Inspection on 06/10/05 for Highgrove

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 05/05/06

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 Unannounced Inspection 10:30 6 October 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 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.V250324.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th April 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. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection on 6th October 2005 lasted for four and half hours. The deputy manager was in charge of the home. Ms Janice Rose, registered manager was taking a day off although arrived for the purpose of the inspection and Mrs Bleach, one of the responsible persons for Samily Care Ltd also arrived to assist with the inspection process. The inspection was undertaken by Jo Palmer and Heidi Banks, Regulation Inspectors. The purpose of the inspection was to assess progress in meeting the requirements and recommendations of the last inspection and assess outcomes for residents against some of the National Minimum Standards. This inspection identified that of the fourteen previous requirements made, three had been addressed and of five recommendations, one had been considered. Following any inspection, the registered persons are expected to submit an action plan detailing how requirements would be addressed to evidence that the home will comply with the regulation, after the last inspection, Mr & Mrs Bleach and Ms Rose declined to submit an action plan although a meeting was arranged to discuss the way forward. Further to the meeting a letter dated 10th June 2005 was sent to the providers detailing progress as discussed and that all requirements would be reviewed at the next inspection. The inspectors spoke with four residents, one care assistant, the manager and Mrs Bleach, took a tour of the home and examined relevant records. What the service does well: Although many concerns have been raised as a result of this inspection, residents spoken with confirmed that they felt they were treated well by a kind and caring staff group. Arrangements for medical care and attention are good. Although provision of social care was not directly assessed, it was evident that residents feel there is sufficient stimulation in the home and that suitable activities are provided. Residents are able to maintain contact with their friends and families with no restrictions on visiting. The provision of meals in the home is good and residents and the cook confirmed that fresh ingredients are used to prepare a range of appetising dishes. The home provides a clean and comfortable environment for resident to live in; residents have been able to personalise their bedrooms to varying degrees with pictures, ornaments etc. Recent decoration and refurbishments to many parts of the home have improved the appearance and Mrs Bleach acknowledges the areas that are yet to be done. The general atmosphere was Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 6 satisfactory having sufficient natural lighting, good ventilation and a reasonable temperature for the time of year. Staffing numbers seem in accordance with a care of Highgrove size although as residents needs are not fully assessed, it is difficult to measure whether staffing numbers and skill are sufficient to meet the needs of residents. What has improved since the last inspection? What they could do better: Many concerns have been raised as a result of this inspection resulting in the inspector recommending to the Commission that enforcement proceedings be commenced. The registered persons must address issues raised as requirements as a matter of urgency to ensure that standards are improved and regulations are not breached. Residents must have information about the care and services provided prior to moving to the home in order that they can make an informed choice as to whether Highgrove is the right place for their needs to be met. Information in the form of a Service User Guide must be available to all residents living at the home. Also to enable residents and their representatives to be confident that Highgrove is suitable for meeting their needs, a pre-admission assessment must be carried out. The registered persons must then confirm in writing, prior to the person moving to the home that, based on the findings of the assessment, the home has the services, facilities and staffing to meet those needs. Following thorough assessment, a plan of care must be written to direct staff how needs are to be met. Any identified risks to residents identified through assessment must be managed according to a planned care routine. Whilst residents spoken with spoke positively about the social care provided, it was not evident that every resident’s social care needs are met as there are no social care assessments identifying the person’s preferred daily activities, routines, cultural and recreational needs. There is no evidence of resident consultation in the planning of personal or social care delivery. Residents must be provided with a written complaints procedure; usually in the home’s Service User Guide, this was not available to residents during this visit, therefore, residents did not know who to raise concerns with or have confidence that their concerns would be listened to. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 7 Requirements of previous reports have not been addressed with regard to risk assessments for individual residents who remain exposed to hazards from excessive hot water temperatures and unguarded hot surfaces, the inspector has recommended to the Commission in respect of this, that enforcement proceedings are commenced. Residents safety is also compromised by poor infection control practices, there are insufficient hand washing facilities for staff. Staff recruitment practices require urgent attention and the inspector has recommended to the Commission that in relation to continued failure to comply, enforcement proceedings are commenced. Staff training procedures are not followed leaving residents in the hands of an unskilled workforce. The registered providers and registered manager must review management practices in order that residents can be confident of clear leadership and control of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 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.V250324.R01.S.doc Version 5.0 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, 3 & 4. Standard 6 in not applicable. Information is available outlining the care and services provided although this was not available to residents. The assessment process is insufficient and does not enable the home to thoroughly assess a persons needs or establish whether those needs can be met at Highgrove. EVIDENCE: The last inspection noted that the Statement of Purpose and Service User Guide were out of date. Following the last visit and at a meeting arranged with the providers and manager to discuss progress in meeting requirements, an up to date Service User Guide had been produced and made available to residents. A copy of this was provided for the commission and noted to contain all the relevant, expected information. This inspection noted however, that this guide was no longer available to residents; Mrs Bleach stated that it had been removed from resident’s rooms, as it needed updating in respect of an anticipated change of staff. However, the requirement remains, that each resident shall be supplied with a copy of the Service User Guide. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 10 The last inspection made the requirement that accommodation must not be provided to persons at the home until their needs have been assessed. One person recently admitted to the care home had not had a needs assessment prior to admission. The assessment had been completed on the day of admission resulting in this person being admitted to the home without any prior acknowledgement or recognition of their needs. There was no evidence of the resident’s involvement or consultation in the assessment process or their agreement with the outcome. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 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 The systems for resident consultation are poor with little evidence that resident’s views are sought or acted upon. There is no comprehensive or reliable care planning system in place to effectively provide staff with the information they need to satisfactorily meet resident’s needs. Resident’s health and welfare needs are met in part through visits to doctors and other health professionals as required although risks to resident health and safety have not been identified or acted upon. There are satisfactory arrangements for managing medication in the interests of residents. EVIDENCE: The last inspection reported that care plans are generic in nature with all residents having the same plan of care; this inspection identified similar, for instance, some care plans examined referred to the individual resident to who it related as ‘them or they’. Where residents have specific individual health needs, these had been addressed to a certain extent although care management plans were not robust, for example, a care plan for a resident with diabetes indicated a need for a low sugar diet, insulin (to be given by a Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 12 visiting district nurse) and that staff were to be aware of the condition referring them to the relevant literature that was kept in the home. The care plan did not identify the normal parameters of this persons blood sugar levels, how frequently and by whom they should be monitored, the signs and symptoms of hyper or hypo glycaemia and how to identify these or the action staff should take should symptoms occur. Some aspects of care planning are very detailed, although the same for each resident, for instance, care plans detailing the action necessary by staff to ensure residents teeth are cleaned, glasses are worn, finger nails are trimmed, hair done etc all demonstrate appropriate action for staff should this be what the resident requires. Care plans examined referring to personal hygiene for two residents indicated that staff should check under their breasts. There was no rationale for this intrusive practice. If a resident had been assessed as having a particular skin condition or was vulnerable to soreness in this area, a care plan detailing appropriate skin care would be suitable, neither of the two residents had skin assessments and neither had any recorded evidence of poor skin condition. One resident care file examined held a hospital discharge summary indicating that the person had dementia and confusion, the home’s assessment (preadmission assessment format completed after admission) stated ‘mental health – good’. There was no mental health assessment and no indication of any mental health needs identified in the care plan. The last inspection noted that risk assessments were not in place to identify any potential risks to residents in respect of their daily activities. The last inspection referred specifically to a resident whose care manager had identified prior to admission that this person must not leave the building unescorted as there was a danger of becoming lost. The last inspection noted that this person had been leaving the home alone for various activities. The inspection made the requirement that all aspects of risk must be assessed and a care plan devised informing staff of the action required to reduce the risks. Whilst Ms Rose no longer considers this person to be at risk, there has been no review of the risk assessment identifying the residents wishes and preferences for going out and the action staff should take should they not return or any acknowledgement for the frequency of review of the assessment of risk. See also section headed ‘Environment’ for inspection findings relating to risks posed by unguarded radiators and hot water. There were no assessments or associated care plans in relation to identified risks. Records and stocks of medication in the home evidence good practice and medication is managed in accordance with legal requirements. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Entertainment and some recreational activities are provided that enable residents to enjoy some of their leisure time. The absence of social care assessments and consultation limits resident’s abilities to let their social, cultural and recreational interests be known and limits staff ability to plan appropriate leisure pursuits. Residents maintain contact with their friends and families who are able to visit freely. A good, varied diet is provided offering a choice of menu; meals are taken in the dining room enabling residents to enjoy each other’s company. EVIDENCE: Residents spoken with confirmed that there was sufficient stimulation in the home; it was evident through speaking with residents and through observation, that the relationship between staff and residents was good. Books, magazines and games are provided in the lounge areas and residents have been able to bring in their own items of interests for their rooms. Social calendars were not inspected although Mrs Bleach and Mrs Rose confirmed that the home had taken residents on outings and had a garden fete in the summer. The social, cultural and recreational needs of residents had not been assessed in order that the home should know the level of activity required for individual residents. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 14 Residents spoken with confirmed that the provision of food was good with appetising meals being served. In brief discussion with the cook in the kitchen it was evident that meals are prepared from a set menu using fresh ingredients purchased from the local supermarket. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complainants are not directed through an available written procedure detailing how their concerns will be addressed, therefore, they cannot be confident that their complaints will be listened to or 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 in the Service User Guide, this was not available to residents. Mrs Bleach and Mrs Rose confirmed that no complaints have been received directly by the home. The Commission received one complaint and referred this to the provider for investigation, it was considered that the matter was fully investigated and no further action was necessary. The last inspection made the requirement that the home’s policy for the protection of vulnerable adults was revised to ensure that information provided for staff was in accordance with local authority guidelines, this inspection noted this to have been done. No untoward incidents have been reported. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Bedrooms, bathrooms toilets and communal areas provide sufficient room for residents and a satisfactory standard of décor. Furnishings and fittings are generally, but not always, well maintained. The atmosphere in the home was, in the main, satisfactory with sufficient light, ventilation and at a suitable temperature for the time of year. Residents are presented with hazards from the environment in relation to the risks of accidental scalding from hot water and radiators which compromises their safety. Facilities for staff to ensure against the spread of infection are not in accordance with recommended best practice. EVIDENCE: There is evidence of continuing improvements to the décor of the home, several rooms have been decorated, some new furnishings have been provided and some rooms now have suitable locks to their doors. Some rooms are provided with lockable storage space. Rooms are personalised to varying Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 17 degrees, as residents are able to bring in items of their own such as ornaments and pictures. Some furniture and fittings are looking somewhat ‘tired’ and are in need of replacement; Mrs Bleach confirmed that this is in hand as part of the on-going programme of refurbishment. An old refrigerator is used for storage of dry foods in the kitchen; the door is tied shut with string. Bathrooms and toilets are conveniently sited around the home, additionally, nine of the sixteen single rooms have en-suite facilities, one ground floor bathroom is in a state of disrepair and needs modernising, tiles are missing from the bath surround and the bath sealant is stained and not watertight. In two of the three bathrooms water temperature was tested by hand, both were too hot to place a hand under, one was tested using the home’s own bath thermometer. This is not a calibrated thermometer and is tied by string at a distance that cannot reach the running tap. On filling the bath from the hot tap sufficiently for the thermometer to reach the water, the reading rose to the top of the temperature scale, which was 50 degrees. As the thermometer was not capable of reading temperatures higher than 50 degrees it is not possible to measure the actual bath temperature. Hot water temperatures from basins were also too hot to place a hand under. Radiators in resident’s rooms remain unguarded. The requirement of previous reports is repeated (although reworded to be more specific) and the inspector has recommended that the Commission issue a Statutory Notice to the registered persons in respect of this breach of regulation. The last inspection made the requirement that staff must be provided with suitable hand washing facilities to prevent the spread of infection, this inspection visit noted that this has not been addressed, no anti-bacterial soap or disposable towels are provided for staff in accordance with infection control procedures. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 The needs of residents are not sufficiently assessed to judge whether there are adequate numbers of staff on duty to meet those needs although in terms of numbers, staffing levels are in accordance with other similar care home establishments of the same size. Limited progress has been made in ensuring that staff are safely recruited or equipped with the skills necessary to meet assessed need. EVIDENCE: Rota’s demonstrate that there are between two and three care staff on duty in the mornings and either the manager or deputy manager is also available. In the afternoons there are two or three staff including the manager or deputy. The deputy was due to leave her position the day following inspection; Mrs Bleach confirmed that she would recruit another deputy shortly. One member of staff with a second sleeping in/on call covers the night shift. In the absence of thorough assessments and care plans, it is not possible to measure whether there are sufficient staff to meet the needs of residents. Previous inspections have made requirements regarding the home’s recruitment process to ensure that robust procedures are in place for the protection of residents. this inspection noted that whilst most relevant documentation is held on staff as has been previously required, one staff file examined did not demonstrate that a CRB* check had been carried out or that a POVA* check had been made. The requirement of previous reports is Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 19 repeated (although re-worded to be more specific) and the inspector has recommended that the Commission issue a Statutory Notice to the registered persons in respect of this breach of regulation. There has been no induction or foundation training for staff at the home, Mrs rose confirmed that she has not been able to carry this out yet although a training pack is available. * CRB – Criminal Records Bureau POVA – Protection of Vulnerable Adults – a list of persons held by the Secretary of State who are deemed unsuitable to work with vulnerable adults Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 37 & 38 Management practices do not promote and safeguard the health, safety, and welfare of residents; there are no clear lines of accountability and there is no evidence to indicate how improvements are to be managed, the poor management arrangements for the home leave the residents at risk. EVIDENCE: Samily Care Ltd took control of the home from the previous owners in June 2004, Mrs Rose, registered manager, continued to be employed to manage the home. Mrs Rose has obtained a management qualification although the details of this were not discussed during this inspection. This, and previous inspection reports have evidenced that management practices in the home are not transparent, there is no clear role identification. Mrs Bleach visits the home regularly and prepares a report under regulation 26 as required each month. Copies of these reports received by the Commission demonstrate to some extent an inspection of the home and interviews with staff and residents. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 21 These reports do not indicate any discussion with the manager about improvements, the National Minimum Standards or developments in relation to requirements of inspection. Residents and staff do not benefit from the ethos, leadership and management approach of the home, as it was evident that residents spoken with were not aware of the role of the manager or how decisions were made regarding their care. Also evident during this inspection was the registered person’s lack of confidence in staff. On arrival at the home, the deputy manager was in charge although it was to be her last working day, she did not have access to the home’s office and the records that would be necessary for her to competently carry out her role. Mrs Bleach confirmed that she does not undertake regular supervision with Mrs Rose and Mrs Rose confirmed that likewise, she does not supervise staff. An example where lack of supervision is detrimental to service provision was evident during this inspection in relation to staff training. Both Mrs Bleach and Mrs Rose stated that it was the responsibility of the deputy manager to assess the need for, and organise, the appropriate training for staff. As the persons registered to provide care and manage Highgrove, Mrs Bleach and Mrs Rose must take responsibility for ensuring that all areas of practice and service provision meet the required standards. Delegation of responsibility is acceptable where the delegate is supervised and supported in their actions. Records required by regulation for the protection of residents are not up to date and accurate, particularly in respect of resident assessments, care records and risk assessments. Although resident care files require attention, these are held in the home, other information concerning care management arrangements, contract and financial information are held in the home’s office which is not accessible to staff or residents. Records relating to the testing and maintenance of fire alarms, emergency lighting and fire fighting equipment demonstrate that all equipment is serviced and maintained at the required intervals. Records relating to staff fire training could not initially be found although Mrs Bleach then found that these records were held in individual staff files. These were not examined. The health and safety of residents is compromised by poor practice in relation to infection control procedures, water temperature regulation, surface temperatures and staff training. Requirements regarding the Safe Working Practices standard (standard 38) have been made under standards 25, 26 and 30. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 3 1 X 3 3 1 1 STAFFING Standard No Score 27 3 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X X 1 1 1 Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The registered persons must supply a copy of the Service User Guide to each service user; this must contain a summary of the home’s Statement of Purpose. This requirement was first made at the inspection dated 10.09.04 and is repeated for the third time. Accommodation must not be provided to persons at the care home until their needs have been assessed; assessments must be comprehensive and provide sufficient detail to enable staff at the home to understand the needs to be met. This requirement was first made at the inspection dated 07.04.05 and is repeated for the second time. The registered persons must demonstrate that the service user or their representative have been consulted with regard to the assessment process and have agreed with the outcomes. The registered person must write DS0000061344.V250324.R01.S.doc Timescale for action 1 OP1 4&5 30/11/05 2 OP3 14 30/11/05 3 OP3 14 31/12/05 4 Highgrove OP4 14 31/12/05 Page 24 Version 5.0 5 OP7 14 & 15 6 OP12 16 7 OP21 23 8 OP25 13 to service users following the pre-admission assessment to confirm that, based on the findings of the assessment, the home is able to meet their needs. 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 is repeated for the second time. The registered persons must demonstrate that they have consulted service users about their social and cultural interests and make arrangements for them to engage in local, social and community activities. Service users must be consulted about the programme of activities arranged by the home which must then provide planned social care that meets their needs. Bathrooms must be maintained, kept clean and reasonably decorated, and be suitable for the purpose of achieving the aims and objectives of the home. The registered persons must ensure that all residents have a robust, individual assessment of any risks of accidental scalding posed by unguarded radiators, pipe- work and hot water. Risk assessments must address individual considerations including the person’s mobility, DS0000061344.V250324.R01.S.doc 30/11/05 31/12/05 30/11/05 02/12/05 Highgrove Version 5.0 Page 25 9 OP25 13 10 OP25 13 history of falls, confusion and their level of understanding if they are physically independent enough to take themselves for an unassisted bath. Action to be taken by staff to ensure risks are reduced or eliminated must be explicit and all assessment and care planning documentation in relation to this must be available for staff reference. This requirement has been made repeatedly over the last five inspections (wording has changed over time to provide more clarity) and is now repeated for the sixth time. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. The registered persons must produce a schedule of maintenance demonstrating time-scales for completion of works, including radiator and pipe work guards and hot water regulators. This requirement has been made repeatedly over the last five inspections (wording has changed over time to provide more clarity) and is now repeated for the sixth time. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. Radiators and pipe work must be guarded and hot water regulated to a temperature around 43 degrees centigrade. This requirement has been made repeatedly over the last five inspections (wording has DS0000061344.V250324.R01.S.doc 02/12/05 31/01/06 Highgrove Version 5.0 Page 26 11 OP25 13 12 OP26 13 13 OP29 19 14 OP29 19 15 OP29 19 16 OP29 19 changed over time to provide more clarity) and is now repeated for the sixth time. The inspector has recommended to the Commission that Statutory Notices are served for breach of regulation and noncompliance. Hot water must be regulated to a temperature around 43 degrees centigrade. To prevent the spread of infection, staff must be provided with suitable hand washing facilities including anti-bacterial soap and disposable towels. This requirement was first made at the inspection dated 07.04.05 and is repeated for the second time. The registered persons are to obtain a POVA First check on the member of staff identified at inspection and send written confirmation to the Commission within 72 hours. The registered persons are to obtain a current Criminal Records Bureau certificate for the person identified and send written confirmation to the Commission within 72 hours of this notice that until such time as this is received, the staff member shall not work unsupervised. With immediate effect, no new staff are to be appointed until such time as a satisfactory POVA First check has been made. With immediate effect, any new staff appointed who have a satisfactory POVA First check must not work unsupervised until such time as a satisfactory CRB certificate has been obtained. DS0000061344.V250324.R01.S.doc 31/12/05 30/11/05 24/10/05 24/10/05 05/10/05 05/10/05 Highgrove Version 5.0 Page 27 17 OP30 18 18 OP32 26 19 OP32 10 20 OP36 18 21 OP37 17 The registered persons must ensure that all staff are trained to a level that demonstrates their competence. Care staff must receive induction and foundation training within the specified time-scales that conform with National Occupational standards for care staff. Where the responsible individual carries out a regulation 26 visit, the report of these visits must demonstrate that the conduct of the home in relation to the National Minimum Standards and compliance with the Care Homes Regulations 2001 has been examined and identify where and by when, matters shall be addressed. The registered provider and the registered manager must review management practices to ensure the smooth running and organisation of the homes administration for the benefit of residents and staff. The registered manager must arrange for the supervision of staff at regular intervals where all aspects of practice, their training needs and the philosophy of care of the home are discussed and recorded. The registered manager must also receive supervision in this manner from the responsible individual. Records required by regulation for the protection of service users must be maintained, up to date and accurate and service users must have access to their records and information held about them. 31/01/06 30/11/05 31/12/05 31/12/05 30/11/05 Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 28 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 OP19 Good Practice Recommendations It is recommended that the refrigerator in the kitchen that is not working and is currently used for dry storage held closed by a piece of string, is removed. Highgrove DS0000061344.V250324.R01.S.doc Version 5.0 Page 29 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.V250324.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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