Inspection on 19/05/05 for Highbury House

This inspection was carried out on 19th May 2005.

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

Highbury House 11/09/07

Highbury House 12/10/06

Highbury House 07/02/06

Highbury House 20/10/04

Highbury House 04/05/04

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 HOME ADULTS 18-65 Highbury House 207 Outland Road Peverell Plymouth PL2 3PF Lead Inspector Kim Fowler Announced 19 May 2005 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highbury House Address 207 Outland Road, Peverell, Plymouth, Devon. PL2 3PF 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) 01752 753710 01752 796299 Plymouth Society for Mentally Handicapped Children & Adults Mr Ian Philip Oliver Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 18-65 2. Three named Service User over the age of 65 3. Service Users with a Learning Disability some of whom may also have a Physical Disability Date of last inspection 20/10/04 Brief Description of the Service: Highbury House is a care home providing personal care and accommodation for nine people with learning disabilities. It is owned by the Plymouth Mencap Society, which is a voluntary sector organisation, and affiliated to the Royal Mencap Society. This home is located in the residential area of Peverell, close to shops, pubs, the post office and other amenities. The home was opened in 2000 and is situated on the 1st floor of a building on the site of the Plymouth Mencap Society, where there is also another care home and a day centre owned and managed by the Society. There are stairs and a shaft lift available. The ground floor of the building is used by the Local Authority to provide a day service for adults with learning disabilities and there is a separate entrance. All the home’s bedrooms are single and none of them have en suite facilities. There are separate lounge and dining rooms and the home has a call bell system throughout. The home has an attractive patio and garden accessible to all the service users, shared with the other facilities on the site.The home is staffed 24 hours a day; there are 2 care staff sleeping in at night. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 1/4 hours and was a planned Announced inspection. A full tour of the premises took place and staff and care records were inspected. 2 of the staff and 6 of the 9 service users were spoken with during this inspection as well as the Registered Manager. The CSCI received 5 Relatives/Visitors comment cards and 5 Service users comment card. What the service does well: What has improved since the last inspection? What they could do better: Some of the service users care plans need updating and reviewing. Please contact the provider for advice of actions taken in response to this Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1/2/3/4/5 Information provided in the homes Statement of Purpose and Service Users Guide assist service users to make an informed choice of a care home. EVIDENCE: The homes Statement of Purpose and Service Users Guide were seen during this inspection, the manager was aware that some parts of this document needs updating. The manager is considering a video version of the Service Users Guide but due to staff shortages will commence this later this year. No new service users have been admitted to the service since the last inspection. From discussion with the manager he was fully aware of the procedure needed when admitting a new service user including introductory visits. The Service User plans and staff records indicated that the home had the capacity to meet the needs of individual needs. Recorded onto care plans was the specialist service the home uses. These include Physiotherapist, Challenge Behaviour service, SCOPE and a Chiropodist. The home also has use of the enabling service to assist service users and during the inspection one service user was going out with his enabler. One service user recently had an accident and the home put together a package of care for the rehabilitation of this service user including extra staff and specialist input. Case tracking provided evidence on 2 service users contracts, these contracts contained information on the terms and condition of occupancy and the cost and room numbers. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6/7/8/9/10 Service users are encouraged to make decisions about their own lives. EVIDENCE: Case tracking provided evidence on 2 service users in the home. Both the care plans seen were comprehensive in detail and provided information on the needs of the service users. Evidence was recorded that the home had involved the family, Care Manager and advocate in recent reviews. The service users are involved with their own reviews and on day to day involvement with shopping and preparing meals. None of the service users in the home manage their own finances but many do hold a small amount for everyday items and more is available on request. Mencap employs a designated person to be appointees for benefits for service users. The home has a meat delivery and staff and service users discuss on a daily bases the planned use of this for the daily meal. This information is then recorded into the homes daily menu diary. Service users are responsible for cleaning their own rooms and assist with the cleaning of the homes kitchen/dinning rooms. The cleaning rota was seen clearly displayed on the wall for the day and person responsible. This is carried out with staff assistance. The manager informed the inspector that any service users not out during the day is involved were possible with the cleaning. Case tracking provided evidence on the risk assessments held on individual files. One service user who recently had an accident had their risk assessment reviewed regularly. The staff receive a health and safety course during their induction and this is renewed every 3 years. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 10 The home also has a file to cover risk assessment for the home. All staff had completed the basic first aid training course. All service users files are confidential and secure in the homes office. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11/12/13/14/15/16/17 Service users can be confident that they will be part of the local community and that staff will provide support where needed. EVIDENCE: One service user informed the inspector that they work at a charity shop three times a week. Other service users attend college via their day centres. At present none of the service users wish to attend church. Two service users have paid work as cleaners locally. Some service users were going out to their voluntary work, day centres, and their enabler during this inspection. Service users had a sense of routines and a sense of purpose about their day. One service user spoke to the inspector about their trip out to the shops. Many of the service users attend the local club, which is within the grounds of this home. One service user has started to attend a local gym and the home has a good relationship with the neighbours. During the recent election all service users were offered postal voting or attendance at the polling station, this was carried out via a meeting. None of the service users chose to take up this opportunity. The home staff rota seen during this inspection showed that it was flexible to cover outing and appointments. Evident on the homes notice Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 12 board was a trip being organised via Mencap that service users could go on. Two service users informed the inspector of their holidays including a trip to Cornwall. 2 other service users are going on holiday to an ex member of staff house in another county, the manager confirmed that risk assessment had taken place to cover this event. Many of the other service users go out regularly on day trips organised by the home and with discussion with the service users going. 2 service users have restriction on some aspects of their everyday lives and evidence of this was recorded into individual care plans. These were agreed through a multi- disciplinary meeting and signed by the manager. Both these guidelines require updating. The home does not have a set menu but a regular meat order and it is discussed daily with the service users in the home the planned meal for each day. This information was then recorded into the daily menu diary. This diary was seen as evidence and showed that each meal has a varied and balance diet. Some service users spoken with confirmed that the food in the home was good. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18/19/20/21 The home provides excellent personal support for the service users in the home. EVIDENCE: All personal support provided to service users is clearly recorded into individual care plans. One service user who had an accident had his changing needs clearly recorded to cover his time of being immobilised. The service users and the manager confirmed that time to go to bed and get up is flexible. All service users wear their own clothes and service users spoken with confirmed this. The home has a key worker system in place and were possible service users choose who they work with. Some aids are available and seen in situ including a wheelchair and hoist. Grab rails are also in place. Recorded into one service user file was that they are still seeing the Physiotherapist. District Nurses have carried out some staff training. The inspector was witness to a staff handover where information was passed about the need for a key worker to contact a GP for an appointment, the chiropodist visiting the home and a local dentist appointment booked. All rooms are single for the private visits of health care professionals. The medication was checked during this inspection and the home has one service user on a controlled drug. This was checked and the number was correct. The homes medication policy was seen but the procedure for the administration and disposal of medication was not seen during this inspection. The disposal of medication record was seen. The inspector would Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 14 recommend that the staff sign when a medication is discontinued. The home also has a policy on homely remedies. The wish’s on their death is clearly recorded into individual care plans. And either signed by the service user and/or their family. Case tracking provided evidence that one service user is seeing the local Clinical Psychologist. The homes accident forms were seen and case tracking provided evidence that the service user who had a recent accident had an accident and incident form completed and detailed information on the treatment and care needed to aid their recovery. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22/23 The home has a clear complaints procedure in place and service users can be confident that their complaints or concerns will be listened to and dealt with. EVIDENCE: The home complaints policy and procedure was seen during this inspection. Both are available in sign language for service users. The homes designated complaints form and record was seen. The CSCI has not received any complaints. All staff had completed the Adult Protection training and the Manager is planning to renew his training. All staff had CRB check and evidence was seen of 2 new staff having been POVA checked. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24/25/26/27/28/29/30 This home maintains a suitable environment for its stated purpose. EVIDENCE: Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 17 The home is accessible for the people who live there and it is well decorated and comfortably furnished. The overall living space exceeded the required standard. Furnishing, fitting and equipment is of good quality. All bedrooms are single and one of the bedrooms is under 10 sq m and none of the bedrooms have an en-suite. Some of the service users in the home at the time of the inspection showed the inspector their bedrooms. This confirmed that they were all individually decorated and reflected the personality of the occupant. All of the bedrooms have wash hand basins. There are two bathrooms, one containing a bath hoist, and one has an overhead-tracking hoist. There are three toilets, one in each of the bathrooms and a separate toilet. There is a staff bathroom off the office. All of the bathrooms were clean, domestic in character and lockable. The home has a large lounge and a dining room and both these rooms are well furnished and recently redecorated. There is a small kitchen that is well equipped. The laundry room has a large washing machine and tumble dryer. There is accommodation for 2 staff to sleep in, one in the office and one in a separate bedroom. The home has a garden and patio area. Both can be accessed via the fire escape from the lounge. The current level of aids and adaptations, such as handrails, bath hoists and a shaft lift, met the needs of the service users. The home has level access to all the communal areas and bedrooms. The home had a call alarm system throughout. The home was found to be clean and free of offensive odours. There are good laundry facilities. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31/32/33/34/35/36 The manager promotes and supports staff training to ensure the service users receive a good service. EVIDENCE: The job descriptions were seen for each post and were appropriate for staff to understand their roles. 2 staff had completed their LDAF training and 3 new staff are due to start soon. Presently only one staff has a completed NVQ but 4 staff are currently part way through their NVQ. The home has recently recruited 2 new staff both due to start soon. The manager informed the inspector that the home currently has one staff member of long term sick and the employed staff have been covering were needed. The home has a low turn over of staff and many staff had been at the home for over 2 years. The home has a mix staff team and no staff member is under 18 and one staff member under 21 is not left in charge. The manager discussed the recruitment process of the 2 new staff and it was evident from this discussion that the manager has a recruitment policy based on equal opportunities. One new staff member’s file was seen and contained 2 references and was waiting for the CRB clearance. One regular staff members file seen contained all the relevant paper work to met this standard. Including a contract with terms and conditions of employment. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 19 The homes Induction training was seen including mandatory training and that the 2 new staff member, not yet started, have booked these mandatory course including Health and Safety. One Personal Development plan was seen for one staff member. The supervision record was seen as was the policy and procedure for supervision. The manager informed the inspector that the home carries out yearly appraisals and staff have access to all policies and procedures in the home. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37/39/40/41/42/43 The management of this home is very good and ensures that the records are maintained. Also that the staff have regular and updated training to met the service users needs and that all service users are happy. EVIDENCE: The Registered manager is due to complete his NVQ 4 by October 2005. The quality assurance system for relatives and next of kin were seen completed and all made positive comments, The quality assurance questionnaires for service users is in the process of being completed and not looked at during this inspection. Evidence was seen recorded onto the homes policy and procedure file that they had been updated and reviewed recently. Records seen were secure and in good order. The pre-inspection questionnaire shows that that regular checks and maintenance is carried out on all equipment and services in the home. The homes staff training record show and certificates show that the staff had received appropriate training including Manual Handling, food hygiene and first aid. The manager informed the inspector that the staff infection Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 21 control training needs updating and he has this in hand. Mencap business and Finance plan is available and the insurance certificate was clearly displayed. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 4 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 4 3 3 3 3 4 Standard No 11 12 13 14 15 16 17 3 3 3 4 3 2 3 Standard No 31 32 33 34 35 36 Score 3 3 4 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Highbury House Score 4 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 3 3 3 D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 23 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 Regulation Requirement Timescale for action 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 16 20 Good Practice Recommendations The care plans for 2 should be updated to include any restriction issues. Staff should sign when medication when is discontinued. Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Highbury House D52-D04 S3519 Highbury House V214964 050505 Stage 4.doc Version 1.30 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!