Inspection on 05/05/06 for Highgrove

This inspection was carried out on 5th 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

Highgrove 18/03/08

Highgrove 22/10/07

Highgrove 06/10/05

Highgrove 07/04/05

Highgrove 10/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Highgrove Stapehill Road Stapehill Wimborne Dorset BH21 7NF Lead Inspector Jo Palmer Key Unannounced Inspection 10:00 5th May 2006 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 Highgrove DS0000061344.V291471.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 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. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highgrove Address Stapehill Road Stapehill Wimborne Dorset BH21 7NF 01202 875614 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) Samily Care Ltd Mrs Janice Rose Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Highgrove is has been operational as a care home since 1991, the present owners Mr & Mrs Bleach have been registered since June 2004 under the company name of Samily Care Ltd. Ms Janice Rose is the registered manager. The home is registered to accommodate 21 older persons for personal care only. The property is a large Victorian house that has been extended and is set in large, well-maintained gardens. The front of the home provides off road parking for several cars. Highgrove is in Stapehill between the towns of Ferndown and Wimborne and is a short walk from the local bus route and post office. Accommodation is provided on ground and first floor levels, the first floor is accessible by a central stairway, there is no lift. Catering and laundry services are provided. The current level of fees for personal care and services and accommodation at Highgrove is between £420 and £520. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 5th May 2006 lasted for four and half hours. A senior care assistant was in charge of the home; the registered manager was on annual leave. The responsible individual, Caroline Bleach was called and arrived for the inspection. Mrs Bleach contacted the assistant manager who was taking a day off to request she come and assist the inspection. This was a ‘key’ inspection where the home’s performance against the key National Minimum Standards was assessed along with progress in meeting requirements of the last inspection. Two inspector’s visited the home who jointly examined relevant records, separated to speak to residents, spoke with the responsible individual and assistant manager, took a tour of the premises and examined medication systems. The Commission for Social Care Inspection sent questionnaires to the home for them to distribute among residents and give to relatives and visiting professionals. At the time of writing the report, eight questionnaires had been returned from relatives and eleven from residents and one from a GP. A preinspection questionnaire was also sent to the manager in order that certain information could be provided, as this inspection was unannounced, the preinspection questionnaire had not been completed although was received by the Commission on 8 May. Information provided will be included in relevant sections of this report. What the service does well: Residents at Highgrove can now be assured that they are provided with the necessary detail about the care and services of the home prior to making a decision to move in. In addition to printed information about the service, resident’s needs are assessed prior to moving to the home in order that they, and the home, can be sure those needs can be met. Residents are issued with a contract detailing their rights and obligations whilst living at the home. Each resident has a care plan describing for staff how their personal care, needs are to be met, some care plans are good and show that staff have considered individual residents abilities to maintain their independence. For residents who need assistance with their medication, systems are in place to ensure this is managed effectively although attention is needed to ensure records are held consistently. Residents spoken with confirmed that their right to privacy was being respected and that staff treated them courteously and with kindness. Residents have been able to form friendships in the home and there was a general ‘buzz’ in the lounge area where residents come together to Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 6 enjoy each other’s company, family and friends are able to visit and some organised social activities are arranged to which they are invited to join residents. Residents confirmed that good food is provided in good quantities, a choice of meal is available from the home’s menu. Residents are able to complain about the service if they are unhappy and a written complaints process informs them of who to complain to and how their complaint will be dealt with. Complaints received by the home have been resolved satisfactorily. Staff have procedures available detailing what they should do if they are unhappy with any aspect of the service and who they should report this to. Highgrove offers safe, well-maintained accommodation where residents have comfortable rooms with some of their own things around them. Bathrooms and toilets are situated conveniently around the home. The home is appropriately staffed with care staff, the manager and assistant manager working, a cook and cleaner working various shifts throughout the week. All staff are appointed following proper vetting procedures and screening and training programmes are in place although need further development. All staff receives regular supervision. Working practices in the home are in place to protect resident’s health and safety What has improved since the last inspection? This inspection evidenced visit evidenced that progress has been made and the service has improved significantly in the following areas where requirements were made: • • • • • • • • Information is now available to residents in the service user’s guide, which details the care and services provided by the home. Resident’s needs are assessed to ensure the home is the right place for them to move to. Two bathrooms have been refurbished to provide better facilities. All radiators and hot surfaces have been guarded to prevent accidental scalding. Staff hand washing facilities have been improved making infection control procedures safer. Staff employment practices have improved ensuring that all staff are appointed following proper screening procedures. At this inspection, accessibility of the home’s records had improved. The disused refrigerator in the kitchen has been removed. Highgrove DS0000061344.V291471.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. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 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 Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 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): 1, 2, 3, & 4. Standard 6 is not applicable Quality in this outcome area is good but could be improved by addressing the good practice recommendation made as a result of this visit, this judgement is made using available evidence. The home’s Statement of Purpose and Service User Guide provide detailed information about the care and services provided at Highgrove. The admissions process is such that it ensures resident’s needs are assessed prior to admission either by the home or under the community care arrangements; residents are assured in writing that their needs can be met by the home prior to signing a contract. EVIDENCE: A requirement was made at the last inspection that the home makes available to residents a copy of the Service User Guide and Statement of Purpose; at this inspection it was evident that a copy of the Service User Guide was available in each residents bedroom. A brief review of the document demonstrated that it was up to date and contained all relevant information about the care and services provided at the home. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 10 On admission to Highgrove, residents are issued with a Contract of Residency outlining the terms and conditions of their stay, a review of this demonstrated that contractual information provided outlines the rights and obligations of the resident, the fees payable and the period of notice. Two care files for residents recently admitted to the home were examined; one held pre-admission information provided by the local authority that was assisting with the funding arrangements. A Highgrove assessment format is also used although in this instance, the information was incomplete; where local authority information is available, it is not a requirement that a care home complete its own assessment prior to admission although would be good practice to do so. However, the resident had signed the incomplete assessment form, residents are asked to sign their assessments to indicate their agreement with the assessment findings, in this instance, it was evident that a full assessment had not been discussed with the resident. The second file was for a resident who was self funding, a pre-admission assessment form had been completed by Highgrove prior to admission indicating the residents level of need and areas where independence was maintained. A resident signing an incomplete assessment form indicates Following the pre-admission assessment and when agreement is reached that the resident’s needs can be met at the home, the manager sends written confirmation to the resident stating that based on the assessment findings, the home is suitable for meeting their needs. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is poor and requirements are made in respect of necessary improvements. This judgement is made using available evidence including a visit to this service. Residents are not wholly supported in their involvement with the care planning and review process, some residents have plans of care identifying how their personal care, health and welfare needs will be met, for those that do not there is some risk that their specific needs will not be met. The procedures for managing medication ensure residents safety although are let down by inadequate reporting for residents newly admitted to the home. Resident’s rights are respected and their right to privacy is supported through generally good care practices and good relationships with staff. EVIDENCE: Five resident care files were examined. One resident did not have a care plan, the resident had moved to the home ten days prior to the inspection. Where care plans were provided, these identified how personal care needs were to be met and provided clear instruction to staff. Care plans detail personal care Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 12 routines indicating choice and individual considerations for the resident including their levels of independence and abilities in maintaining self care routines. Care plans are, in the main, based on information obtained through assessment and specific health assessments were evident in some areas using professional guidance, for example continence care pathways using a format provided by the Primary Care Trust and moving and handling using assessment guidance provided by the local Environmental Health officer. One resident requiring specific moving and handling techniques, had detailed photographic instruction available for staff demonstrating how moving and handling equipment was to be effectively used. Although Mrs Bleach confirmed that the resident had consented to the photographs, they had not been taken in a manner that protected the resident’s dignity. One care file examined for a resident who has diabetes did not have an associated care plan. Printed information was available for staff about the condition and a district nurse attends daily to administer insulin injections. There was limited information available specifically for this resident indicating action to be taken should the diabetes become unstable. A good recording format had been produced although this had not been completed. Residents with specific continence difficulties had care plans detailing action staff needed to take to meet those needs, a detailed assessment had been undertaken to ensure payment for and supply of incontinence pads. However, the resident’s rooms had very strong, unpleasant odours and in one room, the carpet was wet. The responsible individual and a member of staff spoken with confirmed that they are constantly cleaning the room to reduce the odour. It is required however that the registered persons evidence through care planning that the residents needs are managed effectively and that they have reviewed their cleaning schedule and the products used in order to eliminate strong odours (See standard 26). Care records did not demonstrate adequate consultation with the resident in terms of agreeing care outcomes from assessed need and indicating their involvement in the review process. Records demonstrated, and residents spoken with confirmed, that they are able to maintain appropriate levels of contact with community health care professionals; the home supports residents in making and keeping appointments with their GP’s, dentists, opticians etc. A GP who responded positively to all questions posed on a questionnaire sent in respect of the service also stated that the home provides good care. Medication systems are generally well managed in the home with records supporting an audit trail of medicines prescribed, received into the home, administered on behalf of residents and disposed of when no longer required. Some anomalies were noted where residents had recently been admitted to the home and the administration records had been hand written rather than pre-populated by the supplying pharmacist. These records did not indicate the number of medicines received into the home; it was therefore not possible to Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 13 ensure an effective audit trail demonstrating whether the resident had received the correct amounts of the prescribed medicine. Residents spoken with confirmed that their privacy is respected, staff always knock before entering their rooms and they are kind and supportive when meeting their needs. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Residents are able to benefit from activities provided by the home and are satisfied with the social care provided. Limited social care assessments do not provide staff with information concerning individual social and leisure choices for residents although residents were content with the homes social arrangements. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home although there is limited evidence of resident consultation to support this. Residents are provided with a varied menu offering choices of meals that meet their dietary needs. EVIDENCE: Highgrove produces a monthly newsletter detailing social events that have taken place or are due to take place. Events include celebration party for the Queen’s 80th birthday, film shows (DVDs and videos), entertainers, cheese and wine party and a barbecue. The newsletter also provides introductions for new residents and pays tribute to past residents. One member of care staff has Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 15 taken a specific interest in social care programmes and is looking at all aspects of leisure and recreational activity suited to residents needs and preferences. Residents spoken with confirmed that there were sufficient levels of social stimulation and it was evident that there was a general ‘buzz’ in the lounge area where residents come together to socialise and form friendships. Care plans examined did not record in any detail individual preferences regarding religious, cultural, recreational or leisure activities although as residents confirmed that the home meets their expectations, this is not deemed significant. However, it is recommended that ways of formulating specific social care plans are considered in order to be sure the home can meet those needs. Residents spoken with confirmed that they maintain contact with their families and friends. Highgrove is situated in a rural area that is quite a distance from the amenities of the local towns, some residents confirmed however that they are able to get out with the support of their families to visit local places of interest and to socialise. Whilst there is limited evidence of consultation in the assessment and care planning process, residents confirmed that they are able to make decisions and choices and retain some control over their lives, residents spoken with confirmed that they can get up and go to bed when they please, meals times are set although meals can be kept by if the resident is involved in any other activity and they can choose to join in with provided activities if they please, if not they are at liberty to stay in their rooms. Residents spoken with confirmed that meals provided by the home are good and plentiful. Of nine returned questionnaires from residents about the service, five responded saying that they ‘usually’ like the meals (in response to the question ‘Do you like the meals – always, usually, sometimes, never’) and four that they ‘always’ liked the meals. Additional comments received included: • ‘I wouldn’t complain’ • ‘portions are good’ • ‘the meals are lovely but not quite like my cooking at home’ • ‘we have a very good cook’ In the pre-inspection information provided by the home, the manager confirmed that there is a choice of menu and that special diets can be provided. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Any person wishing to complain is directed through a written procedure detailing how their concerns will be addressed, they can therefore be confident that their complaints will be listened to and taken seriously. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively. EVIDENCE: The home’s complaints procedure is contained within the Service User Guide that is available to all residents and their visitors in resident’s bedrooms. A record of complaints received by the home is held, examination of this demonstrated that complaints are responded to within the given time-scale and to the satisfaction of the complainant. One complaint received by the Commission was redirected to the home for investigation; this was managed effectively. A policy document is available for staff reference directing them through appropriate procedures to be followed in the event of any suspicion of abuse; staff training programmes include a unit on adult protection issues. No incidents have been reported. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is good although could be improved by addressing the good practice recommendations. This judgement is made using available evidence including a visit to this service. Accommodation at Highgrove is safe and well maintained although outside areas could be improved for the benefit of residents and visitors. Residents are able to benefit from comfortable, well furnished, generally clean and hygienic surroundings although some unpleasant odours result in residents living in undignified circumstances. EVIDENCE: One bathroom and one shower room have been completely refurbished since the last inspection and now provide clean, hygienic and appropriate facilities for residents. Bathroom’s and toilets are accessible to residents and bath aids are provided as necessary. There was evidence of on-going decoration around the home; Mrs Bleach confirmed that rooms are re-decorated as they become vacant. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 18 Resident’s rooms are comfortable and furnished appropriately and residents are able to benefit from having some of their own belongings around them. The lounge area of the home provides a sociable meeting place for residents. Patio doors lead from the lounge area to the rear gardens via two steps. Residents spoken with confirmed that it was nice to get into the garden in the warm weather and could not recall any difficulties negotiating the steps, it is however recommended that the area is assessed and action taken to ensure safe access is provided. One comment received from a relative on a returned questionnaire was that the external areas of the home could ‘be more attractive, building supplies etc. left in car park, seating is not good…’ The home is generally clean and hygienic although some areas that had strong, unpleasant odours would benefit from a review of cleaning schedules and products used to eliminate odours. Requirements of the last inspection have been addressed with regard to exposed pipe-work and radiators. All hot surfaces have now been guarded with low surface temperature covers. A requirement of the last inspection concerning hand washing facilities for staff in relation to the home’s infection control procedures has been addressed, staff are now provided with appropriate dispensers of anti-bacterial soap, disposable towels and alcohol gel hand rub. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement is made using available evidence including a visit to this service. There are sufficient numbers of staff on duty in the home each day and night to provide the level of care and support needed by residents. Staff training programmes are developing but could be improved to ensure that a staff group that has regular up-dates of their skills and knowledge meets residents needs. Staff recruitment practices are good although are let down by failure to collect all the necessary information and issue contracts. EVIDENCE: Examination of staff rotas demonstrated that there are three care staff on duty each morning, two each afternoon and two each night. Additionally, the manager and assistant manager are in the home at varying times throughout the week, supernumerary to care staff in a management/supervisory capacity. One resident stated that it would be good to be informed if there is to be a change of night staff and when agency staff are used. Three members of care staff have attained NVQ in care to level 2, a fourth staff member has achieved the award although is currently awaiting her certificate to evidence this, this represents 25 of the sixteen staff employed trained to NVQ level 2 Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 20 Staff files examined demonstrated that staff are safely recruited ensuring that all appropriate checks are made as to their suitability including criminal records* checks, health screening and references. One file examined however, did not detail the applicants qualifications and no contract had been issued detailing the terms and conditions of employment; the staff member started employment on 6 March 2006. An induction training programme has been arranged which is held in accordance with the Skills for Care workforce training targets for care staff and the assistant manager is working through the workbooks with all staff. Assessment and measurement of staff understanding is carried out during staff supervision with each staff member and is recorded. *The Criminal Records Bureau check includes a check against the POVA list to ensure the person applying for the position has not been excluded from working with vulnerable people. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement is made using available evidence including a visit to this service. The registered manager would benefit from further management training to ensure she is able to discharge her duties effectively. Quality assurance programmes and audits need to be developed to ensure controlled measurement of care and services provided in order that the home meets its expressed aims and objectives. Residents are safeguarded by good procedures for managing their personal financial affairs with the support of their families. Staff are supervised to ensure they maintain good working practices. The health and safety of residents is protected by procedures that enable the homes fire safety equipment to be regularly checked and maintained, by appropriate planning with regard to moving and handling and appropriate procedures in respect of infection control. Hazards around the home have been reduced since the last inspection with regard to hot surfaces which have all been guarded to prevent accidental scalding. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 22 EVIDENCE: Mrs Rose, the registered manager obtained a City & Guilds management qualification in 2000, this training must now be updated; the C&G units can be used toward the Registered Managers Award. Mrs Rose must also demonstrate that she is abreast of current good care practice and achieve an NVQ in care at level 4 Mrs Rose has distributed questionnaires among residents to obtain their views on the activities provided by the home, returned questionnaires examined demonstrated mainly positive comments although a few suggestions for developing social care were received. There has been no formal audit of results and no action plan. There have been no other audits to establish the quality of the care and service provision and there is no development plan. Mrs Bleach as the responsible individual for Samily Care Ltd carries out monthly visits to the home and submits a report to the Commission and the manager of the home, the content of these were discussed and it is consider that these monthly inspection could be more productive ensuring that Mrs Bleach ensures the home is compliant with the regulations and is meeting the expected standards. Mrs Bleach confirmed that the home does not take responsibility for any residents personal finances and ensures that all residents have representation with their affairs. Several residents are able to retain control over their own financial affairs, for those that are not, the home ensure purchases of services (hairdressing, chiropody) as required and other comforts such as sweets, newspapers, clothing etc. and sends an invoice to the fee payer each month. Care staff receive regular supervision from either the manager or assistant manager, current supervision sessions are used to measure progress in understanding all units of the induction training which all staff are undertaking to update their skills and knowledge. Examination of records of testing and maintenance of fire fighting equipment, alarm systems and emergency lighting demonstrated that these are undertaken at the required intervals. The record of fire drills and evacuations is combined and demonstrates when these occurred; a brief report outlines some detail of the process but would benefit from being more specific including a record of who took part and how long the evacuation took. Other aspects of health and safety have improved since the last inspection, a better moving and handling plan is in place for one resident who requires assistance in this area, hand washing procedures for staff have improved with the supply of antibacterial soaps and disposable towels and hot surfaces have been guarded. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 X 3 3 3 1 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 3 X 3 Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered 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. Standard Regulation Requirement All service uses must have a full and comprehensive assessment on which to base an individualised plan of care that must be followed in order that care needs can be met and risks reduced or eliminated. Service users must be consulted with regard to the decision-making processes of assessment and care planning. This requirement was first made at the inspection dated 07.04.05 and was repeated at the inspection of 05.10.06 This requirement is again repeated as one service user did not have a plan of care, one had no specific plan of care relating to management of diabetes and two would benefit from a review of continence care needs. A record must be held indicating the amounts of all medicines received into the home. Where photographic materials are used to direct caregivers in the use of equipment, photographs must be taken in a manner that respects the dignity of the service user. DS0000061344.V291471.R01.S.doc Timescale for action 1. OP7 14 & 15 30/06/06 2 OP9 13 30/06/06 3 OP10 12 30/06/06 Highgrove Version 5.1 Page 25 4 OP26 16 5 OP29 19 6 OP33 24 The registered persons are required to enable effective cleaning schedules to eliminate strong odours from the home. The registered persons must not appoint any staff member to work in the home until all the conditions of regulation 19, schedule 4 have been met including obtaining verification of the applicants claimed qualifications. The registered persons must establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users 30/06/06 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP3 Good Practice Recommendations It is recommended that where residents are asked to sign their pre-admission assessment information that this is done following their participation in the process and that they have a full understanding of the implications of the assessment. It is recommended that social care plans are formulated for residents that identify, following assessment, how their individual social, recreational, cultural and religious needs can be met. It is recommended that access to the rear garden through the patio doors is assessed and advice sought on control measures that could be used to reduce risks associated with the two steps into the garden. When agency staff are used, it would be considered good practice for known staff to introduce them to residents. It is recommended that at least 50 of care staff are trained to NVQ level 2 by the end of 2006. DS0000061344.V291471.R01.S.doc Version 5.1 Page 26 1 2 OP12 3 4 5 Highgrove OP20 OP27 OP28 6 OP29 7 OP31 8 OP33 9 OP38 It is strongly recommended that the registered persons considered the legal requirement of the Employment Rights Act 1996 that states that a statement of the particulars of employment shall be given not later than two months after the beginning of employment. It is recommended that the registered manager update her skills in care home management and enrol on a level 4 NVQ in care and the Registered Managers Award. It is recommended that the Responsible Individual ensures that she addresses the homes compliance with the Care Homes Regulations and the expected standards as part of her monthly visits to report on the conduct of the home. The record of fire drills and evacuation should be extended to include detail of who took part and how long the process took. Highgrove DS0000061344.V291471.R01.S.doc Version 5.1 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 Highgrove DS0000061344.V291471.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. 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