Inspection on 02/03/06 for Highborder Lodge

This inspection was carried out on 2nd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 12/06/06

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 Adam Parker Unannounced Inspection 2nd March 2006 09:20 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.V285916.R01.S.doc Version 5.1 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.V285916.R01.S.doc Version 5.1 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.V285916.R01.S.doc Version 5.1 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 12th September 2005 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.V285916.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six and a half hours on one day in March 2006. A number of service users were spoken to in addition to the registered manager, the administrator and care staff. Several requirements from the previous inspection have not been complied with and the home has been sent a warning letter about this. An additional inspection of the home took place on 25/01/06 in response to a complaint from a relative of a service user about medication, personal care and staff numbers on duty in the home. The outcomes of the complaint were; 1. Incorrect medication administration to the service user. Upheld. 2. Lack of personal care with regard to dressing. Not Upheld. 3. Lack of attention to personal hygiene particularly regarding bathing and hair washing. Upheld. 4. Lack of staff in numbers to care for Mrs Lloyd. Unresolved. A number of requirements were made as a result of the complaint investigation. What the service does well: What has improved since the last inspection? Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 6 Service users are fully assessed before admission to the home. Care plans are kept under review. The service users guide has been updated to include information about the environment of the home. 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.V285916.R01.S.doc Version 5.1 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.V285916.R01.S.doc Version 5.1 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 Information is available for prospective service users to make an informed choice before moving into the home. The home’s admission procedure ensures that service users are admitted to the home on the basis of a full assessment of their needs. EVIDENCE: Although the service users guide has been updated to include information about the environment of the home there was a reluctance to share the guide with service users in the home. Reasons for this were that the contents of the guide would worry service users and those with poor eyesight would have trouble reading the guide. However on the day of the inspection a suitable service user was identified and received a copy of the guide to read. A large print version of the service users guide should be made available in the home for service users who may have problems reading the current copy. Inspection of care documentation showed that service users are now fully assessed before being admitted to the home. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Service users have individual plans of care for staff to follow to meet their needs. However care could be compromised when there is a delay in writing plans for service users when they are admitted to the home. On the whole service users health care needs are met although the home needs to be more diligent in assessing known risks to service users. EVIDENCE: Care files for five service users were looked at. One of these had been in the home for over three weeks and the other for over a month and despite information being available from assessments they still did not have care plans drafted by the home. This was a requirement at the previous inspection. Care plans for other service users were in line with assessed needs and had been reviewed on a regular if not always monthly basis. At the previous inspection a requirement was issued regarding risk assessments for identified risks however on this inspection it was found that Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 10 one service user who was registered blind and used the stairs in the home did not have a risk assessment completed. Requirements made following a specialist pharmacy inspection on 20th January 2006 were looked at, however these will be checked again at a future pharmacy inspection. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 11 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 The home maintains good links with the local community, places no restrictions on visiting and provides an activities programme to provide service users with regular opportunities for social interaction. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The home has an activities coordinator and a volunteer who assists with activities on three days of the week. The activities organiser assists service users with individual activities. Activities are displayed on a notice board and it was reported that such information is verbally given to service users who cannot access the notice board. The home operates a policy of open visiting. Some service users attend a social club in the village and one is a member of a local artists society. A local clergyman visits the home and Holy Communion is provided on a weekly basis. The home has information available on advocacy services and had plans to contact an advocacy service for one service user in the home regarding their personal finances. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 12 The home provides service users with a menu that includes a daily alternative from the main course. In addition there is always a vegetarian option available. Service users spoken to praised the food available in the home. The home keeps a record of alternative dishes provided to service users. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 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): 18 Staff training in preventing abuse would further protect service users. EVIDENCE: The home has comprehensive policies on the prevention of abuse and a ‘whistle blowing’ procedure. No specific training has been given to staff on abuse prevention although it is incorporated in NVQ training. Due to the low numbers of staff undergoing or having achieved an NVQ qualification, service users would be better protected by training being provided for all care staff. In addition, the home has policies on dealing with aggression and a policy that precludes staff from involvement in service users’ wills. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 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): 19 & 26 The standard of the environment in this home is good with service users having a pleasant, clean and well maintained environment to live in. EVIDENCE: A tour of the home and inspection of selected rooms showed a well,maintained,clean and pleasant environment. The grounds of the home are accessible to service users and the gardens are well tended. The laundry was clean and well ordered with washable wall and floor surfaces and hand washing facilities. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 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): 27,28 & 29 A review of staffing has enabled the home to demonstrate that it can meet service users needs through the numbers and skill mix of staff. Training to NVQ level has not progressed enough to ensure that service users are in safe hands at all times. Poor recruitment procedures have put service users at risk. EVIDENCE: A review of staffing in the home has been carried out, this was required at the last inspection. Based on the training record supplied to the inspector, the home has not been able to achieve the minimum standard of 50 of care staff qualified to NVQ 2 level by December 2005. Despite being raised at the previous inspection the home was still not adopting robust recruitment procedures to protect service users. References had not always been sought where an employee had previously worked in a care setting and three staff had not provided a full employment history with dates. In two cases staff had been given employment without an up-to-date criminal records check being carried out. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 16 Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 17 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 The registered manager is currently working towards an appropriate qualification to further enhance the management of the home. The home does not review aspects of its performance through a programme of self-review and consultations and is not currently seeking the views of service users, relatives and stakeholders. The home needs to demonstrate that staff are appropriately supervised in the interests of the care of service users. Lack of training in the areas of food hygiene and manual handling may put service users at risk. EVIDENCE: The registered manager is currently working towards completing an appropriate qualification for managing the home. Interest was shown in this by Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 18 a service user who asked the inspector about training for managers and owners of care homes. The home has no formal quality assurance system in place, previously relatives were written to regarding the home’s ‘open door policy’ and questionnaires have been sent out to relatives of service users. A file is kept of relatives cards and letters to the home which expressed positive comments about the care of service users in the home. The home provides secure facilities for service users to use for cash and valuables. A number of items of jewellery of unidentified origin were stored together. These should be stored separately with a record of the date and place where found. The home has one bank account only used for service users with individual records kept of the amount deposited by each service user. Although the registered manager stated that there are about six staff meetings a year there is still a need to demonstrate that staff are appropriately supervised through meetings and one-to-one sessions. A manual handling training session took place in November 2005. However a number of newly recruited staff have not received manual handling training since starting their employment with the home and others had not had such training since 2003 or 2004. This lack of current manual handling training potentially puts service users and staff at risk of injury. In addition there is a lack of training for staff in basic food hygiene. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 1 Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 12 (1) (a) & 15 (1) Requirement The registered person must ensure that all service users have written plans of care on the day of admission to the home (timescale of 30/11/05 not met). The registered person must ensure that risk assessments are completed for service user’s identified risks (timescale of 31/12/05 not met). The registered person must ensure that all staff receive training to prevent service users being harmed or suffering abuse or at being placed at risk of harm or abuse. The registered person must ensure that the home has 50 of care staff trained to NVQ level 2. 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(previous timescale of 31/12/05 not met). The registered person must DS0000016463.V285916.R01.S.doc Timescale for action 30/06/06 2. OP8 13 (4) (c) 30/06/06 3. OP18 13 (6) 31/07/06 4. OP28 18 (1) (a) & (c) 19 (1) (a) (b) & Schedule 2 31/07/06 4. OP29 30/06/06 5. OP29 19 (1) (a) 31/07/06 Page 21 Highborder Lodge Version 5.1 (b) & Schedule 2 paragraph 7 6. OP33 24 (1) (a) & (b) 7. 8. OP36 OP38 18 (2) 12 (1) (a) (b) & 13 (5) 9. OP38 13 (3) ensure that enhanced level criminal records bureau checks are carried out by the home for staff employed with checks brought from previous employment. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered person must ensure that all care staff receive appropriate 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 and 31/12/05 not met). The registered person must ensure that all staff involved in preparation and serving of service users food receive basic food hygiene training. 31/08/06 31/08/06 31/07/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP7 OP35 Good Practice Recommendations A large print copy of the service user’s guide should be made available in the home. Care Plans should be reviewed on a monthly basis. Valuables of unidentified origin should be stored separately with a record of the date and location where found. Highborder Lodge DS0000016463.V285916.R01.S.doc Version 5.1 Page 22 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.V285916.R01.S.doc Version 5.1 Page 23 - 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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