Inspection on 01/02/06 for Highbury Nursing Home

This inspection was carried out on 1st February 2006.

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

Highbury Nursing Home 29/07/08

Highbury Nursing Home 08/08/07

Highbury Nursing Home 08/08/06

Highbury Nursing Home 04/10/05

Highbury Nursing Home 17/03/05

Highbury Nursing Home 04/09/04

Highbury Nursing Home 03/08/04

Highbury Nursing Home 11/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Highbury Nursing Home 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX Lead Inspector Kath Strong Unannounced Inspection 1st February 2006 09:35 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 Highbury Nursing Home DS0000024854.V281997.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. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highbury Nursing Home Address 199/203 Alcester Road Moseley Birmingham West Midlands B13 8PX 0121 442 4885 0121 449 7855 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) Flintvale Limited Bernadette Farrell Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Terminally ill over 65 years of age (38) Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Nursing home for the elderly, old age, dementia and terminally ill That Mrs Farrell undertakes further training in the area of Dementia Care and notifies CSCI of the details. 4th October 2005 Date of last inspection Brief Description of the Service: Highbury Nursing Home is purpose built and is located on the outskirts of Moseley Village, a suburb of Birmingham. The home provides residential and nursing care for up to 38 persons who are aged 65 years or above. Bedroom accommodation includes both single and shared rooms, some of which have en-suite facilities. Bedrooms are situated on three floors; these are accessible via stairs or a shaft lift. The communal areas are situated on the ground floor and have recently been extended. All of the communal rooms are linked, which facilitates staff ability in observing residents. The main lounge leads on to a smaller lounge, which leads onto the main dining area. There are two smaller rooms within close proximity one is used as a lounge and the other as an extra dining area. Communal toilets and bathrooms are within easy access of all areas of the home. During clement weather residents frequent a secluded and well laid out garden and patio area. A large unused grassed area is situated to the side of the garden and a generous sized car park is also located at the rear of the premises. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection and to investigate a complaint received by CSCI. The outcome of the inspection was determined by various means. In depth discussions were held with the registered manager who also assisted with the inspection process. Progress was determined in respect of the requirements generated from the last inspection. Relevant documents were examined including three care plans. The staffing levels were checked as well as the arrangements for health and safety. An NVQ Assessor and four residents were spoken with and staff practices were observed. A partial tour of the premises was carried out. At the conclusion verbal and written feedback was supplied to the registered manager. This visit focussed upon the key standards that were not examined at the last inspection and any other determined to be necessary. In order to gain a full insight into the services provide it is recommended that this report should be read in conjunction with the report dated 4th October 2005. What the service does well: What has improved since the last inspection? Two bedrooms have been redecorated; this is an ongoing process when rooms are unoccupied. The flooring in a bedroom has also been replaced. A number of armchairs have been purchased for the communal areas. A large proportion of the wardrobes are currently being replaced in bedrooms. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 6 The home has recently purchased a new air mattress to cater for specialist needs. Bedrail bumpers have been bought to complement the available supply. The respite room has been converted to a shared room and the smallest shared room converted to a single to maximise available space for residents. Some towel rails have been replaced. Single bedrooms have had cupboards wall mounted for storage of toiletries. 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. Highbury Nursing Home DS0000024854.V281997.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 Highbury Nursing Home DS0000024854.V281997.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): None EVIDENCE: Standards 3, 4 and 5 were assessed at the last inspection and were fully met. Highbury Nursing Home DS0000024854.V281997.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, 9, 10 Care plans provide assessments and the action to be taken by staff in meeting individual needs. The services of external professionals are well documented but attendance at hospital appointments are not. The arrangements for administration of medications appeared to protect residents. Observations revealed that staff are not communicating with residents adequately prior to carrying out procedures. EVIDENCE: Care plans include past and present physical and mental health conditions and how needs should be met. Further assessments in respect of mobility, weight, nutrition, basic observations and skin integrity are carried out and reviewed monthly. Files also include short term planning for complications such as chest or urinary tract infections. There is ample documentation of the input of external professionals and their recommendations. Records in respect of resident’s attendance at hospital appointments are poor. A member of staff was observed administering medications and the process was found to be satisfactory and the MAR (medication administration record) charts were appropriately completed. Medications received from the pharmacy are audited and verified by two trained staff. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 10 During assisted transfers of residents it was noted that staff are not assessing and communicating adequately with residents before commencing the procedure. Highbury Nursing Home DS0000024854.V281997.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 The home provides a varied and interesting programme of in-house and external activities. Residents influence the day to day operations of the home. EVIDENCE: Discussions were held with the activities organiser who said that he was currently compiling a file for each resident in respect of their past and reminiscences. The in-house activities offered appeared to be varied and stimulating. Time is also made for one to one sessions with some residents. The home holds parties on occasions such as Halloween, Christmas, New Year and Easter. Birthdays are always celebrated with a cake and tea party. A surprise party was arranged for a resident who was celebrating 60 years of marriage. External entertainers are invited to the home and a fashion show and sales of the clothing is a regular event. Weekly visits are made by church clericals. Outings to a village pub are also arranged. A record is maintained for each resident. Residents meetings are held every two months when plans for external events are discussed. An outing to the Botanical Gardens was discussed at the last meeting. Standards 13 and 15 were assessed at the last inspection and were fully met. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The homes complaints procedure is clear and accessible and indicates that complaints are dealt with within an acceptable timescale. EVIDENCE: Standards 16 and 18 were assessed at the last inspection and were fully met. During the visit a complaint received by CSCI was investigated concerning the homes failure to provide an escort for a residents attendance at a hospital appointment and the high usage of agency staff during one night shift. Both aspects of the complaint were not upheld. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 13 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, 20, 24, 26 Residents live in a well maintained, pleasant and comfortable environment. EVIDENCE: The home has recently undergone extensive building works to extend the communal areas. The communal rooms have increased to a main lounge leading onto another lounge and another room directly adjacent. The dining area is located close to the kitchen for ease of access and a small separate dining room is also available. The extension to the front of the premises has increased the reception area and provided offices/seminar rooms. All rooms offer good wheelchair access. The garden offers a pleasant setting where residents can sit during clement weather. Bedrooms have been re-located to maximise space and facilities. Some bedrooms include en-suite facilities and all others have wash hand basins. Rooms were noted to be homely in appearance and had been personalised to the extent preferred by the occupant. Rooms varied in size and layout and those that were capable contained two comfortable chairs, the statement of purpose has been changed to reflect this. Visitors are able to request further Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 14 seating for those rooms containing one chair. The problem concerning clashing of en-suite doors with bedroom entry doors has been addressed by the rehanging of doors to open in the opposite direction. Suited door locks have also been fitted since the last inspection to ensure residents rights of privacy. The home was found to be hygienic throughout. Standards 21, 22 and 23 were assessed at the last inspection, two were fully met and standard 22 partially met. Highbury Nursing Home DS0000024854.V281997.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, 30 Staffing levels are appropriate for the current client group. Staff are supplied with adequate training to provide the knowledge and skills for them to fulfil their role. EVIDENCE: Staffing levels were examined and found to be satisfactory. The home uses agency staff when gaps are identified and a request is made for agency staff who have worked at the home previously. The home employs separate ancillary staff to carry out other roles thus freeing up care staff to perform their roles. The home employs a workforce of which 50 have had NVQ level 2 training, three staff have completed level 3 and as a consequence are employed as senior carers. Staff receive all mandatory and subsequent refresher training, some of the courses are supplied in-house. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36, 38 The quality assurance system needs to be completed. Care staff do not receive a satisfactory induction programme. Staff practices in respect of manual handling practices are not safe thus putting residents at risk. EVIDENCE: Some work has been carried out in collating a quality assurance system. The registered manager was advised that to complete the process the proposed audit of the kitchen should be carried out, staff involvement needs to be considered and an annual report produced to include resultant action to be taken and timescales for completion. The report should be shared with residents and staff and a copy forwarded to CSCI. The arrangements for the safe keeping and financial transactions in respect of resident’s personal monies were found to be satisfactory. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 17 The inspector was advised that the home is currently compiling an induction programme for care staff that reflects the contents of the TOPSS programme. This remains outstanding from the previous inspection. Although all staff have had training in manual handling the registered manager and the inspector both observed unsafe practices which require urgent attention. Standards 31, 32 and 38 were assessed at the last inspection, two were fully met and standard 38 partially met. Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 19 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 15(1) Requirement The registered person must ensure that resident’s attendance at hospital appointments are fully documented including rationale and outcome. Timescale for action 28/02/06 2. OP10 12(4)a 3. OP22 23(2)n 4. OP33 24(1&2) The registered person must 28/02/06 ensure that residents are fully informed prior to staff providing assistance with their mobilisation needs. The registered person must 30/04/06 demonstrate that an assessment of the premises has been carried out by a suitably qualified person to ensure that sufficient disability equipment is provided to meet the residents needs. N.B. Not assessed on this occasion therefore carried forward. This remains outstanding from the previous two inspections. The registered person must 31/05/06 complete and introduce the already commenced quality assurance system. N.B. This remains outstanding DS0000024854.V281997.R01.S.doc Version 5.1 Page 20 Highbury Nursing Home 5. OP36 18(1)c from the previous inspection. The registered person must ensure that newly recruited care staff receive a comprehensive induction programme that is compliant with TOPSS standards. N.B. This remains outstanding form the two previous inspections. The registered must ensure that staff practices regarding manual handling are such that do not put residents at risk. 30/04/06 6. OP38 18(1)c 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Highbury Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Nursing Home DS0000024854.V281997.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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