Inspection on 14/04/08 for Highview

This inspection was carried out on 14th April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highview 06/04/09

Highview 26/07/07

Highview 06/09/06

Highview 18/03/06

Highview 10/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Highview 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 2HD Lead Inspector Adele Berriman Unannounced Inspection 14th April 2008 12:30 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 Highview DS0000064499.V362168.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 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. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highview Address 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 2HD 0161 792 2610 0161 792 6763 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) Highview Residential Limited Care Home 35 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (22), Physical disability (1) Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category DE is for two named individuals under 65 years of age. If either of these people leave, the service user category will revert to OP. The dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted, where appropriate, to ensure continued compliance with the Residential Forum Guidance in Care Homes for Older People. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The category PD is for the named individual under 65 years of age. If this person leaves, the service user category will revert to OP. 26th July 2007 3. 4. Date of last inspection Brief Description of the Service: Highview is a residential home providing care, support and accommodation for up to thirty-five older people. Of these twenty-five people require personal care only and ten people have dementia and require personal care. Highview Residential Ltd owns the home and at the time of the visit there was no manager registered with the Commission. The home occupies an elevated position off Great Clowes Street in Salford. Access is to the rear of the building via a level access route, which leads to the main entrance/reception area. Parking is available to the rear of the building. The front of the building provides an enclosed patio seating area for residents. Accommodation is provided on three floors, which are all serviced by a passenger lift. There are 32 single bedrooms, 6 with en-suite facilities and 3 double bedrooms. The cost of the service is between £325.87 and £373.52 per week. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use the service experience adequate quality outcomes. An unannounced visit was made to the home on 14th April 2008 between the hours of 12.30pm and 8.45pm. During the visit a selection of records, care plans, policies and procedures were examined and a tour of some areas of the building took place. Observations were made of the activity around the home and several residents, the manager and a senior member of staff gave their views on the service. Prior to the visit to the service a selection of survey forms were sent to the service. Three staff and six relatives completed these forms to tell us their thoughts about the service. Six residents also completed surveys with the support of a member of staff. The service was sent an Annual Quality Assurance Assessment (AQAA) which was completed by the company’s business manager who returned it when we asked for it. The AQAA contained only brief information about what the service does well, what they feel they could do better and their plans for improvement in the next 12 months. The service had received two complaints since the previous inspection, one that had been responded to within 28 days and one complaint was in the process being investigated by the service. The majority of people said that they knew who to talk to if they were not happy and knew what to do if they had a complaint about the service. Two safeguarding issues had been raised within the service since the previous inspection, both of which were referred to Salford Social Services joint agency procedures. Positive comments were received about the home from residents and relatives. Comments included “always made welcome when visiting and encouraged to join in what is going on”, ‘mum is very happy in the home and most of the time it meets her requirements.’ One resident stated in their survey form that they liked their room, liked the girls and all were friendly. Staff stated in their survey forms that they were receiving regular training relevant to their role that keeps them up to date with new ways of working. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service needs to improve their policy and procedures for the storage of medication to ensure that it is stored safely and at the right temperature at all times. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 7 Improvements need to be made to the detail of information recorded in peoples’ care plans. This is to ensure that up to date information is available as to how individual’s specific needs are to be met. If this information is not available, people’s needs may not be fully met. Improvements must be made to the service’s recruitment processes and ensure that appropriate criminal record bureau checks and written references are obtained prior newly to recruited staff members working independently with residents. Failure to carry out appropriate recruitment checks may result in residents being put at unnecessary risk from harm. 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. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefited from having their needs assessed prior to moving into the home to ensure that the home had the facilities to meet their needs and wishes. EVIDENCE: People’s needs were assessed prior to moving into the home. The purpose of this assessment was to ensure that the service was able to meet all the needs of the individual. It was the role of the manager or a senior carer to carry out the assessments. Information gained during the assessment was recorded on a set pro forma that gave the assessor the opportunity to record people’s specific needs and wishes relating to their day to day living. The format considered people’s physical, emotional, dietary, social and health and wellbeing needs. It is recommended in this report that peoples cultural, spiritual and religious needs are also recorded on the assessment format to Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 10 ensure that the information is recorded and considered when developing individual care plans. Completed pre admission assessments were present on resident’s personal files. Highview does not offer intermediate care facilities. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the detail and content of individuals’ care plans to ensure that residents’ needs are fully met. EVIDENCE: Four of the residents’ individual personal files were assessed during the visit. All files contained a personal care plan. Staff stated that they were in the process of updating the way in which people’s needs and wishes were recorded. The care plans contained daily living guidelines to make staff aware of the person’s physical, health, emotional and care needs and wishes. The care plans for people with dementia made reference to the condition but they did not give detailed information about the specific needs of the individual. For example, during the visit all five people resident on the dementia care unit were taken downstairs during the evening. One resident was seen to be very Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 12 disorientated within the large lounge area. It is essential that residents have a detailed care plan that contains information about the specific care needs of the resident to ensure that they receive consistent care and support at all times in an environment they are comfortable and familiar with. There was evidence that some of the care plans were being reviewed on a regular basis. However, some information in care plans was not up to date. For example, one resident was being supported by two staff members for certain aspects of their care, however, there was no record of this in the resident’s care plan. It is essential that up to date information about residents needs is available to staff at all times to ensure that they are aware of how to support the individual appropriately. Detailed biographies and information from Social Services assessments were present on some residents’ files. This information gave the service a further opportunity to get to know the resident and their individuality. Risk assessments were available on resident’s personal files that demonstrated that specific risks to the individual had been considered. Only some of these assessments were being reviewed on a regular basis. For example, one resident’s nutritional assessment stated that it was to be reviewed on a monthly basis. Records demonstrated that the assessment was last reviewed on 08.12.07. It is essential that all risk assessments are reviewed on a regular basis to ensure that all up to date information relating to the identified risks are considered. Records demonstrated that residents had access to local healthcare professionals and that all residents were registered with a GP. Residents who completed survey forms stated that they always received the medical support they required. Information about healthcare visits was recorded in the majority of care plans. It is important that all information relating to healthcare professionals visits is recorded in residents’ care plans to ensure that residents receive the support they require and that up to date information is available at all times. A medication policy was available that gave information to staff and guidance on the administration and disposal of medication, however the policy gave no reference to the administration and storage of controlled medication. It is advised that information should be added to the policy regarding the correct storage and administration of controlled drugs to ensure that the medication is managed appropriately. Care plans contained an information sheet that detailed resident’s medication, a description of the medication, its purpose and possible side effects. This information was valuable to staff and contributed to the safe management of medication. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 13 Medication was dispensed from lockable medication cabinets. When not in use the cabinets were stored in a locked room. During the inspection the temperature of the room was excessively hot and the extractor fan in the room had broken. The manager of the service stated that she was waiting to meet with the dispensing pharmacist to discuss more appropriate storage facilities and had arranged for the fan to be repaired. A system was in place to monitor the temperature of the room daily, however the temperature had not been recorded for several days. The cabinet for the safe storage of controlled drugs in use at the home no longer met the criteria of the recent legal changes for the storage of this type of medication. The manager was advised of these changes during the visit. Medication was recorded on Medication Administration Records (MARs). Several of these records were assessed and the majority were seen to be up to date. However, there were some instances of medication which was no longer prescribed being recorded as having been refused. An accurate record must be kept of all administration of medication. Medication detailed on some MARs was no longer required. It was apparent during the visit that monthly prescriptions for medication were being ordered by the dispensing pharmacist on behalf of the home from the doctor’s surgery. It is strongly recommended in this report that a representative from the home should order these prescriptions to ensure that only current medication required by the residents is dispensed and to minimise any confusion with what actual medication the residents are taking. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from having activities and stimulation available on a regular basis. EVIDENCE: No programme of activities was available at the time of the visit. The manager stated that she was in the process of arranging an advertisement for a part time activities co-ordinator to develop and plan regular activities to meet the residents’ needs and wishes. An entertainer visits the home occasionally, and staff stated that it was intended to organise short breaks and outings for the residents throughout the year. A trip to a local fish and chip restaurant during the month of April was being planned. Three residents stated in their survey forms that there were activities to take part in and three people said there sometimes were. One resident spoken to during the visit stated that he was encouraged by the staff team to maintain his independence and they continued to visit the local shop independently. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 15 A minister from a local church visits the home for any residents who wished to see him. The home had an open visiting policy and residents spoken too confirmed that they were able to receive visitors at any time. One relative stated that she visited the home on a regular basis and found the “staff pleasant and caring” and another relative wrote that they were “always made welcome when visiting and encouraged to join in what is going on.” Three residents spoken to during the visit stated that they had a choice about the time that they got up and went to bed and also around the food that they ate. One relative wrote that ‘all of the staff seem to know and treat the residents as individuals and ask relatives and friends about residents likes and dislikes, and about family history.’ A set four weekly menu was in place and during the visit residents said that they had a choice at mealtimes of what they wanted to eat. All six residents who completed a survey form stated that they liked the meals at the home. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems were in place to protect residents but all staff need to have an awareness of local safeguarding procedures to ensure that any concerns are reported appropriately. EVIDENCE: A copy of the home’s complaints policy was readily available around the home. The manager stated that she was in the process of organising a system for the recording of any complaints. Residents spoken to during the visit and the majority of residents who completed survey forms stated that they knew who to speak to if they were not happy or wished to make a complaint. One complaint has been received by the home since the previous inspection that had been resolved within 28 days and a further complaint had was in the process of being investigated at the time of this report. Guidance was available to staff on protecting residents from abuse; this included a copy of Salford Social Service joint agency safeguarding procedures and an internal policy on the protection of vulnerable adults. The internal policy informed staff on what constituted abuse and also what action would be taken in the event of an allegation being made against a member of staff. The policy did not refer directly to Salford Social Services adult safeguarding procedures. The procedures should be amended to include information and contact details of who staff should refer safeguarding concerns to. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 17 Two safeguarding issues had been raised within the service since the previous inspection. One allegation made by a resident had not been reported immediately by the staff team under the local safeguarding procedures. All allegations must be reported immediately to ensure that they are investigated appropriately. Awareness training in local safeguarding procedures is recommended for all staff to ensure that any allegations and concerns are responded to appropriately. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents will benefit from the continual refurbishment of the home. EVIDENCE: A part-time maintenance person is employed at the home to carry out general maintenance throughout the building. A tour of some areas of the building took place and several bathrooms, bedrooms and lounges were assessed. Following the last key inspection several bedrooms and a bathroom had been fully refurbished and decorated, improving the standard of accommodation for the residents. The service had a planned programme for the refurbishment of the building that would take place throughout 2008. The majority of bedrooms visited contained personal effects to create a homely and comfortable environment. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 19 The furniture and the carpets in the “smokers” lounge were in need of cleaning and a corridor carpet on the ground floor was badly marked and in need of attention. Records demonstrated that regular checks were being carried on fire detection equipment around the home. However, there was no detailed fire risk assessment for the building available. A detailed fire risk assessment must be completed and available to demonstrate that all known risks relating to fire have been considered for the protection of the people in the building. The living environment for the residents was clean and free from offensive odours. However, the main kitchen in the basement was in need of a thorough cleaning. It is essential that a cleaning regime for the kitchen and food preparation areas is maintained at all times. Good hygiene practices were seen around the building with hand sanitizer gels available and leaflets about safe hand washing available in the foyer. A senior member of staff had recently become a ‘link’ person with the local Primary Care Trust to promote health protection by minimising the risk of infection within the home. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate recruitment procedures must be followed to ensure the safety of the people living at the home. EVIDENCE: At the time of the visit three carers, one senior carer and the manager of the service were on duty to meet the needs of the 25 people in residence. One carer was seen supporting five people on the dementia care unit and two carers and a senior carer were on duty on the ground floor supporting residents in other areas of the home. Mobile radios were available to staff for them to maintain contact with each other. The majority of residents stated that staff were always available when they needed them. Staff stated that there were usually enough staff on duty to meet the needs of the residents. One person wrote “when a member of staff fails to turn up for a shift an agency staff will usually cover that shift but not always” Three relatives stated that staff always have the right skills and experience to look after the people living at the home and two people said they usually did and one person said they sometimes did. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 21 A recruitment procedure was available at the home. Five staff files were assessed, including those of the most recently recruited staff members. Not all of the files assessed contained all of the information required. For example, one staff file contained an incomplete application form and two incomplete references. Another file contained evidence of a POVA 1st check being carried out but no evidence of the carers Criminal Record Bureau check being returned. It was of concern that this member of staff had been supporting residents alone on the dementia care unit. The manager addressed this issue immediately. It is essential that only staff who have all the appropriate recruitment checks support residents independently. Failure to carry out appropriate recruitment checks may result in residents being supported by people who are not suitable for the role. There was evidence on staff files that the services’ three day induction into the role had been carried out. All three staff stated in their survey forms that they had received an induction into their role. The Skills for Care induction programme should be introduced to enable staff to benefit from a detailed induction. Three staff had recently attended a training course on dementia and a further eleven staff were due to attend the course in April. A training matrix made available by the service further demonstrated that some, but not all staff had received training specific to their role. There was little documentary evidence of the training that staff had undertaken. The manager of the service stated that she recognised this as a priority and had arranged a meeting with a local training college to explore training opportunities for staff. It is essential that staff receive appropriate training to enable them to continually meet the changing needs of the people they support. Staff stated in their survey forms that they were receiving regular training relevant to their role that keeps them up to date with new ways of working. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements are needed to ensure suitable procedures are in place to promote the interests and wellbeing of the residents. EVIDENCE: At the time of the visit a new manager had been in post for approximately three weeks. The manager demonstrated a good awareness of good practice within social care environments. Along with familiarising herself with the service she was also in the process of compiling an action plan to improve the service and ensure that the National Minimum Standards for Older People are met. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 23 A procedure and facilities were available for the safe keeping of residents monies and personal effects within the home. One the day of the inspection it was not possible to assess these facilities and their related procedures as arrangements had not yet been introduced and ‘handed over’ to the manager. These facilities were assessed as appropriate during the previous key inspection. There was no evidence available to demonstrate that regular consultation with residents was taking place. A quality assurance process should be developed to so that comments and suggestion from residents and the representatives are sought on a regular basis. The manager stated that she was in the process of arranging regular formal supervision sessions with all the staff. A record of ‘planned individual staff supervision’ had been devised to record information relating to the supervision session. Following a requirement from the previous report improvements had been made as to how and when they inform the Commission about accidents and incidents that had occurred in and around the home. Records demonstrated that regular maintenance checks were being carried out around the building. Information supplied by the service stated that several policies and procedures relating to the health, safety and wellbeing of people had been reviewed since the previous inspection. It is advised that all other policies and procedures are reviewed and updated so that the guidance offered includes up to date best practice. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 X 3 X 2 Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement An accurate record of all administration of medication must be maintained at all times. All medication must be stored at the temperature recommended by the manufacturer. Controlled drugs must be stored in a legally complaint drugs cabinet for safety. 2. OP7 15 Improvements must be made to the care planning process to ensure all residents needs and wishes are fully recorded and detailed records maintained of what care was delivered. The corridor carpet on the ground floor of the accommodation needs to be replaced or deep cleaned. 4. OP21 13 A cleaning regime must be introduced to ensure that the basement kitchen area is kept clean at all times. DS0000064499.V362168.R01.S.doc Timescale for action 07/06/08 07/06/08 3. OP19 23 07/06/08 30/05/08 Highview Version 5.2 Page 26 A detailed fire risk assessment must be developed for the building. 5. OP29 19 All staff files need to contain all the information required under Schedule 3; to ensure that all actions have been taken to minimise the risk of unsuitable people being employed. Timescale of 07/09/07 not met. 07/06/08 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. Refer to Standard OP3 OP8 Good Practice Recommendations The pre admission assessment should give the opportunity to record peoples social, cultural and religious needs. All risk assessments should be reviewed on a regular basis and a record maintained of the dates in which the reviews took place. Nutritional risk assessments for individual should demonstrate what factors have been considered when calculating the risk. It is advised that the service develop a system for the ordering and collection that involves a representative from the home checking that the correct medication has been ordered and dispensed. The medication policy must be updated so that it includes information about the storage and dispensing of controlled medication. Residents should benefit from having regular access to activities and stimulation that meets their needs and wishes. DS0000064499.V362168.R01.S.doc Version 5.2 Page 27 3. OP9 4. OP12 Highview 3. OP18 The adult protection policy available in the home needs to be amended and updated with the details of Salford Social Services Safeguarding Adults policy; to ensure that staff are aware of who to contact in the event of them having an adult protection concern. An up to date record of all training and development that staff have undertaken should be maintained at all times. There should be opportunities for staff to complete the formal Skills for Care Induction programme 4. OP29 6. OP38 In order to demonstrate what consultation with residents has occurred, the quality assurance process must be formalised with proper records kept. Highview DS0000064499.V362168.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 © 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 Highview DS0000064499.V362168.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. 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