Inspection on 26/07/07 for Highview

This inspection was carried out on 26th July 2007.

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 14/04/08

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 26th July 2007 1:00 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.V335543.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.V335543.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 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 Mrs Linda Yari 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.V335543.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. 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 the registered manager of the home is Ms Linda Yari. 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 £364.40 per week. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 26th July 2007. During the course of the inspection time was spent talking to several residents, the manager and two care staff. Examination of a selection of care plans, medication records and policies and procedures relating to the home took place along with a tour of some areas of the building. Prior to the visit, questionnaires were sent to the residents of Highview to gain their views on life at the home. Twenty-five residents completed questionnaires with the support of staff at the home and returned them to the Commission. The majority of residents indicated that they receive the care and support they needed at the home and that staff listened and acted on what they said. The majority of residents indicated that they always received the medical support they needed. The majority of residents indicated that there were always activities arranged by the home that they could take part in. All residents who were spoken to during the visit and who completed a questionnaire stated that they knew who to make a complaint about the service. Since the previous inspection of the service two adult protection concerns had been raised relating to the care and support received by one resident. Both these concerns were dealt with under Salford Social Services safeguarding adult’s procedures, and have now been concluded. Positive comments were made by residents about the manager and the staff team at the home. These comments included “ they are all very nice”, “very happy” and “happy with the service I receive”. Throughout the visit the inspector observed a pleasant and comfortable atmosphere around the home with lots of interaction taking place between residents and residents and staff. What the service does well: The manager ensures that the home has the facilities and support available to meet a persons needs before they move into Highview. The service continues to update the care plans to ensure that staff have access to the information they need to care and support people. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 6 Equipment is available in the home to provide stimulating activities for residents. Residents feel that they are treated with respect. Residents are supported in maintaining their independence. The manager and staff team have a good knowledge of peoples’ needs and wishes. What has improved since the last inspection? What they could do better: Improvements need to be made to the recording of medication to ensure that records fully demonstrate that people are having the medication they are prescribed. Failure to record information about medication appropriately may result in people not getting the medication they need. All staff should be aware of Salford Social Services safeguarding adults procedures to ensure that they are able to respond appropriately if needed. Continued improvements need to be made to the physical environment of the home to ensure that residents can live in safe comfortable environment. For example, the refurbishment and or decoration of bathrooms must continue. All relevant documentation and references need to be checked at the time that a person is recruited. All notifiable incidents that occur at the home, need to be reported to the Commission, without delay. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 7 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.V335543.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.V335543.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’s needs were assessed prior to moving into to Highview to ensure that the service delivered at the home could meet the individuals’ needs. EVIDENCE: People’s needs were assessed before they moved into the home to ensure that the service was able to meet all the needs of the individual. The manager of the service carried out these assessments. Information about the individual gained during the assessment was recorded on a set pro-forma that gave the assessor the opportunity to record peoples care needs and wishes relating to all aspects of their day to day needs. Copies of completed assessments were present on individuals’ files and it was evident that information from these assessments had informed the person’s individual plan of care. Highview does not offer intermediate care facilities. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Information was available to assist staff to meet resident’s needs and wishes. However, some shortfalls in maintaining appropriate medication procedures could place residents health at unnecessary risk. EVIDENCE: A number of resident’s individual files were assessed during the visit, including the files of the three residents most recently admitted to the home. Each file contained a pre-admission assessment and a care plan. The manager was in the process of updating the format of residents individual care plans and several of these revised documents were seen. The newly revised care plans detailed people’s specific personal needs, wishes, likes and dislikes and contained information for staff to meet the needs of the individual. For example one care plans stated ‘(X) requires the assistance and support of one carer. (X) is a lady who likes her hair tied back, she likes to wear makeup and jewellery. She also has a special pair of shoes that need to be worn at all times.’ Another entry stated ‘likes her night light on in her room.’ Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 11 Care plans also contained daily living guidelines to ensure that staff are aware of the persons physical, health, emotional and care needs and wishes. Staff stated that this information was updated on a monthly basis, or more frequently of required. The majority of care plans also contained a biography of the individuals’ life that had been devised from information from the resident, their relatives and information that they had brought with them to the home. Records demonstrated that residents have access to local health care professionals and that all residents were registered with a GP. There was evidence that one resident who had recently moved into the home had been assessed by a district nurse for a specialist bed and mattress. Fifteen people stated on their service user surveys that they always receive the medical support they need; eight people said that they usually did and two people stated that they sometimes received the medical support they needed. Several residents commented positively about the medical support they received, these comments included “they contact whomever I need”, “district nurses are very nice” and “when I feel I need a GP they contact one for me.” The home had a policy for the receipt, recording, storage, disposal and handling of medication, which the manager stated, was currently under review. A list of resident’s medication and possible side effects formed part of individual care plans. Medication was stored in a locked room. On the day of the visit the room was very warm. It is essential that medication is stored in an environment that meets the temperature needs of the medication. Two plastic pots were found in the medication room containing medication that two residents had refused several days earlier. The manager arranged for the appropriate disposal of this medication immediately. It is essential that all refused medication is stored appropriately until it can be returned to the chemist. An audit took place of the controlled drugs register and medication. The total of one particular medication documented in the register did not correspond with the amount of tablets available. During a discussion with the manager it appeared to be a recording error and stated that she would address the issue immediately. Medication was recorded on Medication Administration Records (MAR’s). An assessment of a selection of MAR’s took place and several were wrongly completed. For example, one MAR stated that the medication Promazine had been delivered on 19.07.07, however, the medication had not been signed for Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 12 as being administered, nor was the medication available. The manager later stated that the medication had not been delivered and the entry onto the MAR was written in error. Another MAR stated that the medication Cetirizine had been prescribed as given to a resident on a daily basis. However, although the medication was present in the drugs trolley and the information was recorded on the MAR, there were no signatures to demonstrate that the medication had been administered to the resident. Staff were unable to explain why the medication had not been administered. It is essential that residents receive all their medication that is prescribed for them. Some MAR’s had been signed by staff using the letter Q, however, the abbreviations at the bottom of the MAR’s did not contain the letter Q and therefore it was difficult to understand what this abbreviation meant. Clear records of all medication administered/refused need to be maintained at all times. Residents spoke positively about the staff team and said that they were treated in a respectful manner. Staff were observed supporting people in a polite and dignified manner. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 are encouraged to maintain their independence and are able to maintain contact with family and friends. Continual development of the menus at the home is needed to ensure variety for people. EVIDENCE: A structured activities programme was not in operation in the home and the manager stated that this was due to the needs of the residents. The manager stated that an activity takes place everyday, which may include singing, dancing, using instruments, giant connect 4, floor chess and bingo. A visiting entertainer is booked on a monthly basis and occasional ‘wellbeing’ sessions are held. Staff said that the Princes Trust occasionally visit to play games. Eighteen residents stated on their survey forms that there are always activities arranged by the home that they could take part in, four people said there usually were and four people said that there were sometimes activities arranged to take part in. Positive comments about activities received from residents included “I like music and playing cards”, “I like singing and Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 14 dancing”, “I enjoy the music best of all” and “there is always something going on.” Several residents told the inspector that they were supported by staff to maintain their independence; this was demonstrated during the visit when a resident went to the local shop independently with the support of a staff member. Residents spoken to during the visit confirmed that they were able to receive visitors at any time. Residents commented that they were given the choice of what food they ate, if they wanted to join in activities and what time they went to bed at night and got up in the morning. There was a set four weekly menu in place. The menu demonstrated that a choice of two cooked meals was offered at lunchtime; and most evening’s soup and sandwiches were for tea. It is strongly recommended in this report that the menus are developed to demonstrate all the foods that are on offer throughout the day including what fruit and vegetables are served with meals. During the visit one resident said that the food was very basic” and “not much choice”. Five residents stated that they always liked the meals at the home, twelve people said that they usually did and five people said that they sometimes liked the meals at the home. Residents made several comments about the food served at Highview and these comments included “very nice”, “I don’t like some things”, “nice”, “sometimes I don’t like it”, “some days are better than others” and “I love fish and chips.” Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 from abuse, however, all staff need to have training and an awareness of local safeguarding adult procedures to ensure they would be able to respond to any concerns appropriately. EVIDENCE: The home had a complaints policy and a copy of this policy was available in all resident’s bedrooms. One complaint had been made to the home since the previous inspection and all the documentation relating to this complaint was available on the residents file. Discussion took place with the manager about creating a written log to record any complaints and their outcomes. All residents stated on their survey forms that they know who to make a complaint to about the service. One resident stated that they would “see the manager”, and another person stated, “I can talk to any of the staff.” There is guidance and a policy on protection from abuse. The document informs staff of different types of abuse and also states what action will be taken in the event of an allegation being made against a member of staff. However, the policy does not clearly state that any concerns or allegation relating to safe guarding adults must be referred under Salford Social Services Safeguarding Adults procedures, a copy of which was in the home, and also contain the contact details of Salford Social Services. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 16 Information given by staff at the home demonstrated that some staff had received awareness training in the protection of vulnerable adults. However, during the visit a senior member of staff was unable to demonstrate any awareness of Salford Social Services Safeguarding Adults policy and procedures. Two adult protection issues had been raised at the home since the previous inspection. Both these issues were relating to care and support received by one resident living at the home and were addressed under Salford Social Services safeguarding adults procedures. During the visit one resident told the inspector that he had recently moved into the home and that he felt very safe living at Highview. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 17 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): 19,21 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Continued regular maintenance and redecoration of all areas the home is needed to ensure that residents have a comfortable, safe and pleasant environment in which to live. EVIDENCE: A part-time maintenance person is employed at the home to carry out daily maintenance throughout the building. A tour of some areas of the building took place during the visit. Several bedrooms, bathrooms and communal areas were assessed. Since the last key inspection in September 2006 several bedrooms had been fully refurbished and decorated, improving the standard of accommodation for residents. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 18 The majority of bedrooms visited contained resident’s personal effects to create a ‘homely’ environment. However, some bedrooms were in need of decorating. Several bathrooms were looked at. One bathroom had wallpaper peeling off the wall and in the other bathroom wall tiles were missing and in need of replacing. One bathroom that had been under refurbishment at the time of the previous inspection was locked and the inspector was unable to gain access. Staff stated that this bathroom was locked and it was still under refurbishment. It is essential that residents have access to a sufficient number of suitable bathrooms throughout the home and that they are decorated and maintained to an acceptable standard. The furniture and carpets in the “smokers” lounge were heavily stained and in need of thorough deep cleaning or replacement. Several carpets throughout the building were also in need of replacement/deep cleaning as they gave the appearance that they were very dirty. The home was clean, however, several areas of the home had an offensive odour. Six residents stated that the home is always fresh and clean; sixteen residents said that it was usually fresh and clean and three residents said that it was sometimes fresh and clean. Hand sanitizer gel was seen to be available and in use around the home to promote good hygiene practices. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 19 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. Resident’s needs were being met by the staff team on duty, however, appropriate recruitment procedures must be followed to ensure the safety of people living in the home. EVIDENCE: During the visit three carers, a senior carer and the manager were on duty to meet the needs of the residents. The staffing rota demonstrated that a minimum of three care staff and a senior carer were on duty between the hours of 7am and 9pm. Waking night staff were employed to meet the needs of residents between 9pm and 7am. A recruitment procedure was available at the home. Six staff files were assessed, including those of the most recently recruited staff members. Each staff file contained the name, position, start date and a photograph of the member of staff. Information relating to criminal record bureau checks, the homes induction training, application forms and references were contained on individual files. However, not all files contained the information required. For example, one file only contained one written reference and another staff members file did not contain a fully completed application form. One file contained a reference that stated, “I hereby formally introduce”. It is essential that all references be sought at the time of recruitment to minimise the risk of people being employed inappropriately. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 20 Information supplied by the home demonstrated that all but five staff had achieved their NVQ level 2 qualifications and that those five remaining staff were in the process of completing their qualification. Two senior carers were undertaking their NVQ level 3 and domestic and staff that worked in the kitchen were undertaking training relevant to their role. Information supplied by the manager demonstrated that all care staff had undertaken moving and handling training on the 18.09.06 and food hygiene training on 25.11.06. Further information documented that some staff had undertaken their annual training update in manual handling, basic life support, fire safety, health and safety, infection control, COSHH and Riddor. The manager also stated that training had been provided in the protection of vulnerable adults, health and safety and first aid, however the dates for this training were not available and the manager stated that the certificates and information relating to this training was still with the training provider. It is essential that detailed up to date records of training are maintained at all times. There was no evidence to demonstrate that staff had the opportunity to complete the formal Skills for Care Induction programme. Thirteen people stated in their survey forms that staff were always available when you need them, eleven people said they usually were and one person said staff were sometimes available when you need them. Other comments written relating to the availability of staff when needed included “but they can be very busy” and “not all the time”. Twenty people stated that they always receive the care and support they need and four people stated that they usually do. Other comments received included “everyone is very nice”, “staff are very nice”, “very nice with me” and “always very good.” Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the homes manager is competent to fulfil her role; continual development of health and safety policies and procedures is needed to protect people in all areas of their day to day lives. EVIDENCE: The home manager has several years experience in working and management in a social care settings and has recently completed her NVQ 4 award and was awaiting her certificate. During the visit the manager demonstrated a thorough awareness of the needs and wishes of the residents living at Highview. It was evident that the manager operated an ‘open door’ policy as several residents entered the office throughout the day to discuss issues relating to them. Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 22 During the visit four residents stated that they were asked on a regular basis about the service they received. However, there was no documentary evidence of any current procedures for measuring quality assurance within the home. Several accidents were recorded but there was no evidence that they had been reported to the Commission under Regulation 37 of the Care Home Regulations 2001. Discussion took place with the manager regarding what situation need to be reported under Regulation 37. Regular visits are made to the home by a representative of the responsible individual and written report of these visits were available at the home. There was a procedure for the management of resident’s monies, which included the recording of all transactions and receipts. Four randomly selected account sheets and their money balances were checked and were found to be correct. Salford City Council’s Environmental Health Department most recent visit to the service was 14.03.07 in which they addressed several health and safety issues. The manager stated that since that visit a health and safety risk assessment had been developed and was dated 14.05.07 and that further development of health and safety policies and procedures were continuing. A new system was in place to ensure that regular weekly maintenance checks took place. There was documentary evidence available that demonstrated that regular weekly testing of the nurse call system; hot water temperatures and the homes fire detection system were taking place. However, the homes policy states that fire drills and training should take place twice a year but the last recorded fire drill was 28.08.06. It is essential that regular fire drills take place and are recorded. Documents demonstrated that outside contractors had carried out inspections and testing of equipment around the home. One record demonstrated that Portable Appliance Testing (PAT) on electrical items took place on the 20.10.06 and the person who carried out the testing recorded several faults on equipment that needed attention. However, there was no documentary evidence that these faults had been addressed. During the visit the electrical contractor, who was carrying out maintenance at the home, informed the inspector that he had addressed all the faults that had been recorded on electrical items; and had forwarded the relevant paper work to demonstrate that the work had been carried out to the department that oversees the maintenance of the home. It is essential that information relating the maintenance and repairs at the home is stored at Highview and is available at all times. Highview DS0000064499.V335543.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 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X 1 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 2 Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 24 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 All medication must be administered as directed and recorded appropriately to ensure that residents receive all their medication that has been prescribed for them. Medication administration records must contain the correct information relating to abbreviations used. An ongoing plan of redecoration is required to ensure that residents live in an environment where the decoration and furnishing are well maintained. A copy of this plan must be provided to the Commission in writing by 14/09/2007. (timescale of 20.10.06 not met). Timescale for action 31/08/07 2. OP19 22(3)(d) 14/09/07 3. OP21 22 (2) (j) A full audit of carpets around the building is required and those identified as being dirty and/or stained are replaced/deep cleaned. All bathroom and toilets around 07/09/07 the building must be operational at all times to ensure that residents have the opportunity to DS0000064499.V335543.R01.S.doc Version 5.2 Page 25 Highview 4. OP21 16 (2) (k) 5. OP29 19 6. OP38 16 (2) (j) 7. OP38 37 access all bathroom and toilet facilities at all times. (timescale of 20.10.07 not met). People living in the home should not live in an environment that has offensive odours. Greater attention must be made to eradicate these. All staff files need to contain all the information required under Schedule 3; to ensure that all actions have been taken to minimise staff being inappropriately recruited; and to minimise the risk of poor recruitment for people living in the home. Any outstanding requirements made by Salford City Council’s environmental health officer must be addressed; in order that people living in the home know the home meets these standards. So the Commission can evaluate all incidents that may affect the welfare of people living in the home; all accidents, incidents and situations relating to Regulation 37 of the Care Home Regulations need to be reported to the Commission. 07/09/07 07/09/07 21/09/07 31/08/07 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. Refer to Standard OP9 Good Practice Recommendations A thermometer should be placed in the room that medication is stored to monitor the temperature of the room; to ensure that the medication is being stored at the DS0000064499.V335543.R01.S.doc Version 5.2 Page 26 Highview 2. 3. OP15 OP18 4. OP29 appropriate temperature. A review of the menus should take place to include all foods served during meals including vegetables and fruit. 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. All staff should attend local Safeguarding Adults training; the home’s manager should undertake an audit of those staff that need such training and ensure they attend. 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 new staff to complete the formal Skills for Care Induction programme Written evidence of any repairs or maintenance work undertaken in the home should be maintained and be accessible to inspectors fro examination at all times. In order to demonstrate what consultation with residents has occurred, the quality assurance process must be formalised with proper records kept. 5. 6. OP38 OP38 Highview DS0000064499.V335543.R01.S.doc Version 5.2 Page 27 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.V335543.R01.S.doc Version 5.2 Page 28 - 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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