Inspection on 23/01/06 for Hyman Fine House

This inspection was carried out on 23rd January 2006.

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

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

Other inspections for this house

Hyman Fine House 18/07/07

Hyman Fine House 29/06/06

Hyman Fine House 12/04/05

Hyman Fine House 03/02/05

Hyman Fine House 11/10/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hyman Fine House 20 Burlington Street Brighton East Sussex BN2 1AU Lead Inspector Jennie Williams Unannounced Inspection 23rd January 2006 10:40 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 Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 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. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hyman Fine House Address 20 Burlington Street Brighton East Sussex BN2 1AU 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) 01273-688226 01273-695233 Jewish Care Mrs Margaret Stanbridge Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The maximum number of service users to be accommodated is fiftyone (51). The service users accommodated must be aged sixty-five (65) years and over on admission. Twenty-two (22) service users in receipt of personal care only are to be accommodated. Seventeen (17) service users in receipt of nursing care only are to be accommodated. Twelve (12) service users in receipt of personal care, with a dementiatype illness are to be accommodated. One named service user aged under sixty-five (65) years on admission only to be accommodated. 12th April 2005 Date of last inspection Brief Description of the Service: Hyman Fine House is owned by Jewish Care and is a care home that provides accommodation for up to fifty-one (51) residents. It is registered with the above written conditions of registration. The home is located in a residential area of Kemptown, Brighton. There is limited parking at the home, but paid parking is available in adjacent streets. The home is located within easy walking distance of the seafront, local amenities and public bus routes. It is a large home and residents’ rooms are spread out over three floors. There is a passenger shaft lift available to all floors within the home. Rooms are for single occupancy, of which 30 have en suite facilities. The home provides a variety of communal areas, of which one is currently being redecorated. The home has its own synagogue. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Hyman Fine House will be referred to as ‘residents’. This unannounced inspection took place over eight hours on the 23 January 2006. Two Inspectors undertook this inspection. (2nd Inspector is Jenny Blackwell). This inspection was to assess compliance with requirements made at the last inspection and following a recent adult protection investigation that raised other concerns noted by the investigating Inspector. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection report of 12 April 2005. Care plans, staff files, some policies and procedures and medication procedures were inspected. The 2nd Inspector provided the Lead Inspector with a tour of the home, as this was her first visit to the home. Staff, residents and visitors/relatives were spoken with throughout the inspection process. There were forty-six (46) residents living at the home on the day of the inspection. Sixteen (16) residents being provided with nursing care, thirty (30) residents in receipt of personal care, of which eight (8) of these residents having a dementia type illness. What the service does well: What has improved since the last inspection? A deputy care manager commenced employment mid June 2006, who is implementing changes in the care plans and assisting the manager to continue and promote good care practices within the home. Work has been done to ensure compliance with past requirements made, although some remain outstanding. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Prospective residents/representatives are provided with information to make an informed decision if the home can meet their needs. Residents’ needs are at risk of not being fully met due to the lack of information obtained during the pre assessment. EVIDENCE: The Statement of Purpose and Service User Guide were not inspected on this occasion. Prospective residents and their representatives are provided with opportunities to visit the home prior to admission. A resident had recently moved to the home at the beginning of January. It was noted in their care plan, assessments from both Brighton and Hove City Council and the homes admissions assessment contained brief information. The homes assessment was only partly filled in and was missing information about the emotional and mental well-being, social care and religious beliefs. Several parts of the plan that has a section for signing had not been signed. The homes assessment record had improved since the previous inspection although in this case not enough attention had been paid to completing the assessment. The home does not have dedicated accommodation to provide intermediate care. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Some needs are at risk of not being met due to lack of documentation in the care plans. Residents are safeguarded by the medication procedures in place. EVIDENCE: Jewish Care has developed a new care plan format and is currently implementing this format for all residents. Some of the care plans were viewed during the visit to the home. They all had standard sections which included health care activities and risk assessments. The care plan format was more detailed than at previous inspections and designed to better reflect the support needs of the individuals. However, the quality of the inputting of information and signing of the documents varied between the plans. One plan was filled in appropriately with information in all the sections and signed whilst another had brief information. Another care plan failed to reflect that the resident was receiving treatment for a pressure area, although in their “needs list”, reference had been made to them being prone to pressure areas. There was no reflection in the care plan of one individual regarding self-medication. One residents’ care plan reflected that they were an insulin dependent diabetic. It was not reflected in the care plan how often sugar levels required testing, nor was there evidence that checks were being done. It was confirmed that checks were being undertaken. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 10 Detailed conversations took place with the care manager on the shortfalls in the care plans. Care plans need to reflect actual current practice. It was confirmed that the home has recently obtained a digital camera and photos were currently being implemented for all residents. Care planning remains an outstanding requirement. It was discussed with the deputy manager the importance of expanding care notes. The deputy manager informed the Inspectors that some information in the care plans had gone missing. Certain documents that had been in the care plans could not be found. She is conducting an audit of the files and will supply a list of the missing documents to the Commission. She was unable at this stage to ascertain why the documents were missing or had been removed. She was implementing audit methods to address the situation and all staff were being made aware of the serious nature of the missing records. The Inspectors advised to initially ensure that the care staff station is kept locked at all times. It was confirmed that forms have been implemented in individual files for residents/representatives to sign when reviewing care plans. A form has also been devised to clearly demonstrate when a resident has attended appointments or have been seen by any visiting health professional. Residents’ health needs are being met at the home. One resident observed to be wearing glasses confirmed that the home will arrange visits with an optician when needed. Some residents spoken with confirmed that they are well cared for. Residents were complimentary about the staff working at the home. MAR charts spot-checked demonstrated that medications were being signed for at the time of administration. There was only one omission noted. There are accurate records being kept of controlled drugs in use at the home. It was made an immediate requirement that a copy of the risk assessment for the resident who self medicates is forwarded to CSCI, as it could not be located on the day of the inspection. The registered manager confirmed that pain control is being monitored as required at the additional visit undertaken in December 2005. It was confirmed that the pain was due to positional problems with the residents. This has been addressed. Steps have been implemented to ensure that medication is being stored at the correct temperature as required at the last inspection. Residents spoken to by one Inspector confirmed that their privacy and dignity are respected. One Inspector noted that a staff member entered a resident’s room without knocking. This was addressed with the staff member at the time. It is recommended that a blind be installed in the GPs’ room to promote privacy. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 11 There is an unused security camera in a corridor that the registered manager has been asked to permanently remove. This is currently not imposing on the daily lives of the residents. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Residents have mixed views regarding the provision of activities. Visitors are welcomed at the home. Most residents confirmed that their routine and lifestyle in the home are their own choice. EVIDENCE: Time was spent with several residents throughout the day. They were asked about their experiences living at the home. The messages from the people were generally mixed. Some people praised aspects of the home such as the food, staff support and the activities. One person commented that the staff worked very hard. Other people were not so enthusiastic about the home. Some people felt the food was not very good and that there were not enough activities at the home. It was noted that the deputy manager had set up a Food Forum that all residents could attend. A poster was visible on the residents’ information board by the dining room. She said this was in response to some of the residents previous concerns about the food. She was aware that as there were many people living at the home, to be able to set menus that would please everyone would be a challenge and having a regular forum to look at the menus would help. She was also looking into their views about the activities. As action is being taken by the home to address these issues, they have not been reflected as an outstanding requirement and will be reassessed at the next inspection. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 13 There is an activity co-ordinator employed at the home who works full time. An action plan for residents’ activities and social life had been devised in November 2005. On the day of the inspection several activities were taking place. Some residents attended an exercise session and in the afternoon a pianist and a staff member played music for a sing-a-long session, where they took requests from the residents. The residents present appeared to enjoy this session and the friendly banter that took place. It was confirmed that nine residents had recently attended an ice show that was performed in the local community. Residents spoken to by one Inspector confirmed that their lifestyle was their choice. The routines of daily living were flexible to suit their lifestyle. One resident informed an Inspector that they don’t always have a choice when they have a bath/shower. The comment made was ‘I want to have a bath when I want’. It is recommended that the preferences of bathing days be reflected in the care plans. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents/representatives are provided with opportunities to air their views. EVIDENCE: The home has a book where records of complaints are kept. This provided the Inspector with no information regarding what the complaint was about or the outcome. The registered manager confirmed that most of the complaints were about the food provided at the home. The registered manager confirmed that complaints are kept within an individuals file. It was recommended to the registered manager that a central file and clearer records be kept of all complaints. Accessible information must be easily available for inspection purposes. There is a suitable adult protection policy and procedure in place for staff to follow in the event of an allegation of abuse being made. It is recommended that the contact details of the relevant authorities involved in the investigation process are included in the policy. The home has a copy of the Multi-Agency Guidelines for the Protection of Vulnerable Adults. There have been two adult protection investigations since the last inspection. One was between two residents and the manager had not alerted the incident following correct procedures. The other allegation was found to be unsubstantiated, but additional concerns were raised following an Inspectors visit to the home. Concerns raised and requirements made have been followed up within this inspection. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 25 & 26 Resident’s individual rooms are clean and provide a homely environment. Cleaning needs to be improved in some of the communal areas. Some areas of the home are currently being redecorated. EVIDENCE: The home is located in Kemptown, Brighton, and is a short walking distance to local amenities and the seafront. There is nearby access to local transport. Rooms are spread over three floors and there is a passenger shaft lift available for residents to access all areas of the home. There are safety measures in place for the use of the lift accessing the unit designated for the care of residents with a dementia type illness. There is a synagogue located at the same site as the home to allow residents to continue their religious beliefs as desired. Some bedrooms spot-checked were seen to be personalised to reflect the individual’s choice and preference. Residents spoken with by one Inspector confirmed that they were happy with their rooms. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 16 There was tape on the carpet in a corridor that may pose as a trip hazard. This was pointed out to the registered manager and advised to implement a risk assessment and address the issue. This has not been reflected as a requirement as the registered manager confirmed she will address this problem. There were zimmer frames left on a landing on stairway between floors. These may pose as a trip hazard. It is required that staff give consideration to the safe storage of equipment used within the home. There is a call bell system used throughout the home. The Inspectors noted that one section of the call bell system identified a bell ringing for approximately 20 minutes. The room where the bell was initiated was empty when checked. There was a fault with the system. This was addressed with the staff and the registered manager at the time and steps were taken to address this problem. This has not been reflected as a requirement. Call bells were observed to have been left within reach of residents as required from an additional visit made in December 2005. One bathroom had an orange emergency cord being used as the light switch. It is recommended that this be changed to the standard white cord to reduce confusion for the residents. Windows have been restricted as required from the last inspection and the additional visit made in December 2005. The home is working towards the requirement made at the additional visit regarding concerns around door locks. Priority has been given to the EMI unit where the initial concern was raised. It was confirmed that the home is continuing to risk assess and deadlock doors for those identified as being unsuitable to independently lock doors. There is a master key available to the nurses. This has not been reflected as an outstanding requirement as work is being done to compliance. The home was of a comfortable temperature when touring the home. It has been reiterated to staff how elderly people react to cold temperatures with far more severity than younger people. On the additional visit to the home in December 2005, the Inspector noted a resident sitting near an open window, unable of moving herself and complaining of cold. Staff are continually reminded at handover time and at monthly staff meetings to ensure the comfort of residents. The cleaning of some areas of the home require improving and cleaning staff must be educated on the importance of safe storage and use of equipment to ensure the safety of the residents. Communal bathrooms must be thoroughly cleaned. There was evidence that one bath had not been cleaned after use. The bath hoist seats require to be cleaned thoroughly and mouldy slip mats being used must be cleaned or replaced. There are suitable assisted bathing facilities to meet the needs of the residents. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 17 The Inspectors noted a cleaners’ trolley containing hazardous substances had been left unattended. There was also an electrical cord from a vacuum cleaner left unattended across a hallway that posed as a trip hazard. It was made an immediate requirement that all cleaning equipment and materials to be stored securely and left unattended. The registered manager has discussed with the cleaning staff to remove any bed clothing that are worn/stained as required from the last inspection. Additional bed clothing has been purchased. An area of the home had unpleasant odours. A requirement was made at the last inspection that advice is sought regarding the control of odours in the home. The home has purchased new air purifiers but they were yet to be installed. This has not been reflected as an outstanding requirement as the registered manager assured the Inspector that she will arrange to have these installed. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 There is a risk of some needs not being met due to insufficient staffing levels at times. The recruitment procedure needs to be more robust. EVIDENCE: Time was spent with the deputy manager who had recently joined the staff team although she had worked for Jewish Care previously in a different area. She said she was enjoying her work and had spent the early part of her job improving the residents care plans and admission records. She demonstrated enthusiasm to continue to improve the record keeping at the home and was also interested at finding ways of improving the quality at the home. She felt she had been welcomed to the team and was receiving support form the manager. The home had started to support people with additional mental health needs such as dementia in a separate section of the home on the first floor. On the day of the inspection the unit was being redecorated and the group of residents were using a smaller lounge downstairs. The staff team who work with the residents had training in supporting people with dementia. The staff were seen to work consistently with the residents and respond to their needs. One staff member was observed to work sensitively with one person on a 1:1 basis when they became confused and upset. The staff member used techniques to reassure the person and went for walks with them around the building when they needed. Some comments were received from staff and visitors to the home about concerns they had with the staffing levels for the unit. This was fed back to the Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 19 manager who said she was aware of the concerns and was assessing the staffing levels as more people moved to the unit. It is required that the dependency levels of residents needs be kept under review and staffing levels be adjusted accordingly. Staff files were spot-checked where some shortfalls were noted. These shortfalls were discussed with the registered manager. It is required that all staff files comply with Schedule 2. The registered manager confirmed that head office of Jewish Care hold the information of agency staff used by the home. Volunteers working at the home have undertaken an enhanced CRB check. There were some staff that had no interview notes recorded. Some residents were very complimentary about the staff working at the home, with one comment being ‘they are marvellous’. Staff confirmed that they receive relevant training to their duties. There was evidence of training certificates kept within staff files. The home is working towards meeting the required 50 ratio of NVQ level 2 qualified staff. The registered manager confirmed that there were two staff with NVQ level 3; six with NVQ level 2 and an additional five staff to complete their NVQ level 2 studies. There is always a registered nurse on duty at all times. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 There are clear lines of accountability within the home and with external management. Steps implemented will assist in promoting and protecting the health, safety and welfare of residents and staff. EVIDENCE: The registered manager is a registered nurse with current registration with the Nursing and Midwifery Council (NMC). She is registered with CSCI to manage the home. The employment of a deputy manager will assist the manager in the efficient running of the home. Positive changes have already been noticed. Regulation 26 reports are undertaken by external management and forwarded to CSCI. It was reiterated to the registered manager the importance of ensuring Regulation 37 reports are forwarded to CSCI when required. There are clear lines of accountability within the home and with external management. The home has implemented a quality assurance and quality monitoring system. It was confirmed that questionnaires are undertaken every three Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 21 months and are audited by an external company that provides feedback to the home. A copy of the results of a survey undertaken in August 2005 was provided to an Inspector. The analysis of this survey demonstrates that there is a 84 overall satisfaction for nursing residents and a 88.9 overall satisfaction for the residential residents. The home is implementing steps to address areas of shortfalls as highlighted in previous standards. The survey undertaken and analysed by an external company for staff in June 2005 was broken down into five areas. The results of these are in percentages based on the number of staff who are positive to the questions raised. The following figures are the overall score for each set of questions. Aspiration of the Unit – 88 , Staff satisfaction and achievement – 83 , Supervision – 78 , Training – 95 and Delivery of care – 80 . The reader needs to be aware that the above figures are not related to any CSCI inspection methodology processes. The financial viability of the home was not assessed on this occasion. Hyman Fine House is owned by Jewish Care and has given no cause of concern regarding financial viability to date. There was evidence that staff are receiving regular supervision. Senior staff member who provide supervision have all received training in the supervisory role. Staff are kept up to date with all mandatory training. There were unsafe manual handling practices noted at the last inspection. The registered manager confirmed that all staff have received an update in manual handling training and plans to implement sessions every month. There were no poor practices noted on this occasion. Fire alarms are tested weekly and the home undertakes fire training twice a year. An external company provides this training. The deputy manager undertakes a health and safety check of the home every couple of weeks and the registered manager assists in this process once a month. Any shortfalls identified are then addressed. This has been implemented following a requirement made at the last inspection. The Inspectors noted an area not used by residents, was being used by staff on occasions to sleep over at the home. The registered manager was not always aware when the room was being used. This sleep over arrangement was not reflected in the fire risk assessment. The registered manager and deputy manager are required to implement safety measures to ensure all people in the home at all times are protected in the case of an emergency. It was confirmed that all equipment is PAT tested and serviced by an external company. There was casing for a box missing that was exposing wires. This Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 22 had been identified internally two weeks ago and not action has been taken. This must be repaired. The recording of accidents requires to be improved. Some did not reflect a time or the location of an accident and some were written on the incorrect forms. There was no follow up noted or action documented to take to reduce the accident reoccurring. Shortfalls were discussed with the deputy manager on the day of the inspection. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 X X 3 X 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 2 Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 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 OP3 Regulation 14 Requirement That detailed pre assessments are undertaken on all prospective service users. That all sections of the assessment are signed where applicable. That care plans cover all aspects of health, personal and social needs. Care plans must reflect actual current practice and be reviewed on a monthly basis or earlier if the needs of an individual changes. (Timescale 12.04.05 & 20.01.06 not met) That a copy of the audit of missing documentation in care plans is provided to CSCI. That a copy of the risk assessment for the service user who self-medicates is forwarded to CSCI. (Immediate requirement) That the security camera in the corridor is permanently removed. That staff give consideration to the safe storage of equipment used within the home. That the cleaning in communal areas be improved. DS0000014003.V254400.R01.S.doc Timescale for action 31/03/06 2. OP7 15 31/03/06 3. 4. OP7 OP9 37 13(4) (b&c) 31/03/06 24/01/06 5. 6. 7. OP10 OP22 OP26 12(4)(a) 23 (2) (l&m) 23(1)(d) 28/02/06 28/02/06 28/02/06 Hyman Fine House Version 5.0 Page 25 8. OP26 13(4) 9. OP27 18(1) 10. 11. 12. 13. 14. OP29 OP37 OP38 OP38 OP38 Schedule 2 37 23(4)(c) (iii) 13(4) Schedule 3 (j) That all cleaning equipment and materials to be stored securely and not left unattended. (Immediate requirement) That the dependency levels of service users’ needs are kept under review and staffing levels adjusted accordingly. That staff files comply with Schedule 2. That Regulation 37 reports are forwarded to CSCI when required. That suitable safety measures are implemented for staff sleeping at the home. That the box exposing wiring is repaired/covered. That the documenting of accidents be improved. 23/01/06 31/03/06 31/03/06 28/02/06 28/02/06 28/02/06 28/02/06 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. 2. 3. 4. 5. 6. 7. Refer to Standard OP10 OP12 OP16 OP18 OP22 OP28 OP29 Good Practice Recommendations That a blind be installed in the GPs’ room. That the preferences of bathing times be reflected in the care plans. That a central file and clearer records be maintained of all complaints. That the contact details of the relevant authorities involved in adult protection are included in the policy and procedure. That a light switch cord is changed to the standard white cord and not the emergency cord colour. That the home continues to work towards the 50 ratio of NVA level 2 qualified staff. That interview notes are kept on all new staff. Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Hyman Fine House DS0000014003.V254400.R01.S.doc Version 5.0 Page 27 - 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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