Inspection on 05/06/06 for Highfields

This inspection was carried out on 5th June 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfields 29/11/05

Highfields 16/08/05

Highfields 28/09/04

Highfields 20/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Highfields 1 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH Lead Inspector Lynnette Gajjar Key Unannounced Inspection 5th June 2006 09:25 Highfields DS0000023950.V294336.R01.S.doc Version 5.1 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 Highfields DS0000023950.V294336.R01.S.doc Version 5.1 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 Adults 18-65. 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. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highfields Address 1 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH 01732 465987 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) The Avenues Trust Limited Mrs Janet Winter Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users with learning disabilities may also have physical disabilities Care of one Service User who has been diagnosed with Alzheimer’s Disease is restricted to one person whose date of birth is 07/07/1926 Care of one Service User is restricted to one person whose date of birth is 09/02/1937 29th November 2005 Date of last inspection Brief Description of the Service: Highfields is a purpose built bungalow for six service users with a learning disability. It is one of three situated in close proximity to each other that are maintained by Kelsey Housing Association and managed on a day-to-day basis by The Avenues Trust Ltd. It is in a quiet residential area of Sevenoaks within walking distance of the town centre and main line transport systems. There is limited parking on site. Highfields is single storey bungalow with six single bedrooms including en suite shower and toilet. All bedrooms have a TV point. There is no emergency call system in the bungalow, except for in the assisted bathroom. There is a lounge and dining room and a small rear garden. Highfields has separate day staff and one waking night staff, with an additional floating waking night member of staff who rotates between the three houses on the site. The homes current scale of fees range from £981.84 to £1253.27. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, the first in the year running from April 1st 2006. The visit lasted from 09:25 to 15:45pm. The home currently has 6 people who have lived at the home together for the past 5 years. The visit was spent talking directly with those living at the home, both privately and collectively, with staff, and the registered manager. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of those living at the home in the report. Some judgements about quality of life and choices were taken from limited conversation with those living at the home, and much direct observation followed by discussion with care staff and evidencing records held at the home. A tour of the premises was undertaken, with time spent assessing various records and case tracking. Information was also gathered through a pre inspection questionnaire completed by the manager and comment cards returned to the Commission. Documentation was in good order, with good monitoring systems in place by the registered manager and staff. The recommendations from the previous inspection had been implemented. A number of CSCI “comment cards” (completed questionnaires) were sent out but none were returned prior to the report being written. Those received will be used as part of the next key inspection. Compliments recorded in the home’s compliment book included: “What a lovely friendly staff and residents. Everyone made us very welcome & made us a cup of tea while we waited a great home” A Contractor visiting the home. Feedback from last stakeholder survey: “We are very satisfied and grateful for the care afforded to (name). This is certainly a lovely home and long may it continue: Relative “Adequate staffing, carefully chosen & well trained staff. Adequate funding confirm consultation /communication at all levels” Relative “ I would like to compliment the staff team working in this bungalow, from my first day on placement I was made very welcome by both staff and service users. All of the service users receive the highest standards of care. Along with this they are treated with the utmost respect and consideration. The Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 6 house offers a very homely and welcoming feeling and all the service users appear very happy and content.” Student Nurse. The service users and staff in this home have expressed their wishes that they be referred to as ladies and gentlemen, as opposed to service users. What the service does well: What has improved since the last inspection? The ladies and gentlemen have benefited from the recruitment of two new care staff and stabilising of the support team at Highfields. The ladies and gentlemen living here are benefiting from the increased promotion and encouragement of ‘active support’ in every day living skills as well as social activities. This has included consultation and support from the Tizzard Centre in assessing and working with staff to develop this further. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The ladies and gentlemen living here and their representatives have access to the information needed in making a decision as to whether the home can best meet their needs. EVIDENCE: Service user guides seen today were in both clearly written and pictorial formats. The home uses the organisation template for this. Due to the nature of this service, those living here would better understand a simpler format. It was acknowledged by the registered manager that minor adjustments to staff details were in hand for both the service user guide and statement of purpose and copies would be forwarded to the Commission on completion. Three of those living here have done so since it’s opening on 16th May 1995, followed by a further 2 moving in, in 1998. The last admission was in 2001. The group have lived compatibly for the past five years. The key working and person centre planning process continues to develop, to offer clear promotion and support in identifying personal aspirations and meeting individual care needs at a pace suitable to them. The registered manager demonstrated a clear understanding regarding the category and needs of those living here and what the home could best meet. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 10 Her knowledge and experience of the homes capacity to meet individual needs is good. The Avenues Trust have clear procedures to follow if a vacancies was to occur, including formal assessments, trial visits and involvement of those already living here. Care plans seen today contained a written tenancy agreement/contract, which gives the persons’ security and rights of residency to Highfields but does not give details of the actual private room assessed as best meeting their care needs. The registered manager stated this will be addressed through contract reviews and room plans. This document clearly lays out the tenants and landlord’s rights and responsibilities. Representatives had signed some contacts and staff detailed where others had declined. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Person centred care plans, risk assessments and guidelines continue to develop offering detailed information to ensure consistent support by staff to meet the individual health and social care needs of those living here and to track the care provided. EVIDENCE: Through discussion with a staff and assessing one current care plans in detail, it is clear that those living here are given full support and encouragement to maintain personal contact with health and social care professionals, to maintain good standards of health and social care. Guidelines and risk assessments enable staff to access information that is most important and to maintain individual and collective goals safety. Photographic, pictorial and object referencing is used to aid communication and better understanding by the ladies and gentlemen living here. Daily diaries are kept for each person that have pre-written topic headings. Staff complete these in detail each day, with topics including the time they get Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 12 up and go to bed, the activities they have taken part in, what they have eaten, GP and other appointments plus other details of their day. Giving good summary of the active care and support given and reciprocated. In house care reviews take place regularly. Interaction between the ladies and gentlemen and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Observed with one gentleman in particular with appropriate two-way banter and fun by both parties. Records seen were stored securely. To comply with Data Protection alternative storage of the yellow accident form was discussed and implemented by the manager. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The ladies and gentlemen living here are given encouragement and support to make choices about a range of local social and recreational interests at a pace suitable to them. The menus and food provided offers the quality, nutritional value and healthy fresh products. Affording them the right to exercise choice and control over their diet. EVIDENCE: The ladies and gentlemen living here are able and encouraged to follow hobbies and interests of their choosing and the staffs knows individual personal preferences. Care records reflect that a steady, though flexible routine occurs on a day - to -day basis and individuals feeling safe with this. Outings happen daily; offering leisure opportunities such as the local pub as a particular favourite, having ‘lunch out’ and walks to the park. Many trips to theatre, shows, daytrips to the coast were discussed. As well as more relaxing watching personal videos, TV, and listening to music. Due to personal Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 14 experiences some individual’s participation in local activities and outings can cause anxiety but this is being encouraged and supported to increase opportunities at a pace suitable to the individual, including holidays. There are planned structured sessions at the home by Magic Moments, Physical Motivation and Musik with Neil. Holidays are planned with two choosing to go together as like noisy music and lively entertainment “ (Name of person) and staff have been practising the Karaoke already” causing lots of laughter by the resident. Others have chosen a quieter time and environment. Specialist bungalows for physical disability have been arranged. Contact with families and relatives are promoted on an individual basis, through visits, telephone calls and letters. Personal money is kept in individual cash tins in the homes safe. Detailed records are kept of the money put in and taken out. General details are kept in a bounded book so that staff can see at a glance how much each person has left. For additional security the cash tins are taped up and signed by staff after they have opened them. A finance tin and records were sampled and the records tallied with the money in the safe. Then menu offers a varied and wholesome variety of meals, with ample fresh fruit and vegetables. These are tailored to the specific that those living here like and dislike. Specialist diets are catered for, with specially adapted crockery and cutlery to assist those as required and PEG feeding. Due to nil by mouth alternative activities are planned at mealtimes for those who receive their nutrition through the PEG feed in a dignified and appropriate manner. Clear support and guidelines for assisting individuals are in place, that are personal, respectful of preferences and special support needs to make mealtimes an enjoyable time. Direct observation showed mealtimes to be at a pace comfortable to the individuals. The ladies and gentlemen are supported to be involved in write shopping lists, purchase foods locally and be involved in the preparation and cooking of foods to the best of their ability. The manager has been working hard with staff to implement the ‘active support’ framework to the home. Through support and consultancy from the Tizzard Centre this has been effective. The staff team have taken this on board with enthusiasm and those living here are becoming more involved in everyday activities at a pace suitable to them. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18,18,20 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, social and personal care needs of those living here are well supported with regular contact with specialists and external professionals. The ladies and gentlemen are treated with genuine respect and dignity by care staff and are protected by robust medication procedures. EVIDENCE: Staff are clearly aware as to the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing. Care plans indicate staff have a good understanding of individual physical and emotional needs. Good practice in relation to medication management and storage is in place. MAR Sheets are clearly written with clear PRN guidelines of administration. One staff member tends to take lead in the ordering and returning of medication in each bungalow. Staff are due to undertake medication training this month. Some staff has been specialist trained to undertake administering Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 16 phosphate enemas and PEG feeding. This is reassessed and monitored six monthly by the district nurse. The staff team have been working closely with Learning disability team on reassessment of a person living at the home who has PICA, which could seriously affect their wellbeing. Good strategies have been implemented with an improvement of behaviours noted and better understanding by the staff team of how to support the individual. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse is promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. It is evident for the majority, they would be heavily reliant on a relative/ advocate/staff to identify concerns and raise them on their behalf. The home’s records indicate they have not had any formal complaints. Staff who have been spoken with evidenced a good understanding of how to protect and prevent abuse, including reporting under local procedures. A number of staff have just completed training in this area. There are no current Adult Protection alerts regarding this home. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The ladies and gentlemen live in a clean, comfortable and homely environment, which would be enhanced further by the redecoration of en-suite bathrooms and re-assessment of the garden area to make safe access and meet the assessed needs of those with limited mobility and are wheelchair users. EVIDENCE: The home is a purpose built bungalow, well presented, and bright, with adequate internal space and equipment for those requiring full physical care. There are good standard of hygiene and cleanliness. The dining room and communal areas have been redecorated recently and were light and airy. The dining area has a high ceiling. The top half of the walls in this area have clouds and hot air balloons painted on them, which was very effective and took away from the ‘corridor’ effect it could have. Individual bedrooms have been decorated to their needs and tastes and contain their personal possessions etc. All bedrooms have en suite shower Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 19 facilities. One has have been redecorated with new flooring and a tiled area around the shower. Unfortunately the tiles do not reach the ceiling. Other ensuites are in need of redecoration and action taken to ensure seals around the flooring and ceiling are effective. Wallpaper currently here has become stained yellow with the chemicals used when cleaning. At the last inspection the manager understood the remaining en-suites would be retiled and decorated. There is also one communal bathroom with a bath, bath hoist, weighing chair, storage and call bell. The ladies and gentlemen have the use of a lounge that is comfortably furnished and has a TV, video, DVD, music centre and a small sensory area. The kitchen has been refurbished as part of the ongoing maintenance schedule for the home. However consideration to unit height and work surfaces to meet the needs of the tenants had not been undertaken and so to be involved in ‘active support’ depending on personal need, the ladies and gentlemen have to sit or use a free standing table which their wheelchair fits under. There is a large new range style cooker; microwave, dishwasher, fridge, freezer and all were clean and tidy. Flooring has been replaced. The laundry is at the front of the house. There is a sink/drainer, commercial washing machine with sluice facility and a drier. There is not a separate hand washbasin if the main sink is being used to soak soiled laundry. There are shelves on the wall where baskets, which are colour-coded for each service users’ clothes, are kept. Individual specialist equipment is assessed through Occupation Therapists and purchased on an individual basis, from comfortable chairs, beds, and hoists, grab rails and bathing equipment. Further advice should be sought for accessing the garden. Particularly grab railing on steps, painting of edges of steps, patio, levelling of pathways, levelling of grassed areas and making this valuable leisure resource safe for access by the tenants. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service A staff team that receives good training and on-going support and supervision in meeting individual needs of those living at Highfields. The ladies and gentlemen living here have benefited from stabilizing of the staff team, resulting in good morale and enthusiasm to improve the individuals whole quality of life. EVIDENCE: The home has benefited from the stabilizing of staff team through two new staff, with one who is working through their probation period. And one has returned from maternity leave. All have undertaken a thorough and comprehensive recruitment and working through their induction programme including all core training with set targets set with the registered manager. All staff undertakes induction linked to LDAF criteria. The organisation continues to encourage and support care staff to completed their NVQ 2 and 3 in care, but new staff have to achieve full probation before being put foreword for this. The home currently has one staff holding NVQ 2 or 3 in Care and a further two working towards this at present and two who have applied to start this qualification. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 21 Staff feel supported by the manager and senior managers of the organisation. “The best organisation I have worked for, good training.” “I really like coming to Work, the training has been very good too.” Full-recorded supervision takes place at least monthly including set action points and goals. New staff have additional 3 and six monthly appraisals as part of their probation period. Yearly appraisals also take place. The registered manager has clear levels of expectation from the staff team and has extended probation periods for staff to develop into their roles. Care staff spoken with and directly observed evidenced clear and good understanding of different individual care needs. The ladies and gentlemen reacted fondly towards individual staff and their help. With positive conversation, appropriate touch and nodding ad shaking of heads to yes no questions by the inspector. Staff were seen to support individuals respectfully but also with respectful familiarity resulting in some fun joking and banter from both parties. Staffing rosters have reflected changing care needs of individuals. The home is currently running with 2.3 staff vacancies. A regular particular agency worker (who has been coming to the home for three years) covers this. Staff files are held at head office. Typed forms are sent to the home to hold detailing references received, CRB Number and disclosure, personal details etc. All those assessed today showed appropriate checks have been undertaken and are store securely. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The ladies and gentlemen living here have their personal preferences, support and care needs encouraged through the registered managers open leadership, monitoring systems and the promotion of a safe home and working environment. EVIDENCE: The manager is a qualified registered learning disability nurse. She also holds the NVQ level 4 in Management and has achieved the Registered Managers’ Award. Staff continue to express a high regard for their management approach to the home. The ladies and gentlemen through the interaction observed appeared very comfortable and well supported by the manager. Her arrival to the home today brought an air of relaxation and confidence that gave a calming effect on the home, routine and staff during the busy morning routine. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 23 Monitoring health and safety in the home is to good standard, equipment serviced as required to maintain a safe home and facilities. Risk assessments are completed for individual’s activities. Full fire protocols and records are maintained satisfactorily. The registered manager evidenced a good understanding of accident/incident recording and reporting under regulation 37 to the Commission, as well as assessment and monitoring of falls. The introduction of a monitoring /auditing tool will assist the manager with observing for patterns and triggers at a glance rather than searching though paperwork but also ensure forms are filed away securely. Accident Incidences are monitored from head office with monthly reports and graphs indicating patterns and trends for the manager to address. Staff training records showed ongoing training in health and safety, food hygiene, moving and handling, care of the back, fire awareness, COSHH with some having been completed others booked with coming months. This is monitored by head office and staff informed when refresher training is required. A full insurance certificate was on display and concurrent. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 25 N/A Are there any outstanding requirements from the last inspection? 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 YA10 Regulation 17 Requirement Records 17 (1) (b) In that accident /incident records are filed to comply with data protection and freedom of information Acts. Full action plan with proposed completion dates to be submitted by 30/07/2006 Timescale for action 30/07/06 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 YA1 Good Practice Recommendations It is recommended amendments in hand to the service user guide and statement of purpose are implemented and a copy supplied to the Commission and Service users within 28 days of revision. It is a good practice recommendation that contracts are reviewed to ensure they include the room to be occupied and that this room meets their assessed needs. Where representatives are not willing to sign these Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 26 2 YA5 3 YA6 4 YA20 5 YA24 6 7 YA24 YA30 8 9 YA33 YA42 documents on service users behalf this is recorded as such. It is a good practice recommendation that any original and reviewed documents are dated and signed by the author, to ensure that the latest and most up to date version is followed It is recommended the medication key be kept separately to the main bunch of keys to comply with the Royal Pharmaceutical guide to managing medicines in care homes 2003. It is recommended that serious consideration be given to an OT assessment and advice sought regarding safe access to the garden for those with limited mobility and wheelchair users. It is recommended that en-suite bathrooms be retiled, decorated with the seals to the ceiling and flooring improved to promote good infection control management. It is a good practice recommended that a separate hand washbasin be installed into the laundry room for good universal precautions when the main sink is in use for soaking soiled laundry. Recruitment should continue to fill vacant posts as soon as possible. It is recommended that staff training in moving and handling should be reviewed to ensure compliance with Manual Handling Operations Regulations 1992 for renewal and updates at least yearly. Highfields DS0000023950.V294336.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Highfields DS0000023950.V294336.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!