Inspection on 27/09/06 for Highgrove Care Home

This inspection was carried out on 27th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Highgrove Care Home 10/11/05

Highgrove Care Home 22/06/05

Highgrove Care Home 16/02/05

Highgrove Care Home 17/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Highgrove Care Home West Rd Mexborough Doncaster South Yorkshire S64 9NL Lead Inspector Janet McBride Key Unannounced Inspection 27th September 2006 10:15 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 Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highgrove Care Home Address West Rd Mexborough Doncaster South Yorkshire S64 9NL 01709 578889 01709 578842 paulhulbert@ntworld.com www.winniecare.co.uk Winnie Care (Highgrove) Ltd 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) Mrs Christine C McDonnell Care Home 78 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (57) of places Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. One named Service User under 65 years old to reside on the residential unit Highgrove Care Home provides a separate 21-bedded EMI residential unit. The Registered Manager, Christine McDonnell, must undertake and complete further training on Dementia Care conversant with her professional status. One named service user to be admitted to the unit on rolling respite Date of last inspection 10th November 2005 Brief Description of the Service: Highgrove Care Home provides residential and nursing care accommodation for older people, it is registered for 78 beds on three units, comprised of a nursing and residential unit, on the ground floor, residential unit on the upper floor and a separate 21 bedded residential EMI unit. All the bedrooms are single, and the home has two specific bedrooms for high dependency nursing service users. Highgrove Care Home is located in the town of Mexborough and is in within walking distance to local shops, public houses and other community amenities. Highgrove was first registered in July 2002, and since 2005 as been owned by Winnie Care, who has other homes in the area. Fees range from £375:00 to £420:00:00 per week, as at October 2006. The above charges are plus nurse banding for those residents that require nursing care. Other extras are for hairdressing, chiropody, newspapers and magazines. The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to residents and their families. The home last published inspection report was also available for resident and relatives to read. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this Unannounced Key Inspection at Highgrove, which took place over two days on the 27/9/06 and the 02/10/06 2006 11:00 hours were spent at the home. The home is registered for 78 beds on three units. Pre-Inspection work was carried out for example, analysis of notifications and any other relevant documentation. During the Inspection various documentation and records were examined for example, medication records, staff rotas, staff training files and case tracking of three residents care plans, one from each unit. These were cross-referenced with medication records and any other relevant documentation. Tour of the premises and direct and indirect observation of staff interaction with residents throughout the visit and information was gathered from as many different individuals as possible that had contact with the residents in their environment, for example individual interviews with members of staff, including the manager. Talking to some of the residents within the home and feedback from relatives and visitors on the day. The Inspector would like to thank all the staff and residents for their cooperation in the Inspection process, and any issues or concerns that were raised were discussed with the manager at the end of the Inspection. What the service does well: What has improved since the last inspection? Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 6 The home has addressed all the requirements made at the last Inspection, 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 Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 7 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 Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 8 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): 2, 3 and 4. Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to the service. All resident’s needs are met, with pre assessments being completed before they move into the home and residents are issued with contracts/statement of terms and conditions to ensure they are fully aware of the services and facility provided. EVIDENCE: Residents can visit the home prior to their admission to assess if they want to live there, and new residents are admitted on the basis of a full assessment has been completed, to ensure their needs will be met. The home offers a wide range of services, including specialised e.g. dementia care. Residents are assessed for residential EMI and residential and nursing care needs, the home does not offer intermediate care, but can offer respite care when beds are available. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 9 Evidence was seen in care plans that were case tracked, that care management assessments had been completed for residents placed by funding Authorities, and that self -funded residents had a written assessment prior to admission completed by the management of the home, involving other professional involved in their care, for example consultants, CPN, Continence nurses, speech and language therapists. Once admitted various assessments had been completed and plan of care put in place, which was relevant for each individual. The range of fees is documented on page 5 of the report, also any extras that are charged, residents are issued with contracts/statement of terms and conditions to ensure they are fully aware of the services and facility provided. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is Adequate. This judgement has been made using the available evidence in records, talking to staff and a visit to the service. Residents receive health and personal care based on there assessed individual needs, and is referred to any specialist services when required. Staff not keeping relevant medicine records up to date affects this outcome. EVIDENCE: Care plans seen were found to be of a good standard, three care plans were case tracked one from each unit, and those seen reflected the health needs of residents by including appropriate risk assessments and body maps are used to document either pressure areas or body marks, nutritional assessments are undertaken and involvement of dietician when required and weight checked on a regular basis. Evaluations were done on a regular basis, evidence that some residents have been involved in planning of their care. Some issues raised on the last inspection had been addressed, and found that staff had completed checklists, Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 11 and documenting if residents don’t wear dentures or hearing aids, and the reason why. Residents have access to health care services, and evidence that residents are referred to other health professionals when required, the EMI unit also have access to a Consultant Psychiatrist and CPN services that visit the home on a regular basis. Residents can also access to dental, optician and chiropody services when appropriate. The homes accident book was seen and appropriate documentation had been completed, the manager also ensures that regulation 37 is sent to the Commission for Social Care Inspection. The manager also completes a monthly accident analysis report, which was also examined. Medication records were discussed with the manager and the person in charge of each unit and observation of medicines being given to residents on one unit. The home has a comprehensive policy on the safe receipt, storage, handling and administration of medication, which complies with the requirements of the Medicines Act. The home has arranged for the collection of waste medicines, with records kept. An audit of the records and stock checked on the day raised some issues; Mar sheets that were hand written were not signed by members of staff, and no reason was documented when medication was omitted, photos missing on a number of records. It was also noted that staff did not always ensure the resident had taken their medicine, or had signed it before administering. During the Inspection staff were observed carrying out tasks; talking to residents and staff appeared to be both prompt in attending to their care and attentive to residents. Staff that was interviewed gave examples of how they ensure that residents receive privacy and dignity within the home. Those residents that could voice their opinions had very positive views on the home, stating staff was good and most of them were always cheerful when carry out their duties. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is Good. This judgement has been made using the available evidence, interviewing staff, residents including observation at mealtime. Opportunities for residents to participate in variable activities if they wish, and for residents to receive a wholesome and appealing balanced diet with a selection of choices for meals. EVIDENCE: The home as two activity organisers who work four days a week, both was interviewed during the inspection and the inspector attended a residents meeting on the day. Social activities are co coordinated across the home, which are advertised so that residents, relatives and visitors are aware what is taking place within the home. The home arranges monthly meeting for residents and minutes are taken, evidence was seen that kitchens staff had attend these meeting to discuss issues relating to the food within the home. The home produces a monthly newsletter, which is very informative, and they have an information board, which contains loads of useful information for both Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 13 residents and visitors for example, results of quality audits undertaken, Inspection reports and how to contact external advocates. Residents were able to confirm that activities take place and informed the Inspector of what took place to celebrate various special days. Family and friends can visit at any reasonable time and can see resident in private if they wish, relatives seen confirmed they can be involved in residents care for example attend reviews and discuss care plans. Some residents seen had the capacity to make choices and could give examples, when to get up and go to bed, what to wear, what to eat and if they take part in activities. When staff were interviewed they were asked about those residents who don’t have the capacity to make choices how the deal with this; always encourage residents to make a choice and involve relatives in this process whenever possible, e.g. life history, hobbies and likes and dislikes. Lunchtime was indirectly observed on all three units; menus were on display and all meals are served by kitchen staff either directly from the kitchen or from a hot trolley, meals looked appealing and appetizing, even liquefied meals were well presented. Tables were nicely set and had condiments available. Residents were asked about food at the home, they stated they had a choice, including a cooked breakfast. Staff was available to give assistance and residents had sufficient time between courses to eat their meals The cook was interviewed and discussion about her role and menu’s, she stated that residents always have a choice, food and drinks are available 24 hours a day. They work on a four-week menu, and special diets are catered for. The home usually uses local shops for fresh vegetables and fruit and a local butcher for meat. Residents like and dislikes are usually recorded, and she attends residents meetings to answer any questions about the menus and food within the home. Evidence was seen that nutritional assessments are completed and involvement of dietician if necessary. Environmental health visited 31/3/06 and issued a few minor requirements, for example new chopping boards and repair damaged tiles all these issues had been addressed. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 14 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 and 18. Quality in this outcome area is Good. This judgement has been made using the available evidence, and information received from notifications and interviewing staff on the day of the visit. Residents are protected by the homes policies and procedures, and resident, relatives and visitors are provided with information to enable them to raise any concerns or complaints about the home or their care. EVIDENCE: The home has an appropriate complaints procedure, the procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints, the address and telephone number of the Commission for Social Care Inspection is also included in the procedure. The pre Inspection questionnaire stated that they had three complaints since the last Inspection therefore these records were checked. Records examined show that these complaints had been dealt with promptly with clear details of how they were investigated and the action taken with feedback to the complainant. The home does have an Adult Protection procedure including Whistle Blowing. The registered manager encourages staff to disclose information regarding the protection of residents and the providers ensure staff receives training to enable them to recognise signs of abuse. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 15 This was discussed with some of the staff interviewed on the day; and all staff is aware of the homes abuse policy, and could explain to the Inspector about the policy and whistle blowing. There have also been two referrals made to adult protection since the last inspection, the registered providers and the registered manager have assisted fully during these investigations. All staff is CRB and POVA checks completed, before commencing employment with the home. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is Good. This judgement has been made by a visit to the service talking to visitors and tour of the premises. Well-maintained and renewal of equipment ensures that residents live in comfortable environment, with private space that allows them to have their own possessions around them. EVIDENCE: Location of the home is near shops and other community facilities; it is a well maintained, safe and accessible for residents. The reception area of the home seems to be a favourite place to sit for some of the residents, two of the residents informed the Inspector they enjoy sitting, here “they can see what happening and who comes in and out of the home.” Tour of communal areas on all three units found them all to be clean and tidy some issues were raised on the nursing unit e.g. lounge carpet very stained. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 17 Residential unit the lounge chairs were well worn and stained, corridor walls in the unit were very marked and in need of re-painting. Dining room very full as they have a lot of residents on this unit, the home are addressing this by looking at alternative ways of dining e.g. two sittings the residents will be consulted on this issue. During the day a number of residents gave comments to the Inspector, about dining arrangements want to be able to sit with my friends” “they should knock a wall down and make it bigger”. EMI unit as babble locks on the doors to the unit, tour of all the communal areas were satisfactory. Random sample of bedrooms on each unit was seen, all the bedrooms had been personalised with service users own items, photos and other memorabilia. Each bedroom looked very comfortable and was furnished to a high standard; some residents had own phones and fridges in their bedrooms. The home has two specific bedrooms on the nursing unit for high dependency residents these are very large bedrooms for any equipment that may be needed. One issues raised some of the bedroom windows, restrictors had been taken off and this made open to wide, this as been found on passed inspections and was discussed with the manager and advised that this practice must cease and windows closed to the required opening to ensure safety for residents. One bedroom on the EMI unit the carpet was very stained and the bed was old mental type that looked well worn, however the bed had been replaced by the end of the Inspection. Laundry facilities at the home are satisfactory, it was found to have the required impermeable flooring and was well organised. Staffs who were interviewed gave good examples of how they ensure that infection control is maintained within the home. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Good. This judgement has been made using the available evidence in records, interviewing staff and a visit to the service. Appropriate staffing and skill mix, to meet residents care needs, and on going development of staff to ensure they have the skills and knowledge to carry out their role. EVIDENCE: Staff numbers was discussed with the manager, who stated that staffing numbers are dependent on the care needs of the residents. Duty rota clearly identifies staff within the home and their role, including ancillary, domestic and kitchen staff, the manager is supernummary with two identified deputy managers. The home has a very stable staff group, which ensures continuity of care by staff who know the residents. Recruitment policy and practice was examined, three files were checked, and these were new staff at the home. It was evident that the home operates a through recruitment procedure, based on equal opportunities and ensues the protection of service users; e.g. two written reference, gaps in employment checked, CRB and POVA checks completed, PIN and qualifications of nurses, and, ID documentation of each member of staff was also in files, these files were well organised and easy to follow. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 19 Through interviewing staff and examination of training files it was evident that staff had the skills and knowledge to fulfil their roles within the home, and the company offer on going development for staff via NVQ training. The home have 45 care staff, 17 have completed their NVQ level 2 or 3 and 6 other staff members are working towards this, the company are trying to ensure that 50 of care staff will be NVQ trained. Training and development files were available, and training matrix shows what training has taken place and which staff have attended, all staff has their own training file and all new staff undertake the TOPSS training induction this was confirmed by staff at the home that they work through this package, there as been quite a lot of training since the last inspection, for example, most staff have completed fire training and abuse training, one nurse confirmed they continue with their own development and attend courses as required by their registration. Other staff members of staff confirm the training they had completed when being interviewed. However a number of staff still requires updates in moving and handling, and Dementia training for some staff working on the EMI unit. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is Adequate. This judgement has been made using the available evidence in records, talking to staff, resident and visitors and a visit to the service. Residents live in a home that is run and managed by a manager that is experienced, and tries to ensures so far as is reasonably practicable the health, safety and welfare of each resident, but with regard to the window restrictors being taken off and this practice was found on passed inspections this is a health and safety risk for residents and as affected this judgement. EVIDENCE: The homes registered manager his fully aware of her responsibilities and provides leadership, guidance and direction to staff to ensure that residents receive consistent quality care. She has completed the Registered Managers Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 21 Award and will commence on a Dementia course, to fulfil her own development needs. Quality monitoring systems are in place and a number of audits have been completed since the last Inspection, and this evidence was available for the Inspector to examine, e.g. care plans, accident analysis and pressure sore audits all these are completed on a monthly basis. Highgrove has achieved and maintained the, ‘Investors in People’ award. Quality monitoring of care provision is done via sending questionnaires to residents usually once or twice a year, records show this was done in march and August 2005 and more recently in June 2006 the results were very good with most residents stating that the home offers good overall care, and staff attitudes got the best response with most residents stating staff are excellent, and during the Inspection a number of residents were very positive about the home, and the care they receive. Resident’s money was discussed with the homes administrator and records checked, which show that each resident had individual monies with appropriate records and receipts kept. Secure facilities are available with records of any possessions that are given for safekeeping. The homes also as a social fund account, two members of staff sign this and at periods relatives are also asked to check these records. The area manager on an annual basis audits all monies and records. Health and safety was discussed with the manager and staff that were interviewed, also observation of practice and maintenance and service records examined. Records show that all records were up to date and satisfactory, with up to date current certificates for lift and hoists within the home. Some staff still requires mandatory training in moving and handling, and observation during the day saw staff using wheelchairs without footplates. Other health and safety issues raised, window restrictors being taken off all these issues was discussed with the manager at the time. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Medication; 1) Staff must ensure that service users take their medication and them sign Mar sheet. 2) Photos are required on some Mar sheets. 3) Staff must ensure that stocks of medicines are rotated. 4) The fridge in which medicines are kept must have the temperature checked and recorded on a regular basis. Premises must be kept in good state of repair and décor with reference to; Lounge chairs in nursing and residential unit. Carpet must be replaced in the identified bedroom. The Registered provider should ensure that a minimum of 50 of care staff have NVQ Level 2. Timescale for action 02/10/06 2 OP19 23(2)(b) 01/01/07 3 4 OP24 OP28 23(2)(b) 18(1)(c) 01/12/06 01/03/07 Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 24 5 OP30 18(1)(c) 6 OP38 13(4) (c) Staff must have the appropriate training for the work they perform for example, Dementia training for staff that work on the EMI unit. Health and safety of service users. 1) Staff must ensure window restrictors are used. 2) Staff must ensure that footplates are used on wheelchairs. Staff must have updates on moving and handling. 01/01/07 02/10/06 7 OP38 13(5) 01/12/06 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 OP20 Good Practice Recommendations The home provides appropriate dining space for all service users. Highgrove Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Care Home DS0000058632.V312139.R02.S.doc Version 5.2 Page 26 - 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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