Inspection on 12/06/06 for Highborder Lodge

This inspection was carried out on 12th June 2006.

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

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

Other inspections for this house

Highborder Lodge 02/03/06

Highborder Lodge 12/09/05

Highborder Lodge 27/01/05

Highborder Lodge 18/08/04

Highborder Lodge 17/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 Highborder Lodge Marsh Lane Leonard Stanley Stonehouse Glos GL10 3NJ Lead Inspector Mrs Helen James Key Unannounced Inspection 12th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highborder Lodge DS0000016463.V296740.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. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highborder Lodge Address Marsh Lane Leonard Stanley Stonehouse Glos GL10 3NJ 01453 823203 01453 822841 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) Mr Roger Bruce Thorne Mrs Barbara Anne Thorne Mr Roger Bruce Thorne Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must obtain a qualification at level 4 NVQ in management and care or equivalent by 31st March 2007 2nd March 2006 Date of last inspection Brief Description of the Service: Highborder Lodge is situated in the village of Leonard Stanley near Stonehouse. The home is an adapted early Victorian house with a large purpose built extension. There are 38 single rooms and 2 double rooms all with ensuite facilities. Two shaft lifts provide access throughout the home. There are two lounges and a dining room and other areas where service users can sit. Adaptations and hoists are provided to enable staff to care for the needs of service users. Most rooms have extensive views of the surrounding countryside. Level access is provided to the well-maintained grounds. Highborder Lodge DS0000016463.V296740.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 commenced on one day in June 2006, with two site visits that took 8 1/2 and 5 1/2 hours. On the first site visit the Pharmacist for the Commission accompanied the inspector to inspect medication practice within the home. During the site visits the inspectors spoke to a number of residents, some relatives, staff working in the home and the Manager of the home. Files of four resident’s were looked at in detail to include their medication and accident records. Surveys were left for staff to complete and return following the inspection; none have been received to date. What the service does well: What has improved since the last inspection? Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 6 Recruitment practice has improved but there are still areas that require attention such as ensuring references are back prior to the individual starting work; ensuring copies of training certificates are taken for files and ensuring that a documented induction is carried out when an employee starts. There is little evidence that staff induction and mandatory training are being given to the required standard and whilst some carers are doing their National Vocational Qualification (NVQ) training this cannot replace the training provided to the individuals by the home. This deficit puts residents and staff at risk. The Manager and admin team are trying to arrange a series of training sessions for staff and evidence of this was seen. What they could do better: The Manager must ensure that the induction and mandatory training is given to staff to the required standard to ensure that staff practice in a safe and efficient manner whilst caring for residents. Training relating to care issues must also be ongoing and a documented training and development plan must be available for all staff at the home. Despite assurances that the Manager/Provider manages the home and oversees care practice through Senior Care staff, there is an obvious lack of leadership within the care team despite some good skills and abilities amongst the team members. This culminates in a variety of practices being implemented, some that are or may not be in line with current care practices. This must be addressed immediately as this is putting the care and welfare of residents at risk and also junior staff. Mr Thorne confirmed that he would look at ways of managing this; options were made to Mr Thorne by the inspector during the inspection. A pharmacist inspector carried out a specialist inspection of arrangements for managing medicines (Standard 9 National Minimum Standards for Older People). Stocks and storage arrangements for medicines, a sample of records about medicines and the medicine procedures were looked at. Staff were observed giving out medicines to residents at lunchtime. There were discussions with the Manager and three members of staff. There was little evidence of improvement from the unannounced inspection in January 2006. Some issues of serious concern were found and requirements for immediate action were made. During the second inspection day the Inspector witnessed unsafe practice with regard to medication administration yet again. This was discussed with staff and the Manager at the visit and immediate action was required from the Manager. He informed the inspector that he and the senior staff would be discussing and reviewing administration practice and timings of medication throughout the day at a meeting the following day, to ensure that safe medication practice was in place in the home over the 24 hour period. The Manager/Provider and staff were informed that further breaches might lead to the Commission for Social Care Inspection considering enforcement action, to secure compliance. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 7 Although most of the requirements from the last inspection have now been complied with the issues arising from this inspection relating to medication practice, training and care management caused the inspectors concern. Requirements have been made and as unmet requirements impact upon the health, safety and welfare of residents and staff, failure to comply by the timescales may lead to the Commission to considering further action to secure compliance. 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. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 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 and their relatives are well informed about the home prior to admission although some of the information available in the home needs to be updated for accuracy. A full pre-admission assessment is completed to ensure that the needs of each resident can be fully met. This is reassessed on admission. EVIDENCE: The home has a Statement of Purpose and Service Users guide, a copy of which was seen. A yearly review must be carried out to ensure that residents and their families receive accurate information about the home. Relatives of a person recently admitted were spoken with and all confirmed that they are very happy with the home and they had no concerns. They felt they were kept well informed and feel that there is appropriate stimulation in the home. These relatives visit regularly each week so have a good picture of the home. The home has admitted two new residents since the last inspection. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 10 One of these could not be spoken with as she had gone out into Stroud on the bus, on her own during the inspections. Residents spoken with confirmed that they are given choice in what they do whilst independence is maintained. All the comments made by residents and relatives were very positive. Records of the newly admitted residents were seen and all had assessments completed. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. However, quality regarding medication is poor. This judgement has been made using available evidence including a visit to this service by a pharmacist inspector. Not all of the service user’s health, personal and social care needs are set out in an individual plan of care. Health care needs are fully met. Service users are still not totally protected by the home’s policies and procedures for dealing with medicines. Medicines are still not always managed and given to residents in a safe way. This can affect the health and well being of residents. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 12 Five care files were examined in detail for the purpose of this inspection and included medication and accident records. A pre-admission assessment form is available for use. All care files were found to have assessments completed on different assessment formats, a new format has been introduced and a Senior Carer is in the process of ensuring all resident have the new format and that this reflects the current health status of the resident. The Senior Carer assessing them signed all the forms but there was no evidence that the resident or families had been involved in the assessment or review process. Generally, as problems were identified, care plans were completed and these were then reviewed monthly. It was also noted that in several instances where risks had been identified there was no risk assessment documented. Another senior carer is dealing with risk assessments and she is in the process of ensuring that these are all in place. Care plans did not always identify that residents had a wound/catheter etc there was no care plan relating to this need and therefore no reference to the District Nursing input, although at least four District Nurses were seen during the inspection visiting the home. Other omissions such as type and size of pads in use for continence issues were also evident and must be addressed. A moving and handling risk assessment is completed and reviewed monthly. The home has residents who have diabetes controlled by diet, diet and tablets or one who has insulin and gives her own injections. Records mentioned blood glucose monitoring but did not record the results. Residents health care needs are met but all the visits are recorded in the daily record, even GP visits to review medication, and it takes a great deal of searching to find the information if you can find it. It is required that a Professionals Visiting form is established in the care record to record this information. Care staff complete brief daily records but do not always record all the relevant changes and there were a lot of gaps left in recording. As these are legal documents, each page must be completed or a line drawn through to avoid retrospective records. Accidents were recorded in the daily records and cross- referenced with accident forms that had been completed. The Manager was reminded that under data protection that all accident forms taken out of the book and kept elsewhere for auditing purposes. Residents observed in the lounge and dining areas were all addressed politely, were told what was about to happen, where they were going and what for etc. and spoken to politely, in a friendly manner and appropriately. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 13 The staff who deal with the medicines have received training but in addition to studying training courses staff must be assessed as competent to administer medicines safely. Some night staff have not attended medication training. Arrangements must be made to make sure staff who administer medicines at night are fully trained. Observation during the inspection showed that safe practices are not always followed - (immediate requirement made). Since the last inspection a trolley with lockable cases attached is used to transport medicines around the home but this is not sufficient to hold all medicines in a safe and convenient way. Medicines labelled for one resident are used for other residents taking the same product as staff said there was not room on the trolley to hold all containers. There were loose blisters of tablets – these must be kept within the labelled packet with all the information about the medicine. Any carer performing specialist procedures, such as taking blood samples to monitor blood glucose, must receive additional training from the healthcare professional responsible for delegating this task to the home. Lancing devices used to obtain blood samples must comply with the information in the Medical Device Alert issued in November 2005 (copy provided) to protect residents and staff from cross infection. Locked storage is provided but the medicine storage room could not be secured on the day of inspection as the lock had broken. (immediate requirement left). The temperature in the room was 30°C. Weekly records showed no higher than 18°C. The thermometer may need checking. Correct fridge temperatures were recorded but the fridge needed defrosting. Eye drops are not handled safely. Many containers were not dated when opened. More than one bottle of the same product was opened for some residents. Staff did not understand about correct storage in the fridge – {new bottles of Xalatan drops were not stored in the fridge as they should be} (immediate requirements left.) The insulin pens in use (correctly kept at room temperature) must have a date when first used and the name of the resident. No other medicine containers were dated on opening so audit checks were not possible except for antibiotic courses. It was not always possible to tell if stock was used within the recommended periods. Some out of date products were found. The manager now signs and checks the controlled drugs record book regularly. The anomalies in records found at the last inspection had been investigated. There are better records of medicines in this category returned to pharmacy. There were anomalies with the MAR chart in recent records. Checks on recently prescribed antibiotic courses for three residents showed that more doses were recorded as given than the stock available. This indicates poor recording or residents may not have been given the medicines as prescribed. Other records indicate two laxatives for one resident are not given as prescribed and an antibiotic cream for another resident is not applied as prescribed. The labels on three Nomad boxes (used by the pharmacy to supply many medicines) did not correspond with the information on the MAR charts or with Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 14 the number of tablets in the various compartments. This is the responsibility of the pharmacy but staff checking in the boxes should have noticed this. Printed Medication Administration Record (MAR) charts are provided each month from the pharmacy. Staff have to write some charts where there are changes or for new residents but dates are not clearly included. Staff responsible must sign handwritten entries and include a second staff signature to indicate checks for accuracy. Details for insulin were not correctly written for one resident. The dose given to residents where a variable dose is prescribed is not always recorded. The dose of one medicine written on the MAR chart was not the same as the directions on the pack of tablets supplied for a resident who had recently returned from hospital. The strength of tablet was also missing. The doctors’ FP10 prescriptions are not generally checked in the home before being sent to the pharmacy. This is best practice and has been recommended at previous inspections. Some medicines are prescribed to give ‘as required’. There are no written plans in place describing what ‘as required’ means for each resident. Risk assessments are needed for residents who look after and self-administer any of their medicines. The manager said this was being done following the last inspection. There are a lot of medicines in use. Staff described asking doctors to review medicines when they have particular concerns. The home should have a system to make sure doctors are asked to review medicines for all residents at least once each year. The medicine policy / procedures seen were due for review in June 2003. Some information is now out of date. Two procedures sent to CSCI for comment in February 2006 were not seen. The pharmacist inspector had provided detailed comments in writing. The manager said he was reviewing these now. Up to date procedures are needed and to be available to all staff so that it quite clear what standards are expected. A recent edition of a medicine reference book (BNF) was not seen. All carers observed demonstrated dignity, privacy and respect in their dealings with the residents. One example was a carer showing one resident where she was sitting for lunch and guiding another back to her room. This was done in a very gentle and caring manner. Residents were spoken ‘with’ and not ‘at’ by the carers and relatives were also being kept informed of all that was going on. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 15 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): 12,13,14 & 15 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Residents experience a stimulating and varied life at the home with visitors and community links encouraged, various informal activities being made available and appetising food being provided. EVIDENCE: A notice board in the home indicates the weekly programme of events. Group sessions and individual ‘one to one’ sessions are undertaken by the activity volunteer. She does reminiscence, board games, walking around the garden, art class, bus trips and anything the residents would like her to arrange. She sees residents when they come in and discusses with them what they like doing. There are also activities that are run in the local village that residents do attend. The hairdresser visits each week and communion is held at the home. Many residents like sitting or walking in the garden when the weather is warm. On the day of inspection two residents had gone out on their own, one on the bus to Stroud the other out on his tricycle through the villages. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 16 There did not appear to be any records relating to activities that residents had participated in, although residents spoken with told the inspector what they had been doing or enjoyed doing with the activity lady. This needs to be addressed. One resident stated that ‘she joins in with everything, she really enjoys it’; whilst another said she doesn’t join in activities as’ I just enjoy reading my books, reading the paper, doing the crossword and watching the sport on TV’; one relative spoken with feels satisfied that her aunt is offered activities to participate in but does not choose to do so and that activities are appropriate. Visitors are always made to feel welcome and there were a number of people visiting throughout the day. One felt that visitors received good support and hospitality as well as the residents. All who were spoken with felt they were offered choice in how and where they spent their days. Both residents and the relatives spoken with confirmed that everyone was happy with the food provided. The home manager has reviewed the catering provision at the home with the seniors and has made two new cook appointments to enhance the quality and choice at the home. One cook has not started yet, and when she does the cooks are to review the menus and choices available for the residents and are to review HACCP. The Kitchen is to be looked at, at the next inspection. All food safety checks are completed to include fridge and freezer temperatures, food probing and food labelling and dating. Environmental Health visited in August 2006 and tiles needing replacing have been done. Apart from Diabetic diets there are no other special diets to cater for at present. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 17 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 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 and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The home reported that they had received no complaints since the last inspection and the Commission has also not received any complaints. The home has a complaints procedure that all spoken with were aware of. One relative spoken with stated that ‘I have no concerns about the care or the home and I always feel confident to discuss concerns with the manager and staff and know who to approach’. A second relative was also positive about the home, the care and the staff and said they had no complaints but would tell the staff if they did. The home has its own policy on abuse and adults at risk file and has been sent the ‘Alerters’ Guide’ to add to this. Six staff have undertaken training on abuse awareness/adult protection and the rest of the staff group need to undertake this training. Staff spoken with confirmed they had received this others felt they needed this training although in discussion they knew what they would do if they saw abusive practice or saw anything that bothered them. A section on abuse should be included in the induction programme. All new staff should receive this as part of the mandatory training and other staff should receive regular updates. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 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. The standard of décor within this home is good and no maintenance issues were identified. Residents live in a safe well-maintained environment. The standard of cleanliness was good but there were issues of infection control identified that need addressing to ensure that residents are not at risk of cross contamination and have a clean and hygienic home to live in. EVIDENCE: Most of the rooms in the home were visited. All areas seen were clean and in good decorative order. The Manager reported that he does a regular audit monthly of the home to check whether any work needs to be completed and to look for any health and safety issues. There were several infection control issues noted on the first day of the inspection, largely being the number of unmarked toiletries in communal Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 19 bathrooms, suggesting that they may be communally used; these included roll-on deodorant, powder, bubble bath, shampoo and creams. These had been removed on the second day of the inspection and none were found in communal areas. The inspector also noted that staff were walking around wearing plastic care gloves and the inspector needed to ascertain that they were not using the same gloves for everyone (cross contamination issues). When staff were questioned regarding this, they said they put them on to do anything related to dealing with residents including drugs. It was reiterated that it does not respect residents’ privacy and dignity if staff put them on in communal areas to attend to personal tasks for the resident. They should be put on in toilets and bathrooms or in the privacy of the residents’ rooms. The majority of staff have received control of infection training in the last three months. On the second visit to the home the following day no one was observed walking around the home with plastic care gloves on. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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. Staff are employed in sufficient numbers to meet the residents needs and care observed was appropriate. There does appear to be a lack of leadership of the care practice leading to inconsistency of practice in the home. Morale remains high with a low staff turnover so there is some consistency for the residents. The procedures for the recruitment of staff have improved but must be maintained to protect the people living in the home. A staff-training programme has commenced but needs to be developed further to cover all mandatory training for all staff and care issues. EVIDENCE: There was one Senior Carer, four care staff and the Manager on duty on the day of inspection. In addition to this there was a cook, kitchen assistant, four cleaners, one admin and a maintenance man. Three of the care staff and the admin and Manager were spoken with. Twelve of the care staff had worked at the home for longer than 2 years; nine for a year and four were new this year. The staff stated that there was a keyworker system in the home and a list was available for the inspector to see, none of the keyworkers for the residents’ Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 21 casetracked were on duty during the inspection. Staff felt they had time to spend with the residents, as there were only a few highly dependent residents. They felt the activities volunteer was very good and did a lot with the residents on a ‘one to one’ basis or in a group. They confirmed that the home had regular staff meetings, which were minuted. Staff enjoyed working at the home but they felt that there was little communication with the Manager and they weren’t always listened too, with respect to care issues. However, action had been taken about their complaints about the catering. The Manager is approachable but reportedly doesn’t always act when issues relating to care are bought to his attention. A handover is given at each shift change. The care staff write the daily records and feedback any changes in condition to the Senior Carer on duty. They all had access to the records and knew all about the residents and how to meet their needs. Staff said that it was a good supportive team and it is a happy place to work. They feel there is enough time to give to the residents and they are given choice. Residents spoken with confirmed that the staff were very caring and met their needs. Staff are gradually completing National Vocational Qualification training and appear to enjoy doing this. Six have NVQ level 2 and eight are currently studying this. Two have NVQ level 3 and two are currently studying for this. One is currently studying for NVQ level 4. Mandatory training in fire, health and safety, moving and handling, food hygiene and first aid training are gradually being updated to have all staff trained to the required standard. It is imperative that domestic and kitchen staff also receive the appropriate training. Training records for all staff were seen. Two cooks who have been recruited recently did not have any certificates on file relating to food hygiene although this was confirmed at interview. The Manager reported that they would both be going on training to update their knowledge with the possibility that they would do the advanced certificate, which would enable them to train the staff in basic food hygiene, as all care staff have access to the kitchen and handle food. Records of four newly appointed staff were seen and were improved. All had completed application forms, CRB/POVA checks, health questionnaires and had provided two written references. Although in one case references had not yet been received (she was starting the following week), one did not have a full employment history and none had copies of training certificates on file. These issues must be rectified. There were no interview records or induction training records on files seen. Highborder Lodge DS0000016463.V296740.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is judged to be adequate. This judgement has been made using available evidence including a visit to this service. The Management of the home is good but there is still a lack in leadership, guidance and direction of care on a ‘day to day’ basis. This needs to be addressed as a matter of urgency, as potentially it could lead to residents being put ‘at further risk’ (See Standard 9). There still does not appear to be a clear development plan in place for the home and in areas such as training. The system for service user consultation is improving but must be continued and developed. There are processes in place to safeguard the financial interests of residents. The health, safety and welfare of the people using the service are in the main protected and safeguarded. EVIDENCE: Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 23 The Manager/Provider ensures that managerial duties are fulfilled and is in the process of finishing the NVQ Managers Award. The manager /admin staff deal with financial transactions for the residents with regard to personal monies. Records were seen at the inspection and account sheets were available for each resident. The Manager audits these regularly. The home has commenced a quality assurance programme and has a variety of regular monthly Manager audits in place. A questionnaire survey is being sent out at the moment to residents/their families etc; it is expected that the results of these will be collated and an improvement plan developed to indicate that views have been acknowledged and/or acted upon. Other survey possibilities were discussed including one to visiting professionals to the home. Other audits of medication, medication records, daily records, care plans etc should all be audited as part of a Quality Assurance system in the home, so that any shortfalls can be identified and drawn to the attention of the staff responsible to rectify. Accident records are checked and audited to monitor patterns in the home. When records were examined it was noted that the accident record is being kept in the book. It is essential that under data protection that all these are kept elsewhere. Staff confirmed they had received some supervision and the system is ongoing. The supervision records seen indicated that the staff member had been observed during care practice and then had had a formal one-to-one session with their supervisor where staff and supervisor both discussed training needs, development and areas for improvement. This is then discussed and arranged with the Manager/admin of the home. The system should be developed so that all staff records demonstrate formal supervision sessions at least six times a year. Catering and domestic staff should be included in the supervision and appraisal cycle. Some mandatory training and updates are still lacking for some staff and this is in the process of being addressed with the Manager/administrative staff trying to arrange a variety of training for staff (see standards 19). Staff spoken with, to include someone fairly recently appointed had not received fire training to date. Failure to comply with fire safety training requirements endangers the lives of the residents and staff and must be rectified. Records were seen of fire safety checks such as fire alarm and emergency lighting check these were being carried out as recommended. All the required Health and Safety checks are in place. Temperature of stored water is checked and recorded for prevention of Legionnella and the Manager was advised that yearly sampling should be implemented. Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP32 Regulation 12(1) Requirement The registered person must ensure that a system is put in place to ensure care leadership on a ‘day to day’ basis to prevent residents being put at risk. • The door to the medicine room to be kept locked. • Safe practices always to be followed when giving residents their medicines. • All medicines to be stored at the correct temperature. • All eye drops to be used within 28 days of opening containers so the date of opening must always be written on the label. All staff that handle medicines must receive accredited training and be regularly assessed as competent to administer medicines safely. Staff measuring blood glucose levels to be formally trained. Suitable storage equipment with sufficient space to be provided to make sure medicines can be held securely and administered safely to residents. The manager to prompt the doctors to review medicines for all residents at least once each year. Timescale for action 20/08/06 2. OP9 13 31/07/06 3. OP9 18 20/08/06 4. OP9 13 31/07/06 5. OP9 13 20/08/06 Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 26 6. OP9 13 & 17 7. OP9 13 8. OP9 13 9. OP9 13 Residents to be given their medicines in accordance with the prescription directions from the doctor. Medicines only to be given to the resident for whom labelled. MAR charts must be kept clearly and accurately at all times. Written protocols to be developed for each resident describing the use of any medicines prescribed ‘as required’ The manager must introduce weekly audits to demonstrate medicines are being managed safely on behalf of residents. The medicine policy to be reviewed with the June 2003 guidelines from the Royal Pharmaceutical Society of Great Britain. All staff to be made aware of the policy with checks in place to ensure their understanding and compliance with all procedures. Lancing devices complying with the information contained in Medical Device Alert MDA/2005/063 to be used to obtain blood samples from residents. The registered person must ensure that there are weekly-recorded checks of controlled drugs stock and records. Care planning issues to be addressed: • Evidence that the resident / family have been involved in the assessment and review process via signatory evidence. • Update assessment and careplan to reflect the current health status of a resident. • Implement a Professionals Visiting form in the care record. • Record type and size of pads in use for continence issues. • Record a careplan relating to wounds / catheters / diabetes etc. • Residents Self-medicating DS0000016463.V296740.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 10. OP7 15 20/08/06 Highborder Lodge Version 5.2 Page 27 11. 12. 13. 14. 15. OP7 OP12 OP18 OP26 OP30 15 16(m) 13(6) 13(3) & 12(4a) Schedule 4 6(g) must have a documented risk assessment on their care file. All daily care recording must run sequentially with no gaps between each entry. All residents must have recorded evidence of activities they participate in. All staff must receive Abuse awareness /adult protection training. Ensure gloves used for personal care are not worn in communal environments or in the dining room. All staff files must contain: • Copies of training certificates. • Interview records • Induction training records. The Quality Assurance system to be further developed in the home. All staff in the home must receive mandatory training. 20/08/06 20/08/06 20/08/06 31/07/06 31/07/06 16. 17. OP33 24 18(1a) 31/08/06 20/08/06 OP38 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. Refer to Standard OP9 OP9 OP9 OP38 Good Practice Recommendations The date when opened to be written on all medicine containers. FP10 prescriptions to be checked and copies kept in the home before sending to pharmacy for dispensing The latest edition of the British National Formulary and a file of Patient Information Leaflets (PILS) to be available in the home. Yearly sampling of water to prevent Legionnella should be implemented Highborder Lodge DS0000016463.V296740.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: 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 Highborder Lodge DS0000016463.V296740.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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