Inspection on 12/07/07 for Highbury Residential Home

This inspection was carried out on 12th July 2007.

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 Residential Home 01/06/09

Highbury Residential Home 21/07/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Highbury Residential Home 38 Mountsorrel Lane Sileby Leicestershire LE12 7NF Lead Inspector Thea Richards Unannounced Inspection 12th July 2007 10:00 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 Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 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 Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highbury Residential Home Address 38 Mountsorrel Lane Sileby Leicestershire LE12 7NF 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) 01509 813692 Sudera Care Associates Limited Mrs Rachel Amanda McAuley Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 21st July 2006 Brief Description of the Service: Highbury Residential Home is registered to provide personal care and accommodation for twenty-seven older people with a physical frailty. The home is owned by the Registered Providers Sudera Care associates with Mrs Rachel McAuley as the registered manager. The home is situated in the village of Sileby in Leicestershire, which gives the residents access to the local shops, cafes and other facilities. It is can be reached by public and private transport and there is parking in the grounds of the home. Highbury Residential Home is a conversion of a large house into a care home, and had an extension added in 1991. The original house has three floors and the extension has two. Separate lifts and staircases access these, and there is no access from one to the other except by the ground floor. The home is homely and welcoming and the staff appear to be very caring of the residents. The home has a well- maintained garden and patio area to the rear of the premises for the use of the residents in the better weather. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. There is information available in the reception area including the Registration certificate and the latest copy of the Inspection report from the Commission for Social Care Inspection. The home can be contacted by telephone. The current fee level is £ 380.00. There are additional costs for individual expenses such as personal toiletries, optician and hairdressing. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit the inspector spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 21st July 2006. This included the Annual Quality Assurance Audit completed by the home. The visit took place on the 12th July 2007 and lasted six and a half hours. During the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to two of the residents. To achieve this, the residents and a family were spoken with. The inspector spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. The inspector also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The inspector looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. The inspector looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit the inspector spoke with the manager, staff, the residents and their families. ‘ We get very good care’ ‘ The food is very good’ Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should be updated to show the right provider and manager’s name. The moving and handling training should be updated for some members of staff. A risk assessment should be in place for the use of hoist slings. The front door bell should be mended to make sure that visitors can get attention. Training in the care of residents with dementia should be put in place to make sure that the staff can look after those residents with a degree of dementia properly. The policies and procedures should be reviewed to make sure that staff have up to date information. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 8 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 Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. To make sure that they will receive the right care, residents’ needs are well assessed prior to moving into the home by the completion of a pre-admission assessment and a visit to the home. EVIDENCE: All of the residents who were ‘case tracked’ had received a Statement of Purpose and a Service Users guide. The Statement of Purpose and Service Users’ Guide provide all of the information that is needed about the services that are offered and the Terms and Conditions that apply. This information for the residents, making sure that they they can get the most suitable care. The Statement of Purpose should be updated to show the right provider and home manager names. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 10 One of the residents families spoken with told the inspector that they had a visit from the home manager before their relative was admitted. They confirmed that they were given the opportunity to visit the home before they came in. This makes sure that that the staff in the home have the the right information before the resident is admitted so that the resident gets the best care. It makes sure that the home can meet the residents needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. Members of the staff spoken with said that they did not always know what the residents needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home with an up to date insurance certificate. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff meet the care needs of the residents as identified in the care plans, which the residents and their families are happy with. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in them, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor and other health professionals whenever they needed to. There are records of the residents weight and of the meals that they have eaten, which makes sure that they are having an adequate diet. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 12 The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. The inspector saw residents being treated with dignity and respect when staff spoke with them and undertook their care. Staff seen giving care did so in the right way, giving the residents privacy where needed, and talking to them throughout the procedures. Staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. There are risk assessments in place to cover most of the identified risks for the residents. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. An incident was seen where a resident was permanently sitting on a sling for a hoist and there was no risk assessment in place. This practice could cause damage to the skin and there should be documentation in place to reduce the risk. The manager said that she would put one in place immediately. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had training to give medicines. This was seen by the inspector and medicines were administered individually and the residents were seen to be taking them. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The controlled (dangerous) medicines record was checked and found to be in order. There is a policy in place for the residents who are able to look after their own medicines. There are no residents cuurently taking their own medicines. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their social, spiritual and nutritional needs met. Their views are taken into consideration and acted on. EVIDENCE: There was evidence of some activites being provided for the residents, these were recorded in the residents files. Although there didn’t appear to be a very full programme of activity planned, the residents spoken with were happy with those arranged. On the day of the visit there was no formal activity taking place and the television was on all day in the lounge. The residents spoken with in the lounge said that it was always on, but they didn’t really watch it. There were individual activities going on with some of the residents with staff reading with them or sitting and talking with them. The inspector observed lunchtime in the dining room and all the residents said that they were enjoying their meal and that they always had a choice of meals. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 14 The cook has a good understanding of the dietary needs of the residents including diabetic diets. Visitors are made welcome in the home, this was confirmed by visitors and families spoken with who told the inspector that they were made very welcome at any time. The inspector saw the welcome given to visitors when coming into the home which was warm and friendly. They are spoken with regularly on a one to one basis by the manager. The manager sees each of the residents on a one to one basis every day. There are annual quality audits to get the views of the residents and their families. The manager holds regular residents meetings, which have minutes taken. These practices ensure that the residents maintain contact with the community and their families and that views for improvements can be considered. There is a regular church service within the home which the residents enjoy and the local Roman Catholic church will arrange visits for those residents of that faith. These practices make sure that the pastoral care needs of the residents are met and that all faiths are provided for. A hairdresser visits weekly and the residents told the inspector that they really enjoyed her coming. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if needed. The complaints policy was displayed on the noticeboard and the home is able to produce it in a large print if it is needed. They could look at the possibility of producing it in other languages if required. The complaints book was looked at and two complaint had been received since the last inspection on the 21st July 2006. These had also been sent to the Commission for Social Care Inspection (CSCI). Both the complaints had been investigated by the home and had been resolved satisfactorily. The residents spoken with were happy that they would speak to the manager or a member of staff if they had a problem, and that it would be dealt with. The family spoken with said that they would know how to complain if it was necessary and that if a concen had been raised it was dealt with quickly and pleasantly. The staff spoken with knew how to deal with a complaint which was given to them. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 16 All of the care staff spoken with were aware of ‘safeguarding adults’, the procedure to follow and would be prepared to ‘whistle blow’ if they thought that there was a need to. All of the staff had received formal training in safeguarding adults either through the induction programme or through the National Vocational Award. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a pleasant home, which is run in their best interests. EVIDENCE: Highbury House is located in Sileby just off the main road. There are two lounges, both of which have a television and music centres. There is a separate e dining room, which looks out on the garden. The front doorbell at the home is not working, which could leave people waiting at the door for a long time. The home is well maintained, clean and free from any unpleasant odours and it gives the residents a pleasant place to live in. There is a permanent person who does the maintenance and the garden, which has meant that the home is able to keep these areas up to date. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 18 The gardens and patio areas are very well kept and easy for the residents to get to in the better weather. The bathrooms are clean, tidy and free of any hazards. With their permission, the case tracked residents bedrooms were looked at by the inspector. They provided good accommodation, which had been personalised with the resident’s belongings. The bedrooms were clean and well maintained. There was evidence of equipment such as hoists having been provided to help in the care and comfort of the residents. The cleaning materials were kept in locked cupboards. The hot water temperatures and fire records were checked and found to up to date and in order. There were no outstanding safety or maintenance issues seen on the tour of the premises. The registration certificate and the inspection reports from the Commission for Social Care Inspection was displayed with a current certificate of insurance. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are met and their safety protected by the recruitment policy and by the training that is in place. EVIDENCE: There is evidence of a good skill mix of staff to make sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and relatives surveys felt that there were always enough staff on duty to look after them properly. Three staff files were looked at by the inspector and the required information was complete in all of the files. This included evidence of identification, adequately completed application forms, two written references and Criminal Records Bureau checks. There were records of staff training including induction and the staff spoken with confirmed that they received regular training in moving and handling. There was an incident seen by the inspector where poor moving and handling practices were used. This was brought to the managers attention who showed Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 20 the inspector records that the staff involved had received moving and handling training and that she would follow the incident up. They said that they had training in first aid, food hygiene and medicine training. There is a record of training held by the manager with the certificates in the staff files. Some of the residents are showing some evidence of dementia and consideration should be given to providing the staff training in dementia to make sure that they are able to give them the right care. There is a group of staff completing the National Vocational Award (NVQ), this will bring the total of staff with an NVQ at level 2 or above to 65 which is above the required level. The manager has completed a level 4 in care and is now working towards the registered managers award through the National Vocational Award programme. The National Vocational Qualification is a qualification for care staff to make that they receive the right training in the needs of the resident group whom they are caring for. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is committed to the best care for the residents through training, good communication and thorough recruitment practice. EVIDENCE: The manger was available throughout the visit. She has completed an NVQ at level four and is working towards her registered managers award. The manager is committed to the improvement of the home and has made a lot of progress in raising the standards. There was evidence that regular staff supervision was in place, and the members of staff spoken with confirmed that they had received supervision. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 22 The process of formal supervision time gives the staff and their ‘line manager’ the opportunity to have individual discussions about work and training needs. There are regular meetings held with the staff to pass on and exchange information. The manager meets regularly with the residents and their families as well as one to one discussions both to pass information on and to listen to their views and opinions. There are annual quality questionaires sent out to residents and their families to gain their views about the home. A newsletter has been produced to help to keep the residents and their families informed of items of interest from the home. These practices allow the manager and the responsible person to respond to the residents and the staff’s needs. There are accounts held to manage the residents personal allowances and are being managed correctly with two signatures and the receipts in place. The policies and procedures are in place for the home but have not been reviewed since 2004. Reviews should be put in place to make sure that they still give the staff the right information. They are available for the staff to read to make sure that they know how the residents are to be cared for. Records for the maintenance of fire equipment, fire drills and training were found to be in place and up to date. The registered provider completes a provider report (Reg 26) every month and there is a copy kept in the home. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 23 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 3 Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. 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. 3. 4. 5. Refer to Standard OP8 OP19 OP30 OP30 OP37 Good Practice Recommendations A risk assessment should be provided to protect the resident from damage to the skin from the use of a hoist sling. The doorbell should be able to be heard to make sure that visitors can gain access to the home. That those staff who require it receive further training in moving and handling. That the staff are given training in caring for people with dementia. That the policies and procedures for the home are reviewed and updated. Highbury Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Home DS0000066365.V345725.R01.S.doc Version 5.2 Page 26 - 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!