Inspection on 20/10/05 for Highbray

This inspection was carried out on 20th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highbray 24/08/09

Highbray 10/07/08

Highbray 31/07/07

Highbray 22/06/06

Highbray 08/06/05

Highbray 23/09/04

Highbray 06/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOMES FOR OLDER PEOPLE Highbray 84 Mount Pleasant Road Exeter Devon EX4 7AE Lead Inspector Louise Delacroix Unannounced Inspection 15:00 20 October 2005 th 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 Highbray DS0000021947.V259018.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. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highbray Address 84 Mount Pleasant Road Exeter Devon EX4 7AE 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) 01392 676863 Mrs Josefa McLeod Ms Lesley Ann McLeod Care Home 3 Category(ies) of Learning disability over 65 years of age (3), registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 years of age (3) Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: Highbray is a semi-detached end of terrace house in a residential area and less than a mile to the centre of Exeter. It provides care and support for up to three service users. It is registered to offer care for people over sixty five with either a learning disability or mental health needs. The home has three single rooms with a shared bathroom. All the bedrooms are on the first floor. There is one lounge. Meals are served in the dining-area of the kitchen. The staff, the manager and the owners are all members of the same family. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in the afternoon and was unannounced. The manager was on duty and all three residents were at home and watching television in their individual rooms. All the residents contributed to the inspection and as part of the inspection fire records, medication sheets, care files and insurance certificates were looked at. A tour of the building also took place. This report should be read in conjunction with the inspection report for 8th June 2005 as the key standards have been covered over two inspections. What the service does well: What has improved since the last inspection? 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. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 6 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 Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 7 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): EVIDENCE: Standards 1,2,6 were inspected in June 2005. No new residents have moved to the home. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 8 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 Staff support residents to maintain control over their lives but recognise when to intervene or seek advice if a resident’s action potentially puts them at risk. EVIDENCE: Care planning has improved since the last inspection with regular recording, which is appropriately worded, and with clearer outcomes as part of the monthly reviews. Daily activities are now recorded; residents confirmed the content of these records during discussion about their lifestyles and routines. Where a resident’s behaviour could put them at risk, discussion about the risk are recorded and signed by the resident. Care records evidence regular contact with the health services to meet the physical and mental health needs of residents. The manager supports one resident to manage their appointments and acts as an advocate for another resident to try and ensure that their health needs are met in way, which is non-threatening to them. Evidence was seen of referring to a Community Psychiatric Nurse or GP for advice when a resident’s mental health was assessed as deteriorating. Contact with health services is well recorded. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 9 The manager has drawn up a policy for the administration of medication, which covers most areas but does not include what to do if medication is wrongly administered and requires more information regarding homely medicines. Handwritten entries on medication sheets are not always double signed and checked by another staff member. The manager gave examples about respecting residents’ dignity with regards to personal care and privacy. For example, one resident confirmed that they had a key for their room to prevent unwanted intrusions. A resident spoke about being able to wear their own clothes and the manager was seen ensuring that residents’ clothes were well cared for. The manager gave an example of asking health staff to visit the home because of the distress it causes one resident to go to the surgery. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 10 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 Residents’ chosen routines and need for contact with family is recognised and supported by staff. EVIDENCE: All three residents confirmed that their routine was one they had chosen. One resident chooses to go out regularly, particularly to the cinema. Another likes to socialise and attend a club for older people. Whilst the third person said they liked their own company and prefers not to leave the home. They spoke about creating their own routines i.e. going to bed. The home does not provide internal entertainment. The registered manager said that visitors are encouraged to visit the home although due to residents’ circumstances this does not happen regularly. A resident spoke about being able to maintain in contact with their family, and the manager explained how this was managed in a supportive way. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: Standards 16 and 18 were inspected and met in June 2005. No new staff have been employed since the last inspection. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 12 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): 19,25,26 Electrical work has begun to up date the home to maintain safety standards. The installation of radiator guards would also further improve the safety of residents. EVIDENCE: Linked to a previous recommendation from the last inspection, work is now being carried out to re-wire the home. Work has started on the communal lounge, which had included re-plastering therefore making the room unusable at present. The manager explained that when the room is re-decorated, residents would be involved in the choice of décor. She also explained that there were plans to replace some residents’ carpets after their rooms have been re-wired. The CSCI had not been informed of this work or how it was being managed with regards to the impact on residents, and an additional visit will be carried out in early 2006 to check on progress. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 13 Two of the residents said that they chose never to use the communal lounge and the third resident said they could watch television in their own room whilst the work was being carried out. The manager has risk assessed the vulnerability of residents to burning themselves on the radiators in their rooms as they become more frail. The home was clean and free from odours. The manager has sought guidance from the Environmental Health Officer regarding the prevention of cross infection as the washing machine is in the kitchen. She has agreed that service users’ laundry is bagged in their rooms. This is then carried through the visitors lounge and stored in the garage. In the evening, the kitchen in then entered by staff via the backdoor after all food has been prepared. The washing machine is beside the backdoor, which ensures that soiled laundry is not carried though the kitchen. The home does not have a sluicing facility but this is not an issue for the current service user group. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: Standards 27,28,29,30 were inspected. No new staff have been employed since the last inspection. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 15 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): 31,35,38 The system for supporting residents’ managing their personal allowances is good and provides protection for residents. Safety checks are in place but need to be routinely recorded to further evidence the safety of residents. EVIDENCE: The registered manager holds no recognised qualification in social care. From management of this home she has considerable experience of working with older people. She should be making arrangements to ensure that she achieves an NVQ at level four in management and care, or its equivalent, by 2005. The service users’ guide makes it clear that it is the home’s policy that service should manage his or her own affairs. Where this is not possible the home manages service users’ personal allowances. Appropriate records and receipts are maintained with resident signing for their personal allowances. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 16 CSCI have now been sent a copy of the gas service records. The portable appliance test last took place in September 2004 and will shortly need renewing. Fire records are up to date, apart from the weekly fire checks, which was last recorded on 12th September 2005. This is an outstanding requirement. Fire equipment was serviced on 5th September 2005. Appropriate insurance is in place for the home. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 17 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x 1 Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 18 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. 2. Standard OP38 Regulation 23(4) Requirement The registered person shall after consultation with the fire authority make adequate arrangements for reviewing fire precautions, and testing fire equipment, at suitable intervals.( Fire alarms must be tested weekly). Timescale for action 31/07/05 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. Refer to Standard OP1 OP9 Good Practice Recommendations The statement of purpose should reflect the changes to the communal space available to residents. The home should also have a policy regarding the use of homely remedies that states that the resident’s GP or a pharmacist will be consulted and a policy stating what should be done if a resident’s medication is wrongly administered. It is recommended that all handwritten entries on the Medication Administration Record chart are signed and dated by the person making the entry, and checked and signed by a second person. DS0000021947.V259018.R01.S.doc Version 5.0 Page 19 Highbray 3. 4. 5. OP19 OP25 OP31 The manager should write to CSCI with information regarding the current building work with timescales and how residents were consulted about the changes. As residents become frailer, it is strongly recommended that pipe work and radiators should be guarded or have a low temperature guarantee. The registered manager should make enquiries at a local college for a relevant NVQ to up date her own knowledge. Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Highbray DS0000021947.V259018.R01.S.doc Version 5.0 Page 21 - 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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