Inspection on 19/06/06 for Highland Mist

This inspection was carried out on 19th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highland Mist 06/06/08

Highland Mist 03/12/07

Highland Mist 15/05/07

Highland Mist 11/01/07

Highland Mist 21/02/06

Highland Mist 02/08/05

Highland Mist 09/03/05

Highland Mist 16/06/04

Highland Mist 26/03/04

Highland Mist 09/03/04

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

CARE HOME ADULTS 18-65 Highland Mist Highland Mist Bronshill Road Torquay Devon TQ1 3HA Lead Inspector Sam Sly Unannounced Inspection 19th June 2006 09:30 Highland Mist DS0000018370.V289125.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.V289125.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.V289125.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highland Mist Address Highland Mist Bronshill Road Torquay Devon TQ1 3HA 01803 328156 01803 312697 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 Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Highland Mist provides care for up to 8 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 grassed and patioed front garden. 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 is also used for meals. The ground floor also has a shower room with toilet, three bedrooms, the office/staff sleep-in room, kitchen and laundry facilities, which are outside in the yard. Stairs lead to the first floor, which has a bathroom with toilet, and five bedrooms one of which is en-suite. An additional shower room with toilet is being built. Residents should be aware that a staff member sleeps in the lounge at night. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place during a weekday in June. An Inspector and a Regulation Manager carried out the visit, due to concerns about the continuing large amount of unmet requirements. The visit included discussion with five of the residents, the two staff members on duty and Mrs Hill the Owner. Three resident’s care was partially case tracked. Care records and health and safety records were examined and a tour of the building, including four bedrooms was made. The Inspection process also included a review of contact the Commission has had with Highland Mist over the past year and comment cards from five residents, three relatives/visitors and two staff. Mrs Hill did not send the Commission the required pre-inspection data and information, nor have the Commission received any action plans for requirements made at Inspection in the last 2 years. What the service does well: What has improved since the last inspection? What they could do better: Although there is no doubt about the caring nature and good intentions of Mrs Hill and staff, the safety of residents is jeopardised by a failure to fully engage with CSCI, and continued non-compliance with requirements. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 6 19 requirements were made at this visit, and none of the 15 requirements made at the previous Inspection in February 2006 have been met. It is concerning that despite written reminders and meetings Mrs Hill continues not to send the Commission action plans to meet these outstanding requirements. The assessment, risk assessment and care planning systems at Highland Mist do not fully identify resident’s needs and how staff are going to meet those needs to ensure residents are safe, at the same time as being as independent as is possible and achieving their goals. Also Resident’s educational, employment and leisure needs must be identified and met. Mrs Hill must ensure the Commission is informed of any event that adversely affects the welfare of residents, and financial records must be kept at Highland Mist to show audit trails for her involvement in their finances. Robust staff recruitment procedures must be adhered to at all times and sufficient staff records, including training records must be kept, and Mrs Hill must have access to these files at all times. Staff rotas must be kept at Highland Mist at all times and staff interview records must detail Mrs Hill’s decision making. Mrs Hill must have an overall training plan that maps out training required for the staff team, including adult protection training, health and safety training and specialist training to meet residents needs. Mrs Hill must implement and maintain a Quality Assurance system, so that the practices at Highland Mist are being continuously monitored and improved. The maintenance and renewal programme for Highland Mist must be up to date and include all short term and long-term projects. The COSHH policy must be implemented and necessary wiring and gas checks must be carried out, as well as the findings of the fire risk assessment. 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. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 7 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.V289125.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The overall quality outcome of choice of Home is poor. Insufficiently detailed assessments mean that resident’s needs are not being identified before admission. EVIDENCE: Two resident’s care planning files, including assessments and daily records were examined at the site visit. Assessments were not examined in detail however, as Mrs Hill said none of the care planning records had been updated since the last Inspection as she was about to implement a new system. This system was shared with the Inspector and Manager at the site visit, and Mrs Hill said each resident’s would be reassessed and their care plan updated within a month. The quality of resident’s assessments has not been sufficient, with requirements made by the Commission to improve the procedures dating back to August 2005. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 The overall outcome for Individual needs and choices is poor. The lack of comprehensive risk assessments and care plans mean staff are not working systematically to keep residents safe, at the same time as promoting independence and reaching resident’s goals. EVIDENCE: Two resident’s care planning files were examined, but not in detail as Mrs Hill said the risk assessments and care plans had not been updated as a new system was being introduced within a month. Daily records and records of visits to professionals and doctors were examined in detail, and were up to date. The quality of resident’s risk assessment and care planning has not been sufficient, with requirements made by the Commission to improve the procedures, dating back to August 2005. The procedures for dealing with resident’s finances were examined, and Mrs Hill said she is not Department of Work and Pensions Appointee for any residents. However, Mrs Hill does handle their money, and get two resident’s benefits for them from the bank. Resident’s spoken to about this, said they Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 10 agreed to this practice. There were appropriate records kept for resident’s cash stored in the Home, however no audit trail for money withdrawn from resident’s bank accounts, or records of residents benefits entitlement, as required at the last Inspection in February 2006. Although Mrs Hill is now alerting the Commission of more events that adversely affect the welfare of residents, an event was discovered in the minutes of a recent resident’s meeting that the Commission had not been notified about. This had been a requirement at the last Inspection in February 2006. The resident’s that filled out comment cards indicated they were able to make choices about what they did each day, and some resident’s managed their own money. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 The overall quality outcome for lifestyle is good. Staff make efforts to engage residents in the local community and encourage residents to lead interesting lives. EVIDENCE: Resident’s each had an activity programme. However, some of these programmes were not being followed, and there was no evidence that a current assessment of resident’s employment, educational and leisure needs had been carried out. This had been a requirement at the last Inspection in February 2006. None of the residents currently at Highland Mist are employed or in education. Mrs Hill said she was about to start up a day activity centre for the residents at Highland Mist and her other care home, Surrey Haven, and Resident’s meeting minutes showed that they had contributed lots of ideas of what they would like to happen there including cooking and pottery. Resident’s spoken to were keen to get involved once it started. Mrs Hill said the resident’s would also be doing I.T at the day service. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 12 Residents said they were planning to have a group holiday to Butlins, as they have done for a few years now, in September. Comments from residents received by the Commission stated that they ‘would like to go out in the community more’ and have ‘people take them out a couple more times a week’. Resident’s often access the community un-supported and have friends and family they like to visit. Relatives commented that they were always able to contact residents whenever they wanted, and were made welcome at Highland Mist. The main support staff are required to give to most residents is encouragement to engage in activities and maintain attendance. Applications are being made to get each resident a free bus pass. Resident’s all had lockable bedrooms and keys were provided. Staff were observed to interact with residents, and residents were able to choose to be alone or be more sociable. Residents said they enjoyed meals, and the most recent resident’s meetings minutes showed that they were involved in planning the menu. Mrs Hill said residents asked for the meals they liked and these were provided. A resident who had recently lost weight rapidly was being monitored closely by the staff. Mrs Hill said some resident’s helped prepare meals. As was evident at the Inspection in February 2006, alcohol was being drunk on the premises, and there was smoking in bedrooms, which is breaking the contractual agreement at Highland Mist. Mrs Hill had still not resolved this issue. Staff handling food still did not all have Food hygiene training, which had been required at the previous Inspection is February 2006. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall quality outcome for personal and health care support is good. Staff appropriately support resident’s personal and healthcare needs and medication is administered safely by staff, with self-medication starting to be promoted. EVIDENCE: The main support staff give residents with regard to personal care is prompting and encouragement to carry it out themselves. Times for going to bed and getting up are flexible and residents said they were happy with the support they got from staff. One resident had recently moved to Highland Mist from Mrs Hill’s other Care Home, because he said he liked the support he got at Highland more. Staff regularly support residents to attend medical appointments, and records are kept of the outcome of these meetings, however this information does not inform the review of care plans. Many of the residents have some professional Care Programme support, and see a Consultant, Doctor or Community Psychiatric nurse (CPN) to review their health. There was evidence that Mrs Hill was working alongside a CPN to enable a resident to self-medicate. Mrs Hill has a background in working with people with mental health needs and as the Owner/Registered Manager monitors the resident’s welfare. Staff Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 14 spoken to had varying degrees of knowledge about the needs of people with mental health problems, which ranged from some training given by another employer to no training at all. Training about mental health was not given at Highland Mist. One resident was being helped to self-medicate. All the other residents had medication administered by staff, and when asked said this was what they had agreed. The medication procedures at Highland Mist were examined and safe measures for the receipt, storage, handling and recording were adhered to. There was some medication in the office awaiting return to the Pharmacist. Mrs Hill said only staff trained appropriately administered medication, as some staff had not received training. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall quality outcome for concerns, complaints and protection is poor. Resident’s views are listened to, however complaints are not investigated appropriately, and residents cannot be sure that staff have the skills to identify and protect them from abusive situations. EVIDENCE: There were no recent complaints recorded in the Home’s complaints book, and the Commission had received no complaints concerning Highland Mist since the last Inspection. Residents commented that staff listen to them, and their concerns were noted to be discussed at resident’s meetings. However, there was no evidence that Mrs Hill had appropriately investigated and recorded a complaint picked up in a resident’s daily records at the last Inspection in February 2006, despite a requirement being made. Neither Mrs Hill, nor any of the staff team have attended formal adult protection training on Adult Protection, although a staff member on duty had done a training module as part of the NVQ course. One of the staff members on duty did not know where the Home’s adult protection policies were kept, and there was no evidence that new staff had read and understood the Local Authority Adult Protection procedures. The adult protection policies at Highland Mist required updating in connection with Mrs Hill’s role in connection with the POVA list. Mrs Hill said a recently purchased training package included adult protection training that all staff would receive. POVA First checks were being carried out for most staff, but CRB checks had not been received for some staff currently employed. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 16 It is of serious concern to the Commission that staff, including Mrs Hill, have still not yet undertaken any formal adult protection training. This is despite an outstanding requirement for adult protection training and staff understanding of the Home’s policies and procedures from the previous 5 Inspections. Highland Mist DS0000018370.V289125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall outcome for the environment is poor. Highland Mist is homely and reasonably clean, decorated and furnished. However, to remain this way staff must have suitable training and the environment must be regularly checked and the maintenance plan updated. EVIDENCE: A tour of the premises was made during the site visit, and some issues were identified: the downstairs bathroom was smelly and required redecoration and new flooring (this had been identified in the last two reports). Mrs Hill said this was being organised. The fence in the front garden had fallen down, and the yard, which contained the washing machine, was dirty and required a thorough clean. The cupboard containing cleaning products was also messy and required sorting out. There was a lot of bags of belongings on the first floor landing, that Mrs Hill said were to be thrown out, and the fire extinguisher by the front door was not in its correct position. Inside the airing cupboard there were old clothes and beer cans on top of the hot water tank, and this had been identified as a fire risk in the assessment Mrs Hill had recently had carried out. The maintenance book was examined and some of these issues, plus some of the issues identified in the last report, and the issues identified in the fire report Mrs Hill had commissioned were not recorded for action. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 18 There was evidence that some maintenance was dealt with though, and a regular environmental risk assessment was carried out. Staff did not have any infection control training or food hygiene training. A recently commissioned fire assessment of Highland Mist indicated a number of areas requiring action. There had been no Environmental Health Inspections since the last CSCI Inspection, and the laundry facilities that were situated in the back yard, were agreed to be appropriate by CSCI in 2002. Highland Mist DS0000018370.V289125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 The overall outcome for staffing is poor. Staff are friendly, motivated and approachable, however, the staff recruitment practices and lack of systematic training means residents do not fully benefit from an effective staff team. EVIDENCE: Staff were observed to be friendly, motivated, accessible, approachable and comfortable with residents, and one resident said staff were ‘absolutely marvellous’. Relatives also reported that staff were ‘very pleasant’, that ‘they [residents] were looked after very well’, and one relative said they ‘could not wish for him [the resident] to have better care’. The rotas were not available, so whether sufficient staffing numbers were on duty at all times could not be assessed. However there were two staff and Mrs Hill on duty during the site visit. Staff worked from 8am –2pm and 2pm – 8pm. The rotas were faxed to the Commission the following day, and showed that there were sufficient staffing levels. When the Inspector and Manager arrived, Mrs Hill did not have the keys to the staff filing cabinet, and had to phone the deputy manager to bring them in. That Mrs Hill has access to staff files was a requirement at the previous Inspection in February 2006. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 20 Four staff files were examined and key information was found to be partial or missing. POVA First checks had been carried out for 3 staff, but one staff members CRB was from an ex-employer, and this employer was not indicated on the application form, so references had not been gathered and the gap on the application form not investigated, two other staff had gaps in employment that had not been investigated and records. Three staff were awaiting CRB checks, although applications had been made. Some references were missing, or telephone references only. New staff had not attended appropriate Induction or Foundation training, and for three staff, training files only recorded that they had attended Fire Awareness training on 2/6/06. Mrs Hill said a training package had recently been purchased and all staff would begin training shortly. There was no overall training plan for the staff group. Supervision was taking place regularly. It is concerning that staff training on the areas of health and safety, adult protection and safe recruitment practices have all been outstanding CSCI requirements since August 2005. Highland Mist DS0000018370.V289125.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall outcome for conduct and management is poor. Issues in relation to health and safety practices could potentially put residents at risk, and a continuing lack of overall monitoring and action to meet CSCI requirements, by Mrs Hill means practices at Highland Mist are not being systematically reviewed and improved. EVIDENCE: Mrs Hill is the Owner, and also the registered manager of Highland Mist. She is undertaking NVQ 4 and the Registered Manager Award. At the last Inspection she said it would be completed by June 2006, however Mrs Hill now thought it would take another month. CSCI records show that Mrs Hill has not returned the pre-inspection data and information required for any planned inspections, dating back to the beginning of 2005. Mrs Hill has also not furnished CSCI with action plans showing how the significant number of requirements, at each Inspection, are to be met since the beginning of 2005. Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 22 It is acknowledged that the residents at Highland Mist have complex needs, and that Mrs Hill involves herself in their day-to-day welfare, however, the range of requirements made, and the continual non-compliance by Mrs Hill is potentially putting residents at risk. Highland Mist has a Quality Assurance system, but no further work has been done to implement it since the Inspection in August 2005. Surveys were last sent out to residents and stakeholders a year ago. Resident and staff meetings occur regularly, and staff have supervision, however, none of this information informs the Home’s Quality Assurance system. Staff had not received the required health & safety training. The fire records showed the appropriate checks were regularly carried out, however the fire alarm test records did not show that one of the fire door self-closers was not working. Appropriate electrical checks are carried out, but gas and wiring require servicing. An environmental risk assessment is regularly carried out and acted on. The COSHH cupboard was untidy, and no COSHH sheets have been filled out for cleaning products. Highland Mist DS0000018370.V289125.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 Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Highland Mist DS0000018370.V289125.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 YA2 Regulation 14 Requirement A detailed assessment of a potential residents needs must be carried out before admission (Previous timescale 02/08/05, 31/10/05 & 30/04/06- not met) Each resident must have a care plan that covers all the identified needs in their assessments. Residents, their representatives and any other relevant professional must be involved in making their plan (Previous timescale 02/08/05, 31/10/05 & 30/04/06- not met) The action required to minimise risks identified in a residents assessment must be recorded in their care plan (Previous timescale 02/08/05, 31/10/05 & 30/04/06 - not met). Mrs Hill must inform the Commission of any event that adversely affects the welfare of residents (Previous timescale 30/04/06 – not met) Mrs Hill must keep all the DS0000018370.V289125.R01.S.doc Timescale for action 20/09/06 2. YA6 15 20/09/06 3. YA9 13(4)(b) 20/09/06 4. YA6 37 20/09/06 5. YA7 20 20/09/06 Version 5.2 Page 25 Highland Mist resident’s financial records at Highland Mist with audit trails for any involvement of herself or staff (Previous timescale 30/04/06 – not met) 6. YA14 YA12 12(1) Resident’s educational, employment, and leisure needs must be identified and met (Previous timescale 30/05/06 – not met) 20/09/06 7. YA42 YA30 YA17 18(c) All care staff must have training 20/09/06 in First Aid, food hygiene and infection control (Previous timescale 31/10/05 & 30/04/06 not met). All complaints must be investigated with records kept (Previous timescale 30/04/06– not met All staff must undertake formal adult protection training, and there must be records to confirm all staff have read, understood and are implementing Highland Mists adult protection policies and procedures. (Previous timescale 02/08/05, 06/10/05 & 30/04/06 - not met) 20/09/06 8. YA22 22 9. YA23 13(6) 20/09/06 10. YA24 23 The maintenance and renewal 20/09/06 programme must be up to date and include issues identified in the Homes risk assessment, CSCI, fire and environmental health reports. In this instance a copy must be sent to CSCI (Previous timescale 31/10/05 & 30/04/06 - not met) The COSHH policy must be fully implemented. Staff must receive training on the areas of mental health that are required to meet the needs DS0000018370.V289125.R01.S.doc 11. 12. YA42 YA32 YA35 13(3) 18(c) 20/09/06 20/09/06 Highland Mist Version 5.2 Page 26 of residents. 13. 14. YA33 YA23 YA34 Sch. 4 19 Staff rota’s must be kept at 20/09/06 Highland Mist at all times Mrs Hill must follow a robust 20/09/06 recruitment procedure, including ensure POVA First checks and CRB checks, and written references before employing staff. Written evidence must be kept at Highland Mist of each staff member’s recruitment process. (Previous timescale 02/03/06 – not met) At interview Mrs Hill must 20/09/06 question, and record her decision-making with regard to gaps in employment, CRB convictions, and poor references (Previous timescale 02/08/05, 31/10/05 & 30/03/06 - not met) Mrs Hill, as registered provider and registered manager must have access to staff files at all time. (Previous timescale 30/03/06 – not met) A staff training assessment and plan must be carried out for the whole staff team. In this instance a copy must be sent to CSCI (Previous timescale 02/08/05, 31/10/05 & 30/03/06 - not met). There must be a comprehensive quality assurance system in place, which captures the views of the residents and stakeholders. An annual report must be produced, with a copy available for CSCI and other interested parties. (Previous timescale 02/08/05, 31/10/05 & 30/04/06- not met) 20/09/06 15. YA34 19 16. YA41 YA34 19 Sch 2 17. YA32 YA35 18(c) 20/09/06 18. YA39 24 20/09/06 Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 27 19. YA42 16 & 23 Mrs Hill must ensure all the necessary wiring and gas checks are carried out and that the findings of the Fire risk assessment are acted on. Fire alarm tests must include checking, and recording any faulty self-closing devices. 20/09/06 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 YA6 Good Practice Recommendations Staff records of residents activity programmes, medical meetings and general daily recording should be reviewed regularly and changes should inform their care plans. Residents drinking and smoking habits should adhere to the contractual agreement made with the home. At least 50 of care staff should have NVQ 2. Staff should have specific training on the areas of equality and diversity and demonstrate how resident’s rights are being supported. All new staff must undertake appropriate Induction and Foundation training Mrs Hill should have gained NVQ 4 and the Registered Manager Award. 2. 3. 4 5. 6. YA16 YA32 YA32 YA35 YA37 Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Highland Mist DS0000018370.V289125.R01.S.doc Version 5.2 Page 29 - 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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