Inspection on 04/10/05 for Highbury Nursing Home

This inspection was carried out on 4th 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

Highbury Nursing Home 29/07/08

Highbury Nursing Home 08/08/07

Highbury Nursing Home 08/08/06

Highbury Nursing Home 01/02/06

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 4th October 2005 09:50 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.V257042.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. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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) Dr Gulshan Rai Arora Dr A C Bajpai Bernadette Farrell Care Home 37 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (37), of places Terminally ill over 65 years of age (37) Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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. 17th March 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 37 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. There is a large dining room leading through to the main lounge. Two smaller lounges are located directly adjacent to the main rooms. 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 car park is also located at the rear of the premises. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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 a site visit in respect of the homes application to increase the accommodation by one bed. The outcome was determined by various means. A review was carried out of the progress made in respect of the requirements made from the last inspection. A tour of the premises was undertaken and relevant documentation was examined. In depth discussions were held with the registered manager and two members of staff were formally interviewed. At the conclusion verbal and written feedback was provided. Please note that this inspection was restricted to previous requirements and recommendations, the admission and care planning processes and the premises and facilities therefore to gain a full overview of the home the report should be read in conjunction with previous reports. What the service does well: What has improved since the last inspection? All communal areas have been re-decorated, bedrooms are re-decorated when vacant or by arrangement with the resident. The extension of the lounge and dining areas have been completed and snagging works were currently being carried out. The work involved partitioning of the dining room from the main lounge. A new shower room and toilet have been installed on the ground floor. The treatment room has been re-located and the space utilised for the provision of a toilet with sufficient space to accommodate a hoist. Storage space has been installed to accommodate a number of wheelchairs. A nurse’s office has been established within close proximity to the lounges. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 Page 6 The first floor lounge has been converted to a shared bedroom and a small shared room converted to a single bedroom. A dedicated hairdressing salon has been identified and partially furnished. The staff room has been re-located to the second floor. Arjo hoists are available within the shower rooms. The garden area is now fully enclosed, a new patio established and garden furniture has been purchased. The front of the premises have been slightly extended to provide offices for the registered manager, administrator and a conference/training room with storage space off. The extension has also served to increase the size of the reception area of the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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.V257042.R01.S.doc Version 5.0 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): 3, 4, and 5 Comprehensive pre-admission assessments are carried out prior to a placement being offered thus ensuring the homes ability to meet all of the identified needs. EVIDENCE: The pre-admission assessment tool provides adequate information and is stored in the care plan for use as the framework for the detailed assessment following the residents admission. Where the home determines that it can no longer meet the needs of a resident a full re-assessment is carried out with the involvement of other professionals in order to confirm the need for alternative accommodation. Prospective residents and their relatives are given a full tour of the home and are encouraged to sample the food and to circulate with other residents and staff. Following admission a 28 trial period of stay and a subsequent review is undertaken before a placement is made permanent. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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 and 10 Care plans clearly indicate the action required by staff to fulfil the identified needs and the assistance of external professionals is actively sought. Personal support is offered in such a way as to promote resident’s privacy and dignity. EVIDENCE: Care plans include past and present physical and mental health conditions and how the identified needs should be met. Further assessments in respect of mobility, weight and nutrition, basic observations and skin integrity are carried out and reviewed each month. The files also included short term plans for such incidences as chest infections or urinary tract infections. There is ample evidence of the input of external professionals and their recommendations. Residents appeared to be comfortable and well presented, staff were observed using the preferred term of address. Personal care is provided in the privacy of the resident’s bedroom or a bathroom. Residents raised no concerns about the standards of care during the inspection. The staff interviewed demonstrated a good knowledge regarding confidentiality and when to report issues that may be detrimental to the well being of an individual. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 Page 10 Staff were observed interacting with residents, there appeared to be a friendly and supportive relationship. Standard 9 was assessed and fully met at the last inspection. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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): None EVIDENCE: Standards 13 and 15 were assessed and fully met at the last inspection. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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 and 18 The homes complaints procedure is clear and accessible and indicates that any complaints will be dealt with within an acceptable timescale. Arrangements for protecting residents from possible harm or abuse are satisfactory. EVIDENCE: The written complaints procedure is comprehensive. The home has not received any complaints since the last inspection. The registered manager assured the inspector that in the event of complaints being made that a log a log including the outcome would be generated. The previous inspection revealed that some staff had not received training in respect of adult protection. The registered manager advised that that this aspect has been incorporated into the homes rolling programme and all staff have undergone training. The two staff interviewed by the inspector demonstrated good knowledge in respect of their duties on occasions of abuse or suspected abuse. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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, 21, 22, 23, 24 and 26 Residents live in a well maintained and comfortable environment. The home does not provide sufficient comfortable lounge seating to permit residents to make choices. EVIDENCE: The home has recently undergone extensive building works to extend the communal areas. The extension to the front of the premises has served to increase the size of the reception. Bedrooms have been re-located to improve the facilities for residents. The garden has also been improved and now offers a pleasant setting for residents to frequent. The extension to the rear of the home has considerably improved the communal space on the ground floor and appeared to be adequate for the registration of the home. Residents have a choice of three lounges, which are situated adjacent to each other and there is a separate dining area within the same vicinity. It was noted that there is good access for wheelchairs in the dining room and scope to increase the discreet seating areas. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 Page 14 The home did not have sufficient armchairs to accommodate all residents when the home is fully occupied. This must be addressed and include a chair in respect of the application to increase the occupancy by one. Further consideration may be required for the supply of seating for visitors. Some bedrooms include en-suite facilities and all others have wash hand basins; communal toilets and bathrooms are strategically located throughout the home. There is an adequate supply of assisted bathing facilities and residents are able choose between shower or bathing facilities. Although the home has a good supply of mechanical hoists the premises have not been assessed by an occupational therapist. Having completed the extension and re-location of bedrooms the registered person must have the environment assessed. Bedroom accommodation was homely and personalised to the degree preferred by the occupant. Suited bedroom door locks have not been fitted however; the registered manager said that they had been ordered. The door to some rooms have the ability to clash with the opening of the en-suite door, which may result in injury to residents or staff. This issue remains outstanding from the previous inspection and should be addressed. Some bedrooms did not contain two comfortable chairs; this included the room in respect of the variation application. The respite room was being re-furbished to increase the accommodation to two persons. The registered manager was advised that an increase in the number of shared rooms would not be acceptable to CSCI as the home already has in excess of 20 shared accommodation. The respite room would be considered for two persons providing a shared room elsewhere in the home with less space that the respite room is converted to a single room. A concern was raised regarding the trailing cable from a mattress to the socket; such practices pose health and safety risks to residents, visitors and staff. A timescale of 48 hours was made to resolve the problem and to ensure no such risks are present in other areas of the home. The home appeared to be tidy and hygienic throughout including the kitchen and laundry rooms. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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): 29 Staff recruitment practices are comprehensive to ensure that residents are protected and supported. EVIDENCE: The homes’ staff recruitment is robust and includes all relevant checks before a position is confirmed. On the day of interview applicants are also requested to complete a questionnaire, which includes the rationale for the application. This is viewed as being good practice. Standards 27 and 28 were assessed and fully met at the last inspection. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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): 31, 32, 33, 36 and 38 The manager is supported by senior staff in providing clear leadership throughout the home and staff demonstrated an awareness of their roles and responsibilities. EVIDENCE: The registered manager is a trained nurse with many years experience with elderly persons. Staff meetings are held regularly and the management of the home encourages an ‘open door’ approach. Staff interviewed spoke very positively about the registered manager. Residents meetings are held very two months and indicate that residents influence the day-to-day running of the home. Resident and relative questionnaires are distributed. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 Page 17 The registered manager conducts audits of the premises and medications as well as regular unrecorded audits of the kitchen. She was advised to document kitchen audits and to produce an annual report of all aspects to include any resultant action required with timescales for completion. The content of the document should be shared with residents and staff. The home provides an induction programme for newly appointed staff however, the programme for care staff is not adequate. The induction must contain all of the items listed in the TOPSS programme. This remains outstanding from the previous inspection. All of the requirements in respect of health and safety generated at the last inspection have been addressed however; during this inspection further concerns have been raised. A trailing cable was found in a bedroom and access and egress of all bedrooms must be safe. The registered manager is a manual handling trainer but was unable to verify that her certificate was still valid. She was requested to supply CSCI with details in respect of this and to cease supplying staff training in the interim. Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 2 3 1 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X 2 Highbury Nursing Home DS0000024854.V257042.R01.S.doc Version 5.0 Page 19 YES 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 2 Standard OP20 OP22 Regulation 23(2)g 23(2)n Requirement The registered person must ensure there is adequate communal seating provided. The registered person must 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. This remains outstanding from the previous inspection. The registered person must ensure that bedrooms are supplied with adequate furniture The registered person must complete the already commenced work in the fitting of suited bedroom door locks, which can be overridden in an emergency. N.B. This remains outstanding from the previous inspection. The registered person must ensure safe access and egress to all bedrooms is maintained. N.B. This remains outstanding from the previous inspection. The registered person must DS0000024854.V257042.R01.S.doc Timescale for action 30/11/05 31/12/05 3 4 OP24 OP24 16(2)c 12(4)a 30/11/05 31/12/05 5 OP38OP24 23(2)b 31/12/05 6 OP38OP24 13(4)a 06/10/05 Page 20 Highbury Nursing Home Version 5.0 7 OP33 24(1&2) 8 OP36 18(1)c 9 OP38 18(1)c ensure that all areas of the home are free from trailing cables. The registered person must 15/12/05 complete and introduce the already commenced quality assurance system. The registered person must 30/11/05 ensure that newly recruited care staff receive a comprehensive induction programme that is compliant with TOPSS standards. N.B. This remains outstanding form the previous inspection. The registered manager must 31/10/05 ensure the validity of her manual handling trainers certificate. 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.V257042.R01.S.doc Version 5.0 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.V257042.R01.S.doc Version 5.0 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. 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