Inspection on 08/06/05 for Highbray

This inspection was carried out on 8th June 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

Highbray 24/08/09

Highbray 10/07/08

Highbray 31/07/07

Highbray 22/06/06

Highbray 20/10/05

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 Announced 08 June 2005 10:00 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 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 D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highbray Address 84 Mount Pleasant Road Exeter Devon EX4 7AE 01392 676863 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Josefa McLeod Ms Lesley Ann McLeod Care Home 3 Category(ies) of LD(E) Learning dis - over 65 (3) registration, with number MD(E) Mental Disorder - over 65 (3) of places Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23 September 2004 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 D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place in the morning over two and a half hours. The inspector met with all three residents, although only briefly with two people as one was going to a doctor’s appointment and the other was going out for the day with a member of staff. The third person said that they did not wish to speak in private about the service, and indicated that they did not wish to answer a number of questions. No new residents have moved to the home since the last inspection. One member of staff went out with a resident and so only the manager contributed to the inspection. The staff team is made up of four family members. During the inspection, care plans, staff records, maintenance records and health and safety records were looked at and a tour of the building took place. What the service does well: What has improved since the last inspection? The home had a number of outstanding requirements from previous inspections. However, since the last inspection, the manager has been proactive in addressing these and they have now all been met, which is very positive. As a result, staff have received the required training i.e. first aid, there is now an appropriate statement of purpose/ service user guide, and policies regarding fire safety and missing persons are now in place. The home now has appropriate insurance cover after enforcement action was taken by CSCI, and steps have been taken to gather views on the service. A number of recommendations related to good practice have also been addressed. Additional information has now been provided about additional costs and notice periods. There is now a completed visitors’ book and a protocol on the protection of vulnerable adults. The manager now has the General Social Care Council code of conduct for staff. Meat temperatures are recorded and the names of people attending fire drills are now listed. Risk assessments are now in place and all staff have CRBs. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 standard(s) 1,2,6 The improved quality of the statement of purpose and service users’ guide helps current residents to know what the service can offer them but does not reflect changes to communal space. EVIDENCE: The statement of purpose and service users’ guide now contains all of the required information in a clear format, which includes terms and conditions but needs additional information added to recognise a recent change in the use of communal rooms. Room numbers have now been recorded appropriately. No new service users have moved to the home since the last inspection. The home does not provide intermediate care. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 standard(s) 7,8,9 The home is unable to demonstrate the daily care provided to residents and how residents are supported to take part in activities and interests. A lack of monthly reviews prevents an overview of residents’ welfare and how changing needs are met. The home has improved its medication procedures, including staff training, and the health needs of residents’ are well met. However, current recording of medication changes and a lack of policy to cover this area of care potentially puts residents’ safety at risk. EVIDENCE: Care plans are based on a thorough assessment of need for each individual resident. Core information is well written, clear and generally contains clear instructions of how to meet the individual needs of each resident. Residents have signed them, which is good practice. However, there is poor recording of the daily lives of residents. For example, for one resident there is a gap of over four months between entries and no monthly review. Recent significant events for two residents had not been recorded. There is also a lack of evidence of activities/interests being met, although on the day of the inspection a member of staff was supporting a resident with a trip to Torquay. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 10 The resident was enthusiastic about this trip. When entries to care plans are made, they are well worded. Records show that residents have contact from a range of health care professionals and advice is recorded. The manager was also able to give examples of how changes in residents’ health, both physical and mental, have been recognised and acted upon. Residents are supported in a variety of ways to access health services; either from visits to the home by professionals, staff accompanying residents or residents choosing to attend appointments by themselves. A resident confirmed this during the inspection as did entries in care plans and the visitors’ book. The manager recognised the need to monitor the residents’ tissue viability and one resident was seen using a pressurerelieving cushion. Medication is kept in a locked cupboard. Medication is now provided in monitored dosage system. The manager confirmed that records are signed as soon as medication is given to service users and that service users are discreetly monitored to ensure that medication is taken. Care plans indicate when service users may feel less willing or able to take medication. The printed medicine administration record chart for residents was checked, and seen to be up to date. However, handwritten changes to the medication records are currently only signed by one person. The registered manager told the inspector that there is currently no controlled drugs kept in the home. If this changes, the home would need to provide a metal cupboard, which complies with the Misuse of Drugs (Safe Custody) Regulations 1999 and keep the required records. The registered manager could give examples when the GP would be called. For example, if a change of medication might be linked to a negative change in the service user’s well-being. The home does not have a written policy on the receipt, recording, storage, handling, administration and disposal of medicines. The home should also have a policy regarding the use of ‘homely’ remedies. The registered and two staff have now attended training to update their basic knowledge of how drugs are used. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 standard(s) 14,15 Staff support residents to maintain control over their lives but recognise when to intervene if a resident’s action potentially puts them at risk. The meals in this home are good, offering choice and variety, and catering for the changing needs of residents. EVIDENCE: Discussion took place about bedtimes with a resident and staff. The resident acknowledged that they had the option of going to bed when they wanted to but wanted the reassurance they received from staff to confirm that this was acceptable. They said they were able to go out, particularly to the cinema and talked about their enjoyment from this activity. Another resident was very clear that they did not wish to go out and preferred to stay in their room, which was respected by staff, although they are encouraged to come downstairs to have their meals. Through records in a care plan and discussion with staff and a resident about finances, it was evident that although residents’ independence was promoted steps were taken when their behaviour put them at risk. Menus showed a varied range of meals and it is now documented that supper is available, which was seen being served on a previous inspection. Likes and dislikes are listed for each resident, and the manager recognised this sometimes varied due to changes in the mental well-being of residents and she Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 12 said that alternatives are offered. It is now recorded if a resident chooses not to eat. On the last inspection, residents were consulted about the food and were happy with the quality and arrangements. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 standard(s) 16,18 The procedure for obtaining CRBs is now robust and safeguards are in place to offer protection to people living at the home. EVIDENCE: The pre-inspection report stated that there have been no complaints since the last inspection and none of the residents raised any concerns about the service. There is now a 28 day response time included in the complaints policy. All four staff now have CRB checks in place and these were all seen during the inspection. The manager has obtained a copy of the multi-disciplinary Alerter’s guide to promote the protection of vulnerable adults within the home. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,25 The standard of the environment within the home is good and provides residents with clean and hygienic surroundings that are improved by some safety features. However, the installation of radiator guards would further improve the safety of residents. EVIDENCE: The home was clean and odour free, and has a number of fire doors throughout. The manager explained that a change to laminate flooring in the room of a resident, which was discussed on the last inspection, had been decided against due to the changing needs of the resident. The home has one lounge, with a second lounge now being used by the owners, who the manager said live in. The one lounge still provides over the recommended communal space for each resident and is smoke free. The manager and a resident explained that only one resident generally uses the front lounge. Another resident said they preferred to watch television in their own room and chose not to use the lounge. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 15 The three residents share one bathroom, which also contains the toilet, and is on the first floor close to all three single bedrooms. Each of which has a call bell system, which was tested during the inspection. All bedrooms have windows that are restricted for safety reasons. Risk assessments state that all residents are assessed as low risk and that radiator guards are not required. This should be reviewed, particularly if residents become prone to falls or their physical health deteriorates. Good practice guidelines state that all radiators, especially in residents’ bedrooms should be covered. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Positive steps have been taken to begin to address staff training needs but this needs further development. EVIDENCE: All staff are over 21 and the manager said the cover at night times is by the owners, who provide sleep in cover. There have been no staff recruitments since the last inspection. The staffing levels are appropriate for the needs of the residents. None of the staff group have a NVQ qualification, which would up date their practice and knowledge, but some of the staff team have recently undertaken training in first aid, health and safety, and medication. The manager has obtained the GSCC codes of conduct for the staff group. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,37,38 The manager has taken steps to demonstrate how the home meets the needs of residents and how she maintains their safety. However, safety measures and documentation need to be improved to further evidence the safety of residents. EVIDENCE: Paperwork showed that the manager has contacted family and GPs to gather views on the service, which were positive. Residents were aware of the inspection. The home now has appropriate insurance cover. The manager now lists the names of people that attend fire drills, and records cooked meat temperatures in line with health and safety practice. Records shows that fire equipment is checked regularly and that thermostatic valves have been fitted to regulate water temperature within recommended guidelines. All fire checks take place at required intervals, apart from the fire alarm, which currently happens on a monthly basis not weekly as promoted by the Fire Service. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 18 The manager was unable to produce paper work to show that the gas boiler had been serviced recently or that the electrical wiring of the home had been tested and is safe. However, documentation showed that portable electrical appliances had been checked. The staff duty rota did not reflect the staff on duty at the time of the inspection. The manager said that one member of the staff team mainly covers sickness and annual leave but agreed their name is regularly recorded as having worked. On the day of the inspection, another member of staff was on duty, whose name was not recorded on the rota. Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 x 2 x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 3 x x 1 1 Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 37 Regulation Requirement Timescale for action 31/7/05 2. 38 3. 38 17(2)Sche A copy of the duty roster of dule 2 persons working at the care home, and a record of whether the roster was actually worked.(The staff rota must reflect who actually worked each day). 23(4) The registered person shall after 31/7/05 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). 13(4)(a) The registered person shall 30/9/05 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety.( Records must be produced to demonstrate that the gas boiler has been serviced and the electrical hard wiring is safe). Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 21 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 1 7 Good Practice Recommendations The statement of purpose should reflect the changes to the communal space available to residents. Care plans should be reviewed monthly to give an overview of each residents care needs, including how their interests have been supported or met. Care plans should have regular records to evidence how care has been provided and how residents have been supported with their daily lives. The home should have a written policy on the receipt, recording, storage, handling, administration and disposal of medicines, which should detail that when a service user dies, medicines should be retained for a period of seven days in case there is a coroner’s inquest. The home should also have a policy regarding the use of ‘homely’ remedies. It is recommneded that all handwritten entries on the Medication Administration Record chart are signed and dated by the perosn making the entry, and checked and signed by a second person. Pipe work and radiators should be guarded or have a low temperature guarantee. The registered manager should begin to plan and make enquiries at a local college for relevant NVQ courses/specialist training for the staff group and to up date her own knowledge. 3. 9 4. 5. 25 28 Highbray D54 D06_s21947_highbray_v222298_080605 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. 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