Inspection on 21/03/07 for Hyperion House

This inspection was carried out on 21st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hyperion House 12/02/06

Hyperion House 11/10/05

Hyperion House 17/03/05

Hyperion House 19/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Hyperion House London Road Fairford Glos GL7 4AH Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 10.00 21st March 2007 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 Hyperion House DS0000016482.V317277.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. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hyperion House Address London Road Fairford Glos GL7 4AH 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) 01285 712349 01285 713126 Info@divacare.co.uk Diva Care Limited Mrs Kathleen Joyce Boyce Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2006 Brief Description of the Service: Hyperion House is situated in the centre of Fairford Town and well known by the local community. It is an extended building, which sits on the main road with its own garden and car park to the side and rear. The Home offers both personal and nursing care to the elderly person. A qualified nurse is on duty at all times. The local GP Surgery visits regularly and Community Nurses attend to the nursing needs of those admitted for personal care only. The private accommodation is located on both the ground and first floors and is predominantly for single occupancy. There are some shared bedrooms and all rooms have ensuite facilities. The communal rooms consist of one large lounge leading into a conservatory, which is used for dining and a smaller lounge/dining area. In addition there are ample communal toilets and bathrooms. The Home offers a laundry service and its kitchen caters for a range of diets. Some form of activity takes place each day and close links with the community exist. At the time of inspection the fees are in the range of £425 to £750, with additional charges for hairdressing and chiropody. People funded through the Local Authority have a financial assessment carried out in accordance with fair access to care Services procedures. Local authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms can be accessed from the Office of fair trading web site at www.oft.govuk http:/www.oft.gov.uk Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over two days in March 2007, and over twelve hours. During this time the inspector spoke to a number of residents, some relatives, staff working in the home, the manager of the home and the provider. Six resident’s files were looked at in detail to include their medication records. Other records seen included seven staff files, training records, and the service users guide and accident records. The general environment was also inspected with particular regard to cleanliness of rooms and equipment. Surveys were sent out to service users, their families and staff prior to the inspection and the results were then collated and fed-back during the inspection and included in the report. A pre-inspection questionnaire was provided prior to the inspection and included rotas, menus and resident and staff details. What the service does well: What has improved since the last inspection? Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 6 On the whole, with one or two exceptions recorded within the report the standard of maintenance appeared to be much improved. A programme to fit guards on radiators was ongoing and other risks identified at the last inspection had been addressed, although there still remained a number of radiators to guard and a potential risk with an unlocked upper floor door. 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. The summary of this inspection report can be made available in other formats on request. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 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 Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users are well informed about the home prior to admission and a full pre-admission assessment is completed. Intermediate care is not provided at this Home. EVIDENCE: A statement of purpose and service users guide was seen in reception, available for visitors to read. Other copies were seen in service users rooms, although the manager reported that often visitors take them home. The manager also reported that the service users guide is due to be reviewed within the next month as it was noted that there are a number of inaccuracies and points that need to be changed. A copy of the amended service users guide is to be sent to CSCI. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 9 Contracts for new residents were also examined, as were letters about to go out to each service user, notifying them of fee changes and detailing RNCC payments where appropriate. Several residents were spoken with to include some who had been admitted since the last inspection. All said that the staff were very kind and caring but two said life was monotonous/boring. Of the surveys received from service users, all indicated that they were happy in the home although one did comment that staff are not always available at the time they are needed. All service users are assessed prior to and on admission to the home to ensure that their needs can be fully met. Pre admission and full admission assessments were seen and gave a clear picture of each service user and how their needs are to be met. Other than the comments above that suggest that although physical needs are met, possibly psycho-social needs are not, there was only one comment from a relative to suggest that personal care was not always satisfactory but the relative had already brought this to the attention of the manager and the lead inspector for the home in the past. The service user herself, when spoken with, confirmed she was satisfied with her care and loved her room and the view. Hyperion House DS0000016482.V317277.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 judged to be good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are set out in the individual plan of care. Service users health care needs are fully met. Service users 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 as far as possible in shared rooms. EVIDENCE: Care files of seven service users were examined in detail to include several who had been admitted since the last inspection and two who require nursing care. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 11 All had both day and night care plans and showed evidence of regular review, with the service user/their representative where possible. All of those seen had clearly identified problems and planned care that reflected their current needs. Core care plans were mainly used but had been individualised. Risk assessments to include moving and handling and pressure sore risk assessments, were also completed and up to date. The manager is currently reviewing the care plan format, commencing with the night care plans. Daily records are also kept, reporting any significant changes, and also making reference to referral/liaison with other agencies such as the doctor who visits each week, district nurses, RNCC and the continence advisor. The doctor was visiting on the first day of the inspection and a district nurse on the second day. Medication records were checked for those service users whose records had been examined. They were all found to be well maintained, although the hole -punch on the pre-printed records did sometimes cause problems. The home had regular contact with the dispensing pharmacist who offers advice and support. Medication storage was also checked and found to be satisfactory and administration was observed on more than one occasion and found to be satisfactory. Residents were able to confirm that staff were all very kind and caring and the staff were all observed by the inspector as being courteous and respectful towards the residents. They were seen knocking on doors prior to entering, addressing them by their correct names and appeared to have a good rapport with the residents and visitors. Engaged signs were displayed when residents were in the bathroom. However, the home has sixteen double rooms, the majority of which are currently shared, and portable screens are used as the means to provide privacy for any personal care given. The inspector did not feel that these curtains were adequate provision for privacy especially as you could see straight through some curtains and some were missing, having been taken away for washing. Several service users who shared a room, were spoken with, and with one exception, all were happy with the arrangement, some stating that their ‘roommate’ was unaware they were there’. It was also unclear in some shared bathrooms to whom personal toiletries, toothbrushes etc. belonged to and several cabinets would not open fully. The home must ensure that adequate provision is made for privacy and storage of personal belongings in shared rooms. One survey completed by a relative stated that ‘ there is no privacy in the lounge for visitors, and no seating, therefore not much incentive to visit’. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 12 However, there appeared to be a number of people visiting the home during the two days of the inspection and the majority of surveys received stated that staff / owners welcomed them into the home at any time and that they could visit their relative/friend in private. Hyperion House DS0000016482.V317277.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 judged to be adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices on a daily basis and if this is difficult for some they are encouraged to make decisions within their capabilities. The food in this Home is varied and residents have enough to eat even if they require a specialised diet or help to feed. EVIDENCE: The service users guide states that activities are available. The manager stated that the home does not have a written activities programme and no member of staff designated to organise activities, but service users enjoy bingo every day and there are other board games available if they wish to use them. However, in one service users file it states ‘ provide a stimulating and varied programme of activities centred around residents needs and preferences’. This resident was observed either sitting quietly in their room or ‘dozing’ in the back lounge throughout the two days of the inspection. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 14 A ‘former lifestyle’ record is completed on admission and these were generally very informative, recording past occupations and hobbies among other things, however, no one was observed pursuing past hobbies other than reading or doing word puzzles which several residents said they enjoyed. A more stimulating lifestyle could be created if this information was utilised. Bingo was played on the first day of the visit and those who took part were obviously enjoying it, but one stated that she did not like bingo and as she had poor hearing did not enjoy sitting in the lounge. Another said, everyone sits there sleeping, so she chose not to go to the lounge. Two residents said they found the atmosphere monotonous and boring but others appeared quite happy sitting and watching the day- to- day activities and one said their day was occupied by all the meals provided. One relative stated in their survey that ‘ there is little or no stimulation for the residents, and unless they are physically able they are seldom given the opportunity to sit in the garden during the summer’. Another stated ‘ my mother is very happy there. The only concern is lack of entertainment and activities, which some other homes provide’. One resident has acquired a cat since admission and her room has a cat flap fitted and provision for the cat’s food and bedding. The hairdresser visits regularly and monthly communion is held. The only people who currently go out, are those whose relatives take them out, but the manager did say that when the weather is warmer, trips to town and to the market might be arranged if anyone wishes to go. The home does not have any transport to take residents out for short outings. Everyone spoken with was very happy with the quality and quantity of the food provided and several mentioned the new chef, who has just organised a new menu (copy provided). Themed meals and special birthday meals were discussed with him, as ideas he is introducing. All of the meals seen appeared very appetising, the emphasis being on wholesome home cooking. One resident mentioned she is on a gluten free diet and said the home caters very well for her. Another will only eat chips and has those provided for each meal. Other dietary needs are catered for. A number of residents had many personal affects around them. Several bedrooms were seen containing personal belongings and looking very homely. Hyperion House DS0000016482.V317277.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 judged to be adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are not always confident that their complaints will be listened to, taken seriously and acted upon. There are arrangements within the Home to ensure that vulnerable adults are protected from abuse. EVIDENCE: The home has a complaints procedure within the service users guide, last reviewed in November 2006, but eight relatives surveys stated they were unaware of the complaints procedure or that they could have access to the inspection report. It was advised that a copy of the last report should be placed at reception with the service users guide and all new service users /their families should be informed verbally of this when a copy of the service users guide is given to them. One stated that they had made a complaint regarding missing personal possessions, but no conclusion was reached and they decided not to take any further action. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 16 A copy of another complaint was seen within a service users file, concerning time to answer a call bell, but this was resolved and there have been no further problems with this. Out of twenty surveys, 10 were completely happy with the service and only two did not feel welcomed or informed of their relatives care. Staff are all given information on whistle blowing and the adult protection procedure as part of their induction programme and a policy on adult protection and prevention of abuse was last reviewed in November 2006. Hyperion House DS0000016482.V317277.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): 19,22,24 25,26 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. This home provides comfortable accommodation that is well maintained and which is kept clean. EVIDENCE: A tour of the building took place during the first day of inspection. All areas appeared clean, comfortable and in good decorative order. One room was in the process of being redecorated and the next was planned. This continues on a rolling programme. There were no odorous areas noted during the two days of the inspection although a comment from one survey suggested that the home was hot and odorous. The temperature was comfortably warm, not excessively hot on this occasion. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 18 A number of new armchairs have been purchased since the last inspection and were found in the lounge. The corridor and ‘back lounge had been re carpeted recently, but the company who supplied this had been contacted and were coming back to replace this as it was already badly stained despite vigorous cleaning programmes. The owner expressed his disappointment with this. It was noted that a chest/sideboard in the back lounge was also badly stained and this was reported immediately to the maintenance man to re-varnish. Other than this, all furnishings appeared to be satisfactory. There did appear to be a lack of armchairs in some of the shared rooms but the manager explained that the occupants of these rooms chose not to spend any time in their rooms except to sleep. There were a couple of small maintenance jobs noted, such as a bath panel loose on one non-assisted bathroom, which the manager reported is not used for bathing, and two en suite bathroom cabinets that needed repair or replacement. Other than this the home appeared to be well maintained. The requirements related to maintenance have been met since the last inspection and a number of radiators have been fitted with guards, but there are still a number that require guards and some of these the inspector regarded as high risk. It was reported that the guard- fitting programme is ongoing and priority must be given to those high-risk areas. Only one other risk was identified in room 16 used for respite care and occupied. The room has double glass doors that open onto a flat roof. The doors were found to be unlocked and a potential danger should anyone walk out onto the flat roof. A bolt was immediately fixed to the outside of this door as a temporary measure until more secure windows/door can be fitted. A programme to replace all the windows with new double glazed windows is also ongoing and has commenced on the upper floor. It was noted that the home is fully equipped with a number of portable hoists, variable height beds, pressure relieving mattresses and cushions and other pressure relieving aids. Hyperion House DS0000016482.V317277.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 judged to be adequate. This judgement has been made using available evidence including a visit to this service. Although this outcome has been assessed as adequate a serious shortfall was noted in the recruitment process, which must be addressed as a matter of urgency. Service users needs are usually met by the numbers and skill mix of staff and are in safe hands at all times. Service users are not always supported and protected fully by the homes’ recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: Rotas were provided prior to the inspection and over the two days of the visit adequate staffing levels were in place with a qualified nurse on-duty at all times with six care staff on the first morning and seven on the second, and three care staff on the first late shift and four the second. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 20 In addition to this there were two cleaners and a laundry assistant, a chef and two kitchen assistants and the maintenance man and administrator. Seven relative survey results felt that there were not enough staff on-duty, and one said this varies, but only one service user survey felt staff were not always available at the time they were needed. There were no comments from service users during the inspection to suggest that they were not receiving the care they needed, no call bells ringing for long periods and staff on-duty did not seem to be rushed. There were also some comments from relative surveys about high staff turnover, and lack of being able to understand overseas staff. The home continues to employ a large proportion of overseas staff. Several were spoken with. Their levels of communication varied. In most cases, they communicated well, but in a few instances their English was limited and they said that ‘they were here to learn English’. The manager stated that there had been a period a while ago when the staff turnover was high, but this appears to have settled. Files of seven new staff were examined. All had completed application forms with a full career history and in some instances a curriculum vitae also. With one exception all had completed a medical questionnaire and signed to confirm they were mentally and physically fit. All had given two written references, with one from their last employer, although in one instance, as the last position was non-care and a previous position care, it was advised that a reference should be sought from the last care position. Where references were given from an employee’s home country, such as China or India, translations were provided where necessary. It was also discussed that references should be on headed paper and verified where possible. In most instances a Criminal Records Bureau (CRB) disclosure was seen. However, in the case of overseas staff, it was noted that some employees had commenced work and did not yet have a CRB check completed and the home had not requested POVA First believing that the police check from their own country was sufficient for them to start. This is not so and all staff must have CRB clearance prior to commencing work and in exceptional circumstances where the home needs them to start work before CRB clearance then POVA First must be obtained. The manager reported that no staff currently have NVQ 2 or 3. Several staff who have been at the home for some time have no interest/commitment to undertake such training. There are plans for five new staff to commence NVQ 2 shortly. Evidence was seen of staff inductions and training, with copies of certificates held on file and details of the induction programme see. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 21 Staff supervision records were also seen and a programme of supervision is in place. Often this occurs as a teaching session on a relevant subject related to conditions of current service users. Only three staff surveys were completed, but all felt they had been recruited correctly, were fully informed about their job and felt well supported by their manager. Two (nursing staff) also confirmed that they received training and supervision. One commented ‘in my opinion Hyperion House is a home with genuine staff, good people dedicated in their work’. Hyperion House DS0000016482.V317277.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 her responsibilities fully. The home is run in the best interests of service users and their financial interests are safeguarded. Health and safety is generally well risk assessed within the Home, although some radiators still pose a potential risk. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has been at the home for a number of years now and has much experience in care of the elderly and has completed the registered managers Award (NVQ 4). The deputy manager assists her in the running of the home and takes the lead in practical care and nursing issues. The provider is in the home most days. Records pertaining to residents’ monies were not inspected on this occasion, but have been found to be satisfactory at previous inspections. Satisfaction surveys have been completed in the past but not for some time. The manager reported that surveys would be sent out this year, results collated and an action plan developed. The report will then be sent to CSCI and will be available for service users and their families to read. Other audits are completed by the home but do need to be developed further as stated in the last report. An accident audit was seen and identified how many falls occurred each month and when a serious accident occurred, but did not identify the frequency of accidents for each service user and the time of these accidents to identify patterns and determine what action could be taken. However, in examining the accident book it was noted that one name had occurred frequently and it had been identified that this resident did get up unsupervised during the night and often fell as a result of this. An alarm has now been fitted to alert staff when this resident is getting out of bed and the frequency of falls has lessened. Maintenance records were seen to confirm that all equipment such as hoists and the lift are serviced regularly and checks are made to fire equipment, fire alarm and emergency lighting test records were seen, as were hot water temperature testing. The manager and maintenance man have recently reviewed the fire risk assessment and records of staff fire and other health and safety training were seen. Only two health and safety risks were noted as detailed in standards 19 to 26 of the report and steps were being taken to correct each of these. Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 24 Consent forms are completed where someone has been identified as requiring bed rails and staff must ensure that risk assessments are completed prior to their use, with all relevant parties, to ensure that this is the most satisfactory method of providing security/preventing falls for each individual. A crash mattress rather than bedrails was used for one resident. The manager also confirmed that bumper pads were not used with bedrails because of the risk of suffocation, but they must also be aware of the danger of entrapment and if in doubt should seek the advice of the Health and Safety Executive (HSE) or the Medicines and Healthcare products Regulatory Agency (MHRA). Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 2 17 X 18 3 3 X X 3 X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 26 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 OP10 Regulation 12(4)(a) Requirement The Registered Manager must make suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. Timescale for action 11/05/07 2 OP12 16(n) 3. OP16 22(5) 4. OP38 13 (4)(c) The registered manager must 11/05/07 consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation having regard to the needs of the service user. The registered person shall 11/05/07 supply a written copy of the complaints procedure to every service user and to any person acting on their behalf if that person so requests. The Registered Manager must 11/05/07 ensure that all areas within a resident’s bedroom are safe and that any risks are eliminated. The timescale of 01/04/07 was not met in full This requirement is related to unguarded radiators and unlocked door/window. DS0000016482.V317277.R01.S.doc Version 5.2 Page 27 Hyperion House 5. OP29 19 6. 7. OP33 OP38 24 13(4) Ensure that all relevant checks and records are completed and satisfactory prior to the appointment of a new member of staff. (This is with particular reference to Criminal Record Bureau Clearances: CRB’s on all staff) A system must be maintained to review and improve the quality of care provided in the home. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated- this relates to use of bedrails and protective coverings. 11/05/07 30/09/07 11/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP10 Good Practice Recommendations Amendments to be made to service users guide and amended copy to be sent to CSCI and to be given to each service user. Where service users have chosen to share a room, screening should be provided to ensure that their privacy is not compromised when personal care is being given or at any other time. Service users interests should be recorded and they should be given opportunities for leisure and recreational activities in and outside the home, which suit their needs, preferences and capacities. Pipe work and radiators must be guarded or have guaranteed low surface temperature. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) should be achieved. 3 OP12 4. 5. OP25 OP28 Hyperion House DS0000016482.V317277.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Hyperion House DS0000016482.V317277.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. 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