Inspection on 12/09/05 for Highborder Lodge

This inspection was carried out on 12th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Highborder Lodge 12/06/06

Highborder Lodge 02/03/06

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 Mr Adam Parker Unannounced Inspection 12th September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highborder Lodge Address Marsh Lane Leonard Stanley Stonehouse Glos GL10 3NJ 01453 823203 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 Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (42) of places Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate two (2) named service users in the category of Dementia (DE/E). The condition will be removed when the two (2) named service users are no longer accommodated at the home. That all senior carers in the home must complete training in caring for persons with dementia by 31 July 2005. Plans for this training must be submitted to the Commission for Social Care Inspection prior to commencement. The Registered Manager must obtain a qualification at level 4 NVQ in management and care or equivalent by 31st March 2007 27/1/05 2. 3. 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.V258944.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours on one day in September 2005. The inspector spoke to four service users and the registered manager was present for the majority of the inspection. Care records and the facilities to meet health needs were inspected as well as the arrangements to supervise staff and the issue of moving and handling training. In addition the files of recently recruited staff were looked at to determine recruitment practices in the home. What the service does well: What has improved since the last inspection? The home has corrected the inaccuracies in its’ statement of purpose and improved the information in the service users guide. The registered manager is now undertaking the registered managers award training. Progress has been made in providing staff with supervision sessions. Foot rests are now fitted to wheelchairs. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Service users and prospective service users have not had the benefit of the information available about the services the home provides to meet their needs. Not all service users have moved into the home having had their needs assessed and being assured these will be met. EVIDENCE: The home has now amended its’ statement of purpose to correct the inaccuracies detailed in the last inspection report and to add information about how the home meets various standards about the environment. The home has a service user’s guide that now only needs a summary of how the home meets the environment standards. There was no evidence that any service users in the home had been given a copy of the service user’s guide. Care files showed that where assessments had been completed they had been kept under review. However in one case a full assessment had not been Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 9 completed for a service user transferred from another care home. Through discussion with the registered manager it was agreed that the assessment documentation should be simplified. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 10 The care planning system in the home is inconsistent and in some cases does not provide staff with the information they need to meet service users needs. There is a lack of risk assessment in the home specific to service users needs that potentially leaves them at risk. Care in the home is offered in such a way as to promote service users’ privacy and dignity. EVIDENCE: Examination of care files showed a varied picture in terms of care planning. One care plan examined was specific and individualised and had been reviewed in response to a change in circumstances. Another care file revealed that a service user had no care plans drawn up despite being admitted to the home over two months previously and in another case care plans had not been reviewed for 9 months. One care plan seen had been signed by a service user’s relative to indicate that they had been consulted. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 11 Care files also showed that service users had access to hospital appointments, chiropodists, district nurses, general practitioners and a hearing aid clinic. Several service users had not been risk assessed where there were documented risks of falling, developing pressure sores and moving and handling. Several service users were spoken to and all confirmed that their privacy was respected and that staff were polite helpful and patient. They stated that staff knock on doors before entering. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No Standards assessed in this section. EVIDENCE: Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 13 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 The home has a satisfactory complaints procedure with information available to service users on how to access this. EVIDENCE: The home has a complaints procedure that provides an assurance that complaints will be responded to within 28 days. Written information is available to service users for referring a complaint to the Commission at any stage. The home has a folder for the recording of complaints but none had been received since December 2003. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 14 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): No standards assessed in this section. EVIDENCE: Although the environment of the home was not inspected it was noted that the home was comfortable clean and well maintained. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 15 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 & 29 The home is not able to demonstrate that it can meet service users needs through the numbers and skill mix of staff. Service users are potentially left at risk through lack of robust recruitment procedures. EVIDENCE: A review of staffing in the home has not been carried out although this was required at the last inspection. This followed comments made to the inspector by care staff giving the example that there are 3 care staff for 40 service users in the afternoon and evening. The recruitment practices of the home were looked at and it was found that robust recruitment had not been followed, with required documentation and information not being obtained before staff were appointed. This included not obtaining criminal records bureau checks, full employment histories, reasons for leaving previous employment and statements regarding the applicant’s health. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 16 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): 36 & 38 The home has made some progress towards providing supervision sessions for staff although more work needs to be done in this area. Moving and handling training that reflected current techniques had not been provided potentially putting service users and staff at risk through unsafe practices. EVIDENCE: The home has commenced the process of staff supervision sessions through meetings although one–to-one supervision sessions had yet to start at the time of the inspection. In addition the home needs to supply evidence on the supervision of non-care staff. Since the last inspection the home has taken steps to ensure that foot rests are fitted to wheelchairs. However required moving and handling training had Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 17 not been carried out at the time of the inspection although the registered manager was hoping to have this completed in the near future. This area of concern was brought to light at the previous inspection where staff reported the use of inappropriate and unsafe manual handling techniques. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 18 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 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 1 Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP1 Regulation 5 (2) Requirement The registered person must supply a copy of the service user’s guide to service users where appropriate (timescale of 30/5/05 not met). The registered person must ensure that service users are fully assessed before being admitted to the home. The registered person must ensure that all care plans are kept under review. The registered person must ensure that all service users have written plans of care on the day of admission to the home. The registered person must ensure that service users have care plans for all their assessed needs. The registered person must ensure that risk assessments are completed for service users’ identified risks. The registered person must conduct a review of staffing in the home through consultation with staff and service users and supply a copy or the findings to DS0000016463.V258944.R01.S.doc Timescale for action 31/12/05 2 OP3 14 (1) 31/12/05 3 4 OP7 OP7 15 (2) (b) 12 (1) (a) & 15 (1) 12 (1) (a) & 15 (1) 13 (4) (c) 31/12/05 30/11/05 5 OP7 30/11/05 6 OP8 31/12/05 7 OP27 18 (1) (a) 31/12/05 Highborder Lodge Version 5.0 Page 20 8 OP29 19 (1) (a) (b) Sch 2 9 OP36 18 (2) 10 OP38 12 (1) (a,b) 13 (5) the Commission (timescale of 30/5/05 not met). The registered person must not employ a person to work at the care home unless he has obtained the information and documentation in specified in paragraphs 1- 9 of Schedule 2. The registered person must provide evidence to the Commission that staff (apart from care staff) receive supervision sessions. The registered person must ensure that all care staff receive moving and handling training that reflects current techniques (timescale of 31/7/05 not met) 31/12/05 31/12/05 31/12/05 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 Refer to Standard OP1 OP7 OP36 Good Practice Recommendations The service users guide should include a summary of information on how the home meets the relevant physical environment standards. Care plans should be reviewed on a monthly basis. Care staff should receive six supervision sessions per year. Highborder Lodge DS0000016463.V258944.R01.S.doc Version 5.0 Page 21 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.V258944.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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