive care plan in place that addressed all areas of personal, social and health care needs. Health care needs had been generally been well met by the home. The home had effective medication policies and procedures to ensure residents are fully protected. Residents are treated respectfully and their right to privacy is generally well maintained although in respect to supporting residents with personal care some improvements need to be made. EVIDENCE: The care plans of five residents were inspected. These were very comprehensively written with all aspects of residents’ individual needs in respect to health, personal and social care needs addressed. The registered manager carries out regular audits of care plans of which there was evidence. Care plans had also been signed by relatives and where appropriate by residents themselves. There was also evidence that monthly reviews of care plans had taken place with residents changing needs and progress reflected. Subject to a previous requirement risk assessments that paid particular DS0000007027.V341517.R01.S.doc Version 5.2 Page 13 attention to falls had been completed for all residents whose care plans were inspected and where necessary measures to reduce risks had been specified. General risk assessments were also in place that looked at other risks presented by residents’ individual needs. There was evidence from individual care plans and other records within residents personal files inspected that all their physical and emotional health care needs had generally been very well addressed meeting a previous requirement. All residents whose care plans were inspected had health risk assessments completed in respect to pressure sores, nutrition, continence and to monitor dependency levels. These had been reviewed monthly. Residents had also been monitored for depression and there was evidence that where concerns had been identified that there had been liaison with a consultant psychiatrist who had undertaken further assessment of their needs in this area. Records also demonstrated that there had been regular contact with a range of health professionals including a GP, optician, chiropodist/podiatrist, speech therapist amongst others. Monthly weight of residents had been carried out apart from one where it was noted that their weight had not been recorded for the past three months. The residents weight had been stable and no problems with loss of appetite had been specified. This was brought to the registered manager’s attention who agreed to look into this and that it would be addressed. The home has a robust medication policy and procedure that covered all aspects of handling, administration and storage of medication. Only qualified nursing staff have responsibility for the administration of medication to residents. A community pharmacist visits the home periodically to look at the home’s medication. The last report that was completed in December 2006 was seen and this gave generally positive feedback about the management of medication by staff at the home. A sample of medication records was looked at and these were all found to be accurate. Medication risk assessments had been completed to assess if residents were able to take responsibility for their own medication but at the time of the inspection none of the residents were selfadministering medication. In respect to cold storage of medication, fridge and room temperatures had been recorded on a daily basis as necessary. However, it was noted that the room temperature had exceeded 25c the recommended level at which it should be maintained on a couple of occasions. It is advised this is looked into in order to find ways to maintain the temperature at a consistent level (See Recommendations). Residents were generally all well dressed and groomed. Observations of interaction between staff and residents were noted as being warm and respectful during the inspection. Also, surveys received from relatives and friends of residents all gave positive feedback regarding the care and support received by nursing and care staff. Individual residents had been issued a key to their room where it had been requested and a risk assessment identified it to be appropriate. For those residents who had refused the option of a key this DS0000007027.V341517.R01.S.doc Version 5.2 Page 14 had been recorded. Previous inspections had identified concerns about the number of male carers working at the home and how this could make providing carers of the same sex difficult. A recommendation at the last inspection was specified that where a resident states a preference on who they would like to support them with personal care efforts should be made for this to be adhered to. At this inspection two residents’ care plans that were looked at had specified a preference to have a same sex carer. However, on speaking to one of the residents it became evident that this had not always been adhered to and neither had the home’s policy of a male carer always being chaperoned by a female staff member. Instead, it was reported by the resident that on occasions two male carers had been present when they had been received support with personal care. This was discussed with the registered manager who reported that there continues to be a commitment to recruit more female carers and two had been employed since the last inspection although staff turnover at the home is very low. However, it is essential that preferences of residents in respect to this area be consistently up held as well as the home’s policy of male carers always being chaperoned by a female staff member. The latter is particularly important as there had been an adult protection investigation previously undertaken at the home in which a resident alleged a male carer had physically assaulted them and it was identified that the male carer had attended to the resident without being chaperoned. The outcome of the investigation was that there was insufficient evidence to substantiate the allegation (See Requirements and details in respect to Standard 23). A previous requirement regarding the home taking measures to ensure all residents have the option of their own room to maintain their rights to privacy, dignity and choice was deemed met. The home has continued to take measures to eliminate the use of shared rooms and only one shared room remains. The aim is that the home will have single rooms only by the end of the year. DS0000007027.V341517.R01.S.doc Version 5.2 Page 15 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. 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. There had been some improvement in activities carried out with residents but more specific activities to meet the needs of those residents with dementia or memory impairment still needs to be put in place. Residents are supported to maintain regular contact with family and friends and where possible to exercise choice and control in their lives. The home does provide a varied and well balanced diet but the cultural needs of individual residents had not all been adequately met. EVIDENCE: Since the last inspection the home had recruited an activities co-ordinator that had been in post since September 2006. As a result some improvements had been made in relation to activities carried out with residents. Individual activity records that had been maintained demonstrated that group activities carried out with residents included bingo, sing-a-longs, catching ball and exercises. In addition, there was evidence that the activities co-ordinator had spent individual time with residents chatting with them and doing their nails. However, in respect to a previous requirement that the home should do reminiscence work with residents as a means of providing them with an DS0000007027.V341517.R01.S.doc Version 5.2 Page 16 opportunity for social interaction and stimulation this had still not been addressed by the home. This would be particularly important for residents experiencing dementia or memory impairment. Also, a recommendation that the key worker system is used to ensure time is spent with individual residents is to remain in place, as this should not be seen as the sole responsibility of the activities co-ordinator (See Requirements and Recommendations). The home has an open visiting policy and visitors were observed coming to see their relatives and friends all day during the inspection. The home supports residents to maintain links with the local community by having a range of local entertainers coming into the home on a regular basis. A local priest and a vicar also come into the home to see residents and to give communion to those that request it. None of the residents manage their own finances. However, residents can bring their personal possessions with them when they move into the home and residents’ rooms that were seen were suitably personalised. It was noted that there was information regarding advocacy support was available on the notice board in the main corridor of the home. The home has a varied menu that provides a choice of food to residents. Cold drinks were available in the dining room throughout the day and also hot drinks were offered regularly. Special diets are also provided such as pureed food where required. The home has separate menus aimed at catering to the needs of those residents that prefer African- Caribbean and vegetarian food. However, it was identified that one resident with whom it had been agreed that they would be specifically provided with West Indian food as part of their stay within the home that this was not being adhered to and they were not receiving meals that catered to their specific cultural needs as regularly as they would like. This needed to be addressed. A lunch- time was observed and the food was well presented. Residents were assisted to eat by staff appropriately and respectfully and it was very relaxed and unhurried (See Requirements). DS0000007027.V341517.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a robust complaints policy and complaints had been thoroughly addressed. Measures had been taken by the home to ensure residents are protected from abuse. EVIDENCE: The home has a robust complaints policy that addresses the stages and timescales for the process. Surveys received from relatives and also residents indicated that they were aware of how to make a complaint if they needed to. The home’s complaint log was inspected. There had been four complaints made since the last inspection. One was made by a resident that a small Christmas tree that was in their room had gone missing. A relative concerning some rings they could not find belonging to their mother made another. The other two complaints were both made by the same relative regarding concerns about the night staff. One of these complaints involved an allegation that the night staff had not responded to a call for assistance by their mother. The relative later withdrew this complaint. All complaints had been thoroughly investigated and a written response had been made to the complainants regarding the outcome of the investigations carried out. The complaint regarding the Christmas tree was substantiated but the other complaints were not substantiated or as mentioned withdrawn. Adult protection policies and procedures in place were robust. A previous requirement that all staff needed to receive training around adult abuse and DS0000007027.V341517.R01.S.doc Version 5.2 Page 18 protection had been met. The home’s training plan and individual staff records indicated that all staff had received training that had been provided in –house. Care staff spoken to did demonstrate that they were aware of different types of abuse and action that should be taken if they identified or suspected abuse. As previously mentioned in respect to Standard 10 there had been one adult protection investigation since the last inspection that involved a resident making an allegation of being physically assaulted by a male carer. There was insufficient evidence to substantiate the allegation although it did identify the carer had not adhered to the home’s policy that male carers should always been accompanied by a female staff member when supporting female residents with personal care. Some appropriate measures were taken by the home to address this matter with the male carer involved. However, as discussed previously it was identified that the home’s policy regarding male carers was still not being consistently up held (For details see Standard 10). DS0000007027.V341517.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a homely and generally well maintained environment with suitable communal facilities although the home may need to consider refurbishment of some of the bathroom amenities to provide easy access to all residents. The home was clean and hygienic. EVIDENCE: The home occupied a large Victorian house on a main road. It was generally well-maintained and overall was suitable for its stated purpose although the structure of the building made some of the bedrooms inappropriate for residents particularly those with mobility difficulties as these rooms could not be accessed without having to manage a small flight of stairs and there was no lift access. However, the registered manager reported that these rooms were no longer in use and instead there were plans in progress to use one of the rooms as a training room for staff. DS0000007027.V341517.R01.S.doc Version 5.2 Page 20 Residents had access to safe and comfortable communal spaces. There was a main lounge area and separate dining room on the ground floor. The lounge area had been divided to create smaller seating areas. The dining area was large and spacious. The registered manager reported that a request had been made to change some of the furnishings in the communal areas, specifically to put carpet down in the lounge area as the floor was tiled and also to have smaller dining tables to try to create an even more homely atmosphere. The home had a garden at the rear of the property that was attractive and well maintained and had seating for residents to sit outside. In respect to bathrooms and toilets the home had adequate facilities on the ground and first floors although it was identified that on the second floor of the home the two bathrooms were not in use as there was not enough access for a hoist to be used and the baths themselves were very low and narrow. As a result residents on this floor had to use the facilities on the other floors. Although it was reported this did not pose any problems, it is important that residents and carers should have easier access to bathing facilities and refurbishment of these bathrooms need to be given consideration (See Recommendations). The home was clean and free from offensive odours on the day of the inspection. The home had suitable laundry facilities sited away from the preparation of food. Subject to a previous recommendation that the temperature of the registered manager’s and administrator’s office that is situated in a part of the conservatory be monitored particularly during the summer months as it was noted at the last inspection that the heat made it very uncomfortable to work in had not been addressed. However, it was reported by the registered manager and the regional manager that there were plans to make alterations to the office to make it a more suitable working space. DS0000007027.V341517.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff including nursing and care staff to meet the needs of residents living at the home. The majority of care staff had achieved or were in the process of achieving a relevant qualification as specified by National Minimum Standards (NMS). Residents had been protected by the home’s recruitment practices. Care staff and nursing staff have access to regular training to ensure the collective and individual needs of residents are met. EVIDENCE: At the time the inspection was held there were 25 residents living at the home. It was reported that the maximum occupancy would be 24 once the last shared room is eliminated. It was observed during the inspection that there were sufficient staff working at the home and the rota was accurate. The home does not use agency staff and overall turnover of staff is very low. At present two nursing staff and three to four care staff work on each shift. It was reported that when occupancy levels reduce to 24 the aim was to reduce the staff to one nurse and four care staff. This is still sufficient to meet the residents’ needs although this may depend on residents’ dependency levels. This will be monitored at future inspections. It was reported by the registered manager and the home’s training matrix indicated that presently fifteen of seventeen carers had achieved or were in the process of completing a NVQ (National Vocational Qualification) Level 2 or 3. DS0000007027.V341517.R01.S.doc Version 5.2 Page 22 Also, one of the senior carers had a degree in nursing from abroad and was planning to do the adaptation course. Of the two care workers spoken to; one confirmed they had achieved a NVQ Level 2&3 whilst other was in the process of studying for their NVQ Level 2. As a result the home had exceeded the target as specified by NMS that 50 of care staff should achieve or be working towards completing a relevant qualification. In respect to recruitment the personnel records belonging to staff that had been recruited since the last inspection were checked. All included evidence that the necessary documents required by regulation including a POVA First check where required, an up to date Enhanced Criminal Record Bureau (ECRB) check, two references and appropriate identification had been obtained prior to allowing staff to commence work at the home. Also, as part of vetting procedures there was evidence of the interview process that had been carried out with staff although it was noted that only one person had conducted the interviews. This was discussed with the registered manager and regional operations manager who reported a new recruitment policy had been drawn up that specifies at least two people should interview staff. It is advised this is adhered to by the home at all times (See Recommendations). The home had a training matrix in place that outlined all the training that had been undertaken by care workers and nursing staff and identified training still to be completed. All mandatory training topics such as manual handling, food hygiene, first aid, health and safety and infection control were included and this demonstrated that staff had received up to date training in these areas. It was reported that the majority of training had been undertaken in –house by the manager who used videos, handouts and worksheets from a recognised training company. The registered manager is also a manual handling trainer. Other courses included in the matrix in which staff had received training were risk assessment, challenging behaviour, falls, communication, foot care, dementia and person centred care. The home had introduced an induction that met with Skills for Care specifications and there was evidence included in individual staff records that this had been completed with new staff. Appraisals had been completed with staff although these did not specify training needs that been identified with individual staff members in order to look at organising training for the forthcoming year. It is advised that this is recorded as part of the appraisal process (See Recommendations). DS0000007027.V341517.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well run and managed. The home is run in the best interests of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The registered manager is a qualified general nurse and also holds qualifications as a manual- handling trainer as previously mentioned, a NVQ assessor and has completed the NVQ Level 4 in management. She has previous management experience working as a team leader in a home for older people with dementia. Overall, it was evident from the inspection that the home was well run and managed. DS0000007027.V341517.R01.S.doc Version 5.2 Page 24 In relation to quality assurance the registered manager had completed a number of audits to ensure standards within the home were maintained, for example care plans had been audited on a regular basis. It was also reported that weekly medication audits were completed as well as monthly health and safety, housekeeping and cleanliness audits. The regional operations manager had completed monthly quality monitoring reports that were kept at the home and were seen. The results of a customer satisfaction survey carried out in relation to the home with residents, relatives and professionals this year was sent to the Commission for Social Care Inspection (CSCI) prior to the inspection and overall feedback was positive. The home had not drawn up a specific development plan that outlined outcomes and aims to improve services for residents based on the results of the surveys although the business plan for the home did include some aims specifically in relation to the needs of residents. The home takes responsibility for managing the personal allowance for the majority of the residents. The home had robust procedures and systems in place for managing these finances and in checking a small sample of records and money belonging to residents these were all accurate. At the last inspection, although receipts were kept for the majority of transactions made on the behalf of residents, it was identified that a record of monies paid to the hairdresser who attends the home for individual residents was not being kept. However, at this inspection this had been addressed. A previous recommendation that when relatives hand money to staff for residents that both the staff member receiving the money and the relative sign the receipt was not checked at this inspection and so will remain in place to be addressed at the next inspection (See Recommendations). The home had ensured the health, safety and welfare of residents had been maintained. There were up to date maintenance certificates in place for gas safety, electrical wiring, fire equipment and specialist equipment such as hoists. Regular fire drills had been completed, fire alarm call points had been tested. Water temperatures had been tested regularly. A previous requirement that an updated certificate for the testing of legionella had been met. DS0000007027.V341517.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000007027.V341517.R01.S.doc Version 5.2 Page 26 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 OP10 Regulation 12(4) Requirement Timescale for action 30/11/07 2. OP12 16 (2)(n) 3. OP15 12(4)(b)& 16(2)(i) The registered person must ensure that where a resident specifies their preference for a same sex carer to support them with personal care that this is adhered to at all times. Also, that the home maintains its policy that all male carers are accompanied by a female staff member when supporting residents with personal care. 30/11/07 The registered person must ensure that a varied and appropriate activities programme is provided to service users both on a group and individual basis and specifically more reminiscence work is carried out with service users. Also that records of activities carried out with service users are maintained. (Previous timescale of 31/03/07 partially met) The registered person must 30/11/07 ensure that where it is agreed with residents that they should receive a diet that meets their specific cultural needs that this should be adhered to. DS0000007027.V341517.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP9 Good Practice Recommendations The registered person should try to look into ways to ensure the temperature of the room where medication is stored is maintained at the recommended level of 25c at all times. The registered person should try to use the key worker system to make sure that individual time is spent with service users particularly those that are bed bound. The registered provider should give consideration to refurbishing the two bathrooms on the second floor of the home providing easier access to bathing facilities to residents and carers on this floor. The registered person should try to make sure two staff are always present and involved in the interviewing process when recruiting staff. The registered person should try to make sure that individual staffs’ training needs are specified within their appraisals. The registered person should try to make sure that when relatives hand money to staff for residents that both the staff member receiving the money and the relative sign the receipt form. 2. 4. OP12 OP21 5. 6. 7. OP29 OP30 OP35 DS0000007027.V341517.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000007027.V341517.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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