Care Home: Highfields

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What the care home does well Highfields provides a suitable, welcoming, bright and airy home for the people living there. Good Equality and Diversity measures are in place to ensure that race, gender identity, disability, sexual orientation, age, religion and belief are promoted and incorporated into what they do. The ladies and gentlemen feel well supported and encouraged by staff to be involved in all aspects of their daily lives to the best of their ability. They are encouraged to take part in the local community and follow personal interests through a varied social and leisurely lifestyle. The ladies and gentlemen feel genuinely liked and respected through the positive interaction with staff and manager. They presented as being relaxed and comfortable with staff indicating they feel safe and secure at the home.There are good relationships with other professionals and G.P to ensure up to date assessments, health care, guidelines and equipment is assessed and made available to promote a safe and supportive lifestyle. The home`s complaints procedures are in a pictorial and audio format making them accessible to the ladies and gentlemen. This is a good example of Equality and Diversity. The ladies and gentlemen benefit from having a committed and motivated staff team, promoting an open and service user led service. The manager offers effective leadership, is motivated and enthusiastic to promoting good practice and a personal service to those living at Highfields. What has improved since the last inspection? The requirement and some recommendations from the previous inspection have been implemented. The ladies and gentlemen have benefited from the appointment of a bank care worker who is also a driver. Since the previous inspection, accident/ incident records are safely stored in accordance with the Data Protection legislation and confidentiality. "Opportunity sessions" have been introduced in an attempt to more accurately obtain the ladies and gentlemen`s views, choices and preferences. This is good evidence of Equality and Diversity awareness. What the care home could do better: Whilst documentation is in general in good order, the care-planning format could be made user friendlier thus providing easier access to staff. Additional information regarding recruitment should be made available in the home. Further work is recommended to ensure that the garden is made more easily accessible to the ladies and gentlemen living at the home. The programme of the redecoration and tiling of en-suite facilities should now be completed. As mentioned at the previous inspection, this would enhance good cleaning practice and infection control management. Infection control would be improved by providing hand wash facilities in the sluice area. The home would benefit from having its redundant furniture and other miscellaneous redundant objects removed.The ladies and gentlemen would benefit from a consistent and fully staffed team. Whilst good monitoring systems are in place, these could be further improved by the devising of a development plan. CARE HOME ADULTS 18-65 Highfields 1 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH Lead Inspector Lisbeth Scoones Key Unannounced Inspection 9 November 2007 10:00 Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfields Address 1 Emily Jackson Close Eardley Road Sevenoaks Kent TN13 1XH 01732 465987 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) www.theavenuestrust.co.uk The Avenues Trust Ltd Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th June 2006 Brief Description of the Service: Highfields is a purpose built bungalow for six service users with a learning disability. It is one of three situated in close proximity to each other that are maintained by Kelsey Housing Association and managed on a day-to-day basis by The Avenues Trust Ltd. It is in a quiet residential area of Sevenoaks within walking distance of the town centre and main line transport systems. There is limited parking on site. Highfields is single storey bungalow with six single bedrooms including en suite shower and toilet. All bedrooms have a TV point. There is no emergency call system in the bungalow, except for in the assisted bathroom. There is a lounge and dining room and a small rear garden. Highfields has separate day staff and one waking night staff, with an additional floating waking night member of staff who rotates between the three houses on the site. The homes current scale of fees range from £981.84 to £1253.27. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced key inspection, carried out between 10.00 and 14.45. The home currently has 6 people who have lived at the home together for the past 6 years. The inspection visit comprised direct observation followed by discussion with the manager and staff on duty. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of those living at the home in the report. Some judgements about quality of life and choices were taken from limited conversation with those living at the home. A tour of the premises was undertaken and documentation examined in respect of care planning, menus, medication records, staff files and staff training. The inspection visit was further informed by an AQAA (annual quality and audit) completed by the manager in great detail for which she is to be commended. No complaints have been received since the previous inspection. A number of CSCI “comment cards” were sent out but none were returned prior to the report being written. The service users and staff in this home have expressed their wishes that they be referred to as ladies and gentlemen, as opposed to service users. What the service does well: Highfields provides a suitable, welcoming, bright and airy home for the people living there. Good Equality and Diversity measures are in place to ensure that race, gender identity, disability, sexual orientation, age, religion and belief are promoted and incorporated into what they do. The ladies and gentlemen feel well supported and encouraged by staff to be involved in all aspects of their daily lives to the best of their ability. They are encouraged to take part in the local community and follow personal interests through a varied social and leisurely lifestyle. The ladies and gentlemen feel genuinely liked and respected through the positive interaction with staff and manager. They presented as being relaxed and comfortable with staff indicating they feel safe and secure at the home. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 6 There are good relationships with other professionals and G.P to ensure up to date assessments, health care, guidelines and equipment is assessed and made available to promote a safe and supportive lifestyle. The home’s complaints procedures are in a pictorial and audio format making them accessible to the ladies and gentlemen. This is a good example of Equality and Diversity. The ladies and gentlemen benefit from having a committed and motivated staff team, promoting an open and service user led service. The manager offers effective leadership, is motivated and enthusiastic to promoting good practice and a personal service to those living at Highfields. What has improved since the last inspection? What they could do better: Whilst documentation is in general in good order, the care-planning format could be made user friendlier thus providing easier access to staff. Additional information regarding recruitment should be made available in the home. Further work is recommended to ensure that the garden is made more easily accessible to the ladies and gentlemen living at the home. The programme of the redecoration and tiling of en-suite facilities should now be completed. As mentioned at the previous inspection, this would enhance good cleaning practice and infection control management. Infection control would be improved by providing hand wash facilities in the sluice area. The home would benefit from having its redundant furniture and other miscellaneous redundant objects removed. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 7 The ladies and gentlemen would benefit from a consistent and fully staffed team. Whilst good monitoring systems are in place, these could be further improved by the devising of a development plan. 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. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. If a new lady or gentleman were to be admitted to the home, their individual aspirations and needs would be assessed prior to the decision being made to become a resident. EVIDENCE: An updated Statement of Purpose was seen on display in the entrance hall. A pictorial service user guide is available. There have been no admissions to the home since 2001. The group have lived compatibly for the past six years. The manager has a good understanding of the category and needs of those living here. The Avenues Trust have clear procedures to follow if a vacancy were to occur, including formal assessments, trial visits and involvement of those already living here. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Person-centred care plans, risk assessments and guidelines provide the staff with detailed information about the health and social needs of the ladies and gentlemen in their care. The contents and layout of the care planning files would benefit from a review to ensure easy access. Staff support the ladies and gentlemen to take risks and make decisions about their lives. EVIDENCE: The key working and person-centred planning process continues to develop and demonstrates clear promotion and support in identifying personal aspirations and meeting individual care needs. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 11 A sample of care plans was examined. It evidenced that the ladies and gentlemen living at the home are given full support and encouragement to maintain personal contact with health and social care professionals. Care plans are regularly reviewed and informed by risk assessments and guidelines. It was however agreed that the care planning files are bulky and that some information was difficult to find. It was recommended that the contents be reviewed. Seen in a bedroom, a laminated plan of care would benefit from a date evidencing recent review. All staff are provided with person centred care planning (PCP) training. The need for delegation of updating and reviewing care plans was discussed with the manager. Photographic, pictorial and object referencing is used to aid communication and better understanding by the ladies and gentlemen living here. See also standard 11 re the introduction of opportunity sessions. Daily diaries are maintained for each person. Entries therein relate to choices made and activities taken part in, the meals eaten, GP and other appointments plus other details of their day. Interaction between the ladies and gentlemen and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support and encourage the ladies and gentlemen to make choices about a range of local social and recreational interests. The ladies and gentlemen are encouraged to have visits from relatives and friends. The ladies and gentlemen’s rights to exercise choice and control over their lives are respected. The ladies and gentlemen are provided with a choice of wholesome meals. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 13 EVIDENCE: As stated in the AQAA: “Since the previous inspection, individual opportunity sessions have been introduced to establish residents’ choices and views. As a result, the ladies and gentlemen are now more able to influence their day to day lives, choices and preferences with regards to clothes, environment, drinks, décor, perfumes and aftershaves, reading materials, music and funeral planning” Outings happen daily thus offering leisure opportunities such as the library, having ‘lunch out’ and walks to the park. Trips to theatre, shows and daytrips to the coast and holidays are organised. Further opportunities for accessing community activities such as swimming pool and tea dances are being explored. In-house activities include watching personal videos, TV, and listening to music. On the day of the visit, aromatherapy sessions were offered. Combined social events are held with the residents who live in the other bungalows nearby. Contact with families is promoted on an individual basis, through visits, telephone calls and letters. Personal money is kept in individual cash tins in the homes safe. Detailed records are kept of the money put in and taken out. For additional security the cash tins are taped up and signed by staff after they have opened them. Weekly checks are made. The menu offers a varied and wholesome variety of meals, with fresh fruit and vegetables. These are tailored to the likes and dislikes of those living at the home. Specialist diets are catered including PEG feeding. Clear support and personalised guidelines for assisting individuals ensure that mealtimes are relaxed and enjoyable. The ladies and gentlemen are supported to be involved in write shopping lists, purchase foods locally and be involved in the preparation and cooking of foods to the best of their ability. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ladies and gentlemen receive the support they need and their physical, and emotional health needs are met. The ladies and gentlemen are treated with respect and dignity by care staff and are protected by robust medication procedures EVIDENCE: Staff are clearly aware of the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing. Care plans indicate staff have a good understanding of individual physical and emotional needs. Care plans evidence that the ladies and gentlemen have Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 15 access to continence advisors, psychologists, speech and language therapists, occupational therapists and NHS healthcare in the community. Good practice in relation to medication management and storage is in place. MAR Sheets are well maintained with clear PRN guidelines of administration. Staff are provided with medication and specialist training to undertake the administration of phosphate enemas, rectal medication and PEG feeding. This is reassessed and monitored six monthly by the district nurse. The staff work closely with Learning disability team in relation to the management of behavioural problems. Good strategies have been implemented with an improvement of behaviours noted and better understanding by the staff team in respect of supporting residents. The manager said that it is her intention to develop an End of Life plan for every resident, which would include a detailed funeral plan. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable those living in and those visiting the home to raise concerns or complaints with staff and people they trust. Safeguarding adults is promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. Through opportunity sessions the ladies and gentlemen are encouraged to voice their opinions about any complaints they may have. A book to comment on positive or negative issues was seen on display. The home’s records indicate they have not had any formal complaints. Staff spoken with evidenced a good understanding of how to protect vulnerable people including reporting under local procedures. Safeguarding adult training is provided with the most recent update in October 2007. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The ladies and gentlemen live in a clean, comfortable and homely environment. This would be enhanced further by the redecoration of en-suite bathrooms and re-assessment of the garden area in respect of safe access for those with limited mobility or wheelchair users. Potential risks to the ladies and gentlemen could be reduced with improved infection control practices. EVIDENCE: The home is a purpose built bungalow, well laid out, spacious bright and airy. Apart from a stained carpet in the lounge the home presented a clean environment. Staff, with some assistance from the ladies and gentlemen, carry out domestic duties. On the day of the visit, a window cleaner was washing the outside windows of the property. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 18 The dining room and communal areas are well redecorated, light and airy. Throughout the property, wall decorations such as clouds and hot air balloons give a cheerful effect. The ladies and gentlemen have the use of a lounge that is comfortably furnished and has a TV, video, DVD, music centre. The lounge contains a cupboard for the safe storage of wheel chairs. A small sensory area is currently not in use and contains miscellaneous furniture. Other no longer used pieces of furniture and equipment were noted elsewhere in the home. The home would benefit from having these removed and the sensory room made user friendly. Individual bedrooms have been decorated to their needs and tastes and contain their personal possessions etc. In one bedroom the chair’s fabric was damaged. It was recommended that this be made good or replaced. All bedrooms have en suite shower facilities. One has been redecorated with new flooring and a tiled area around the shower. As identified at the previous inspection, other en-suites and a communal bathroom are in need of redecoration. This has not yet been actioned. See also standard 39 in respect of a development plan. The home has a well- equipped kitchen where the ladies and gentleman are supported in assisting with preparing meals and making drinks. There is a spacious and well-equipped laundry. Good infection control practices are encouraged and alcohol gel dispensers have been introduced as an additional safeguard. It was recommended that hand wash facilities are made available in the sluice area. Individual specialist equipment is assessed through Occupation Therapists such as comfortable chairs, specialist beds, hoists, grab rails and bathing equipment. Whilst part of the garden has been made more accessible, further improvement would provide a safe and valuable leisure resource. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The ladies and gentlemen are supported by competent, well-trained and supervised staff. Good recruitment practices support and protect the ladies and gentlemen. EVIDENCE: On the day of the visit, the staff comprised the manager, shift leader and two support workers. Since the previous inspection, new staff have been recruited including a bank support worker who is also a driver. However, the home still relies on agency staff. Wherever possible, the same agencies staff are rostered to assure continuity. The manager said that recruitment is on-going. All new staff are provided with LDAF based induction training. A support worker evidenced this by presenting the documentation of his completed induction programme. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 20 The organisation continues to encourage and support care staff to complete their NVQ 2 and 3 in care, but new staff have to achieve full probation before being put foreword for this. The home currently has three staff holding an NVQ in Care and a further staff member is working towards this. Staff are provided with all statutory and specialist training as evidenced on the training matrix. This includes Equality and Diversity awareness. It was recommended that every member of staff have an individual training and development assessment and profile. Staff feel supported by the manager and senior managers of the organisation. “I enjoy working here”. “ The atmosphere is good, welcoming and friendly”. Staff are supported through a formal monthly supervision programme. It was recommended that the action taken when issues are identified be clearly recorded and followed up. New staff have additional 3 and 6 monthly appraisals as part of their probation period. Yearly appraisals also take place. The registered manager has clear levels of expectation from the staff team and has extended probation periods for staff to develop into their roles. Staff files are held at head office. The home holds typed forms detailing references received, CRB Number and disclosure, personal details etc. A sample of these was examined. While information recorded was stored securely and information correct, the form does not state whether POVA checks have been carried out and whether a contract has been issued. This was discussed with the manager. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The ladies and gentlemen benefit from living in a well managed home which is run in their best interests. The ladies and gentlemen can feel confident that good monitoring systems are in place and that their health, safety and welfare is promoted. Additional protection could be achieved by reviewing an infection control practice. EVIDENCE: Since the previous inspection, the registered manager left. Four the last four months the home has been managed by Diane Collins. She has 15 years of experience, 8 of which with the company. This is her first manager’s post. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 22 She holds the NVQ level 4 in Care and has achieved the Registered Managers’ Award. The manager said, “as a service we strive to deliver a unique and quality service which is stringently audited. I believe we are creative and innovative in our approach encouraging and developing skills that will enable more independent and autonomous living.” It was evident that staff respect her and feel supported by her management and leadership style. It was observed that the ladies and gentlemen feel comfortable and well supported by the manager. In-house, the manager is supported by an acting senior and another part time senior who works at the weekend. She is further supported by the Service Manager for the company. The in-house management structure is being reviewed to ensure adequate delegation of responsibilities in respect of care plans and other documentation, staff supervision and audit. Survey forms to be completed by anyone who visits the home were seen on display. Stakeholders’ questionnaires are sent to health professionals and family. The AQAA submitted evidences that health and safety measures are monitored and equipment serviced timely. Risk assessments are completed for individual’s activities. Excellent monthly monitoring visits based on the National Minimum Standards are carried out and recorded Some bedroom doors have been fitted with a magnetic closure to ensure safety if a fire were to break out. Other bedroom doors are fitted with a door guard. As these are slow to respond when activated, it is recommend that the programme of fitting magnetic closures be extended. It is recommended that a development plan be devised regarding improvements to the environment with achievable time scales. Full fire protocols and records are maintained satisfactorily. The registered manager evidenced a good understanding of accident/incident recording and reporting under regulation 37 to the Commission. These are monitored from head office. Staff training records demonstrated ongoing statutory and specialist training. A current full insurance certificate was on display. Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x 3 3 x 2 x x 3 x Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 8 Refer to Standard YA6 YA24 YA24 YA30 YA34 YA35 YA39 YA42 Good Practice Recommendations That the contents of care planning files be reviewed to ensure staff have easy access to the relevant documentation That serious consideration be given to an OT assessment and advice sought regarding safe access to the garden for those with limited mobility and wheelchair users That the en-suite bathrooms be retiled and decorated to promote good infection control management That hand wash facilities be provided in the sluice area That recruitment continues to fill vacant posts That every member of staff has an individual training and development assessment and profile That an annual development plan be devised That the programme of fitting magnetic closures to bedroom doors be extended Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Highfields DS0000023950.V351853.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!