CARE HOME ADULTS 18-65
Highland Mist Bronshill Road Torquay Devon TQ1 3HA Lead Inspector
Stella Lindsay Key Inspection (unannounced) 15th May 2007 10:00 Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 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 Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Highland Mist Address Bronshill Road Torquay Devon TQ1 3HA 01803 328156 F/P 01803 328156 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 Susan Irene Ann Hill Mrs Susan Irene Ann Hill Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11/01/07 Brief Description of the Service: Highland Mist provides care for up to seven adults with mental health needs. The premises are in a residential area of Torquay within walking distance of shops, and the town centre. There is parking to the front of the home, and a garden with a grassed area, greenhouse and a patio. There is also a shed at the bottom of the garden for smokers. Entrance to the house is up several steps into the conservatory, which has a table that can seat four and is used for meals. There is a comfortable lounge. A new kitchen had been provided, spacious enough to enable residents to work alongside staff. The ground floor also has a shower room with toilet and three bedrooms. The laundry facilities are outside in the yard, accessed through a staff room. Stairs lead to the first floor, which has a bathroom with toilet, and four bedrooms, one of which is en-suite. The Manager has an office on the first floor, and there is a room for staff sleeping in. Current charges are £260 - £420. The Home has a Statement of Purpose and Service User Guide for the public to view, but previous inspection reports were not available. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three days in May 2007. It involved discussion with the five residents, two staff members on duty, the owner, Mrs Susan Hill, and the Acting Manager, Ms Lynn Edwards. Care records, health and safety records, staff files and the medication system were examined. Ms Edwards sent the required pre-inspection data and information. A Random Inspection had taken place on 5th April 2007, due to a lack of response to a Statutory Notice that had been sent to Mrs Susan Hill on 21st February 2007. What the service does well: What has improved since the last inspection?
New care agreements have been prepared, to make sure that residents know what Highland Mist offers, and what is included in the fee. Residents had been supported to open bank accounts, so that they can take charge of their own money. The Manager had supported residents to attend appointments with a view to training and voluntary work. They had also obtained subsidised entry to local sporting facilities. All staff had received training in the safe administration and storage of medication, to promote residents’ good health and avoid danger of mistakes. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 6 Builders were at work on improvements to the home. The lounge had been redecorated, and carpeted, and was looking smart and comfortable. The hallway and some bedrooms had been re-plastered and decorated. The bathrooms had been retiled, and suitable flooring had been laid. Paper towel dispensers had been fitted beside the hand basins in the communal toilets, and liquid soap was available. A new kitchen was being fitted at the time of this inspection, to provide better facilities for staff and residents to cook together. The office arrangements were being altered, to give the Manager a quiet office upstairs, and a more easily accessible care office downstairs. A sleeping in room had been made available upstairs, so staff no longer sleep in the lounge. The garden had been tidied up, and a small greenhouse had been provided, as residents said they would like to grow plants. The ‘smoke house’ was cleaned up and painted during the inspection. Recruitment procedures had improved, and checks on new staff had been carried out, to protect residents. All staff had received training in Protection of Vulnerable Adults, Food hygiene and Control of infection, in order to provide a safer service to residents at Highland Mist. The owner had introduced individual supervision sessions for staff, to give them feedback on their performance, and to consider their training needs. The fire precaution system had been improved, with all fire doors seen to be closing properly. What they could do better:
The Statement of Purpose and Service Users’ Guide must not contain any misleading information, so that new residents know what to expect at Highland Mist. Information about all a person’s care needs must be gathered before accommodation is offered, not only their specialist mental health needs so that staff can be prepared to meet these needs. Care plans should include clear guidelines that would enable residents to see how progress towards their goals might be achieved. Care plans should include behaviour management programmes, so that staff react in a consistent and appropriate way. Risk assessments should include clear advice for staff about how to ensure that residents are safe at all times. Risk assessments should be carried out with respect to fire safety of each room and area within the house. This is necessary to assure residents’ safety.
Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 7 The management have started to make arrangements for increased opportunities within and outside the home, but need to make further progress to improve the quality of residents’ lives. Records should be kept of concerns and minor complaints, and what action has been taken in response, so that people know that their voice has been heard. The work on the house needs to continue until the whole house is brought up to standard. The Food Safety Management process must be put into practice, to ensure good food hygiene standards are maintained. Staff are still awaiting training on the specific needs of their client group, to help them improve the quality of residents’ lives. More staff should achieve NVQ2 in promoting independence, to work towards having a qualified workforce. Staff should have specific training on the areas of equality and diversity and demonstrate how resident’s rights are being supported. The Owner or Manager must produce a report based on the information collected through the Quality Assurance system to demonstrate that monitoring is taking place and steps are being taken to improve the service taking into account the feedback that is gathered from residents and others, to make sure that the service is both reliable and responsive. 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. The summary of this inspection report can be made available in other formats on request. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is adequate. Information is available but is not entirely accurate, and pre-admission assessment did not cover all aspects of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Statement of Purpose had been produced which provided information as required by the regulations. The owner said that she intended to up-date it to include the new aims of the service which are currently being discussed. She expects these to include encouraging community involvement and support for residents to work towards independence. Residents said that they had been given copies of ‘the prospectus’ - or ‘Service Users’ Guide’. This includes photos, and local contact information about selfhelp groups. Both need to be checked for accuracy, and to ensure that they are clear about what is available at Highland Mist. One resident had recently moved to Highland Mist without the agreement of their care manager. The owner, manager, and some staff had known them in a different home for ten years. The other recent admission had come for a short stay. A risk assessment had been provided by their Mental Health professional. It would be good practice for Highland Mist to have its own preHighland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 10 admission assessment format, to ensure that a comprehensive needs assessment is carried out before accommodation is offered, to enable staff to be prepared to meet their varied needs. The owner had produced a ‘pathway’ for the process of admission, starting with a visit to the person by a manager and including introduction to current residents. New contracts had been drawn up on behalf of all five residents, to be given to them along with an information sheet – ‘How to look at your contract’, for them to discuss with their family or advocate before signing. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. More progress is needed to provide clear guidance for staff about safe and effective ways of working, and clear guidance for residents on how to work towards their own goals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are being developed, though further progress is necessary, including evidence that residents have been involved. Personal profiles were included, and family connections and personal relationships recorded. Actions agreed need to be more specific, in order to enable residents to see how progress may be achieved. One resident handles his own finances. Another is under the Court of Protection. The Manager has supported the other three to open basic bank accounts, so that their allowances can now be paid directly to them and there is no longer any need to use a Highland Mist account. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 12 Risk assessments had been carried out. These contained information for staff about possible problems, and triggers. They need to include clear advice for staff about how to reduce any risks. Care plans did not include behaviour management programmes. They need clear advice on how to respond to residents’ behaviour, and how to react to disturbed behaviour, including contingency plans for when the normal routine does not work. The owner had sat with residents to consider their support needs, but these ‘contingency plans’ did not include how the resident wanted staff to respond when they were distressed or disturbed. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The management have started to make arrangements for increased opportunities within and outside the home, but these have not yet improved the quality of residents’ lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner is aware of the need to motivate and enable residents to build confidence and engage with activities in the community. The managers were gathering information about local advice and training providers. Two residents were supported to attend a meeting with A4E, to obtain discuss possibilities of voluntary work, with a view to working towards job opportunities. Residents had attended the library, and obtained the card necessary to use the local swimming pool at a much reduced entrance fee. Residents had expressed interest in gardening, materials had been provided to enable people to get started.
Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 14 The home had obtained training materials for literacy and numeracy, and were using these with two residents to help build their skills and confidence before engaging with outside agencies. A kitchen was being provided which had enough space for residents to work with staff for training in skills for independent living, as well as cooking for enjoyment. Within the home, games of pool had been enjoyed, and a karaoke machine had been obtained. Records are kept of residents’ activities each morning, lunch time and evening. This shows that as well as the normal daily activities, there have been outings. Some residents said that their main need is to feel safe, and this need is met at Highland Mist. One said that ‘it is enough’ for him to visit the club at the Town Hall every two weeks. Residents were happy with their meals. Staff were trying with varying success to provide a balanced diet. There was plenty of fresh food available, but some staff did not serve it as they did not think residents would want it. The manager provided a juicer, to help meet the nutritional needs of residents who are not interested in vegetables. There is not a choice, but the menu of the day is written on a white board by the entrance, and residents said that they are given an alternative if they do not like the main meal. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Resident’s health and personal needs are identified, and on the whole met, and medication is administered with care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents health personal and mental health needs were recorded in the care plans and risk assessments examined. Medical records showed that residents attended Community Nurse, Doctor, Psychiatrist, optician, and dental appointments, with support. Access to counselling had been arranged through the GP. A relaxation programme had been given, but staff had not yet supported the resident to use it. There is risk assessment available suitable for assessing the competence of a resident wishing to self-medicate. Currently residents have taken responsibility for creams and inhalers. No Controlled Drugs or homely remedies are in use. The owner checks all medication on delivery. All staff have received training and are competent to administer medication. The Medication Administration Records were examined and found to be accurate. Safety of storage within the new office arrangements was being considered. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. Resident’s views are listened to, but recording of action taken could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Complaints procedure was included in the information available for new residents. There was a complaints book kept in the hallway at Highland Mist; it was empty. As the book was kept in a public place it meant it could not be used to record complaint investigations. It would be good practice to keep a record of any concerns that are expressed, and what action has been taken in response, so that people know that their voice has been heard. A complaint had been received in February from paramedics, reporting that a member of staff did not wake up when needed by a suicidal resident during the night. A statement was received from the staff on duty, who no longer works at Highland Mist. There was a copy of the local authority Alerter’s guidance in the office, and staff had received training in the Protection of Vulnerable Adults. The staff handbook included a section on whistle blowing. Staff were aware of this policy. The managers knew what must be done in the event of any allegation of abuse. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 Quality in this outcome area is adequate. The environment is being improved but building work is not yet complete. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager had produced a plan for improvements to be carried out during 2007 which was being put into practice. Work was in progress to fit a new kitchen in a room that had previously been a bedroom. It is big enough for staff to work alongside residents. The smaller room which has been the kitchen will be used as a care office. Staff were seen to be working with care in difficult conditions. The doorbell was not found to working at any time during the inspection, which could lead to security problems. There is no dining room. A table that can seat four has been put in the conservatory, which does not have easily cleanable flooring. Others eat in the lounge, or the garden. This should be specified in the home’s Statement of Purpose and Service User Guide. Current residents do not want to eat together as a group.
Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 18 The lounge had been redecorated and re-carpeted, and was looking bright and comfortable. Some bedrooms had been re-plastered, decorated, carpeted and furnished. The ‘smoke house’ was cleaned and painted during the inspection. One small green house had been constructed, for residents’ use, and materials had been obtained to provide another. The garden was looking attractive with colourful shrubs. Rubbish had been cleared, and there was a skip at the entrance waiting to be removed. A small upstairs room with no window had been fitted out for the Manager to work on the home’s computer without interruption. The upstairs room that had been the care office will now be the sleeping in room – staff no longer sleep in the lounge. The new care office is downstairs, to be more convenient and accessible. The bathrooms had been retiled, and suitable flooring had been laid. Paper towel dispensers had been fitted beside the hand basins in the communal toilets, and liquid soap was available. The Food Safety Management process must be put into practice, to ensure good food hygiene standards are maintained. A dishwasher had been provided, to ensure hygienic cleaning of crockery and cutlery. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. Staffing had been increased, and supervision introduced, but there needs to be a full training plan to enable staff to meet the needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Support worker and a manager are on duty from 8am till 8pm, plus a cleaner from 9am – 2pm who can also be involved in support work. At night there is one person on sleeping-in duty, with a manager on-call. A written rota is displayed. Three staff files were examined, including two recent recruits. These showed that written references had been obtained, and followed up verbally where required. Proof of identity was retained, and CRB clearances had been obtained. A new recruit was confined to ‘shadow shifts’ while awaiting the arrival of the CRB clearance. There was a suitable recruitment procedure, giving residents opportunity to meet the recruit, and interviews conducted by two managers, with records kept. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 20 A staff handbook had been produced. A risk assessment had been carried out with respect to a staff member who is pregnant, but it needed to include risks associated with lone working and dealing with disturbed behaviour. An induction checklist had been used to ensure that new staff were familiar with the home’s procedures. A Red Crier induction training programme was available, but had not yet been used. Staff were seen to have a positive attitude towards the residents, and to be willing to help, including accompanying people on outside activities. They had not yet received training in mental health needs, but said that they were keen to receive such training and felt is was ‘vital’ to making progress. They had received training in the Protection of Vulnerable Adults, safe administration of medicines, Food hygiene, and Infection control. There was no up-to-date overall staff training assessment and plan. The owner said that she had been offered training by local Mental Health professionals, which was due to start on 25th June. A session on Dealing with Challenging Behaviours has also been booked. Staff should have specific training on the areas of equality and diversity and demonstrate how resident’s rights are being supported. The owner had introduced individual supervision sessions for the staff, with records kept. These showed that staff were given feedback on their performance, which covered teamwork, training needs, tasks and observations, and also communication skills, their ability to identify residents’ needs and act upon their own observations, and their awareness of the impact of their own behaviour. Annual appraisals had taken place. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. Management had made improvements in systems and safety within the home, but need further work to make the service more reliable and responsive to residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner said that the Acting Manager is to register as Manager of Highland Mist. Lynne Edwards is engaged in the Registered Managers’ Award, and has several years experience in residential care with people with disabilities or mental health problems. Residents’ meetings have been held monthly, with records kept. These show that training opportunities, personal hygiene, activities, a holiday, smoking and food were discussed. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 22 Feedback was gathered systematically in September 2006, from residents, staff and visitors, but not analysed or used to inform the home’s development plan. The Training Masters’ Quality Audit has been started, to enable managers to check their systems regularly. Developing a Quality Assurance system annual report based on the analysis of the Quality Assurance system has been an outstanding requirement since 2nd August 2005. A risk assessment had been done with regard to a member of staff who is pregnant. Advice was given to include avoidance of lone working and in order to be able to call for assistance in the event of any problem or disturbed behaviour. Professional fire training had been provided as well as monthly fire drills. All fire doors were seen to be properly shut. The managers carry out a monthly check of the building room by room. This must include a fire risk assessment, to assure the residents’ safety. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 2 X Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement Risk assessments must include the measures to be taken to reduce risk. Arrangements must be made to meet the social interests, community activities, recreational activities, fitness, training and other needs identified in residents care plans so that residents lead fulfilling lives. – work in progress. Timescale for action 30/06/07 2. YA13 12(1)16 (2)(m)(n) 30/09/07 3. YA24 23(2)(b)(d) The environment at Highland Mist must be safe, kept in a good state of repair internally and externally and all parts of the home must be kept clean and reasonably decorated. - work in progress. 13(3) The Food Safety Management process must be put into practice, to ensure good food hygiene standards are maintained. Staff must receive training on the areas of mental health that are required to meet the needs of residents. Previous
DS0000018370.V333966.R01.S.doc 30/09/07 4. YA30 30/06/07 5. YA32 18(c) 30/09/07 Highland Mist Version 5.2 Page 25 timescales 20/09/06 & 31/12/06. 6. YA39 24(2) An annual report based on the analysis of the Quality Assurance system must be produced, with a copy available for CSCI and other interested parties to demonstrate that the service provided is being monitored and improved. (Previous timescales 02/08/05, 31/10/05, 30/04/06, 20/09/06 & 31/12/06). Fire risk assessments must be carried out for each room and area of the house. 30/11/07 7. YA42 23(4) 30/06/07 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. 2. 3. Refer to Standard YA1 YA2 YA7 Good Practice Recommendations The Statement of Purpose should be up to date and accurate, to avoid misleading prospective residents. Comprehensive information about a resident’s needs should be gathered before offering accommodation. There should be information available at Highland Mist about leisure, work, fitness, training, and other opportunities to help residents make decisions about what they want to do with their time, and care plans should include clear guidelines to help them meet their goals. All concerns as well as complaints should be investigated with records kept of action taken. At least 50 of care staff should have NVQ 2. Staff should have specific training on the areas of equality
DS0000018370.V333966.R01.S.doc Version 5.2 Page 26 4. 5. 6. YA22 YA32 YA32 Highland Mist and diversity and demonstrate how resident’s rights are being supported. 7. 8. 9. YA33 YA35 YA37 A more satisfactory risk assessment should be carried out on the staff member who is pregnant. The staff training plan should indicate the training required and completed by staff members. The Manager should have gained NVQ 4 and the Registered Manager Award. Highland Mist DS0000018370.V333966.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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