Inspection on 21/07/06 for Highbury Residential Home

This inspection was carried out on 21st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12/07/07

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 38 Mountsorrel Lane Sileby Leicestershire LE12 7NF Lead Inspector Thea Richards Unannounced Inspection 21st July 2006 12:00 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.V304326.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.V304326.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.V304326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. This was the first inspection since the change of ownership Date of last inspection Brief Description of the Service: Highbury Residential Home is registered to care for twenty seven older people in a large converted property. It is situated on Mountsorrel Lane in Sileby, Leicestershire, where residents have access to the village of Sileby. Highbury Residential Home is a conversion of a large house into a care home, with the addition of an extension 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. There is information available in the reception area including the Registration certificate. The latest copy of the Inspection report from the Commission for Social Care Inspection is available to view in the managers’ office. The current fee level is £ 350.00. There are additional costs for individual expenses such as personal toiletries, optician and hairdressing. Highbury Residential Home DS0000066365.V304326.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 the home that was concluded with an unannounced visit to the home. Prior to the visit the inspector spent two hours reviewing the information relating to the home received since the change of ownership in February 2006. The visit took place on the 21st July 2006 from 12.00 and lasted four hours. During the course of 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 residents living at the home, by talking to the residents themselves; talking with staff supporting their care; checking their records relating to their health and welfare; viewing their personal accommodation (with their consent) as well as the communal living areas. The inspector also checked other issues relating to the running of the home including health and safety, management and staffing areas. During the visit the inspector spoke with other residents in the home, staff, two visitors and the manager. The inspector also observed care practices when staff assisted residents. What the service does well: What has improved since the last inspection? Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 6 This was the first inspection since the change in ownership in February 2006. 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 Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 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 Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 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, 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using the available evidence. Residents’ needs are well assessed prior to moving into the home by the completion of a pre-admission assessment by a trained member of staff or by Social Services. EVIDENCE: The inspector checked the care records of two residents who were case tracked. Completed pre-admission assessments are present in the residents files, identifying their needs, prior to their admission to the home. Care plans reflected the needs of the resident identified in the pre-admission assessment. Staff spoken with said that they were aware of the residents needs prior to them moving into the home. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 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 Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The staff meet the care needs of the residents as identified in the care plans. EVIDENCE: Care plans for two residents were ‘case tracked and were found to contain good individual evidence of care which reflects the care being given to the residents. There is evidence of the involvement of G.P.s, district nurses, chiropodist, optician and dentist present in separate files, providing evidence of comprehensive care being provided for the residents. The daily record of care is up to date. However, there are no entries for the resident’s involvement in activities, which could indicate that the residents are not taking part in activities, which provide occupation and stimulus for them, giving a better quality of life. Staff spoken with were aware of the care needs of the residents and the residents and the visitors spoken with were happy that the care needs were being met. Medication records for the case tracked residents were in order. Staff 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 pharmacist who supplies the home completes six monthly Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 10 audits, which were satisfactory. The above ensures that the residents are protected with the correct medicine administration. There are no residents currently administering their own medication. Medication records for controlled drugs were checked and on one occasion were found to have a second siganature missing. Controlled drugs are drugs that are considered addictive and therefore have stricter controls when being administered. Two signatures are required to confirm that the correct medication is being given, this practice protects both the resident receiving the drug and the staff administering it. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 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, 15 Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. Residents have their religious and nutritional needs met with social needs partly met. EVIDENCE: There was no documentation available to confirm that the residents were taking part in any activities in the home. Care staff undertake one to one activity with the residents such as manicures and sitting and talking or reading to them. On the day of the visit there was no organised activity observed by the inspector but individual interaction between the staff and residents was seen. On the day of the visit residents were observed sitting in a choice of two lounges, in one, where most of the residents were, the television was on all day and in the afternoon the residents were sat in a circle in the lounge asleep. This provides no stimulation for the residents, although the inspector was assured that the residents enjoyed the childrens’ programmes on the television. The residents are taken out locally on occasion and on an annual boat trip, with the staff using their own transport. The home is currently advertising for a dedicated activities organiser which should improve activities and occupation for the residents. There is a choice of meals available and diabetic and vegetarian meals are provided, if there was a need for other diets such as coeliac which is a wheat Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 12 free diet, they would be able to provide them. Residents spoken with all said that they enjoyed the food and were happy with the choices. On the day of the visit, which was on an extremely hot day, the inspector observed frequent drinks being given to the residents which helps to maintain hydration. Visitors are made welcome in the home and some take their relatives out regularly. This was confirmed by visitors spoken with who told the inspector that they were made very welcome at any time. Families and friends are invited to resident meetings to express their views and are spoken to regularly on a one to one basis by the manager. The manager is about to send out a quality questionaire to check the views of the residents and their families. 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 hymn service every six weeks which most of the residents join in with and the local vicar visits once a fortnight to hold a communion service for those residents who wish it. There are currently no residents who require alternative spiritual care. The residents are therefore able to have their spiritual needs met. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff have some knowledge about the processes. EVIDENCE: There is a complaints policy in place which is displayed in the reception area and no complaints or concerns have been recorded in the home since the change of ownership. Residents spoken with were happy that they would speak to the manager or a member of staff, if they had a problem. Visitors spoken with on the day of the visit said that they were aware of the procedure to complain and would have no concerns about doing so. The Commission for Social Care Inspection has received no complaints or concerns since the new owner has taken over. There is little evidence of training in safeguarding adults having been received by the staff. The staff spoken with had some knowledge about safeguarding adults and would be prepared to ‘whistle blow’ if they thought there was a need to. Training in this area should be completed to ensure that the residents are safe from any abuse and that any concerns are handled correctly. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a generally good and safe environment. EVIDENCE: The registration certificate from the Commission for Social Care Inspection was displayed in the reception area, together with a copy of the complaints policy. Highbury Residential Home is a conversion of a large house to with the addition of an extension in 1991. The original house has three floors and the extension has two. Separate lifts and staircases access these, but there is no access from one to the other except by the ground floor. Whilst this does not present a difficulty for the residents, the staff sometimes encounter problems getting from one area to another. The communal areas including the lounges and dining room provide a homely and comfortable environment for the residents to live in. There was an odour of urine in the lounge/dining room area. The manager assured the inspector that she would get this area cleaned. With their permission, the bedrooms of the ‘case tracked’ residents were looked at. The bedrooms provided good Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 15 accommodation and had been personalised with the resident’s belongings. They were clean and safe although one bedroom had a curtain rail hanging down which the manager said that she would get repaired as it could present a hazard to the resident. The room that was shared had adequate provision for the privacy of the residents. One of the bathrooms contained unlabelled toiletries which were identified to the manager and she arranged to have them removed as this could have an infection control risk if used by several of the residents. There were no further outstanding safety or maintenance issues noted on the tour of the premises. There is level access to a patio and garden which enables the residents to sit outside. Records for the maintenance of fire equipment, fire-drills and testing of water temperatures were found to be in order. An environmental health visit had been made six months previously and everything was found to be in order. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29, 30 Quality in this outcome group is adequate. This judgement is made using the available evidence including a visit to the service. The residents’ needs are almost met and their safety mainly protected by the staff. EVIDENCE: There is evidence of a good skill mix of staff to give the care identified for the residents needs and the number of staff on duty reflected the duty rota. Residents, staff and visitors spoken with felt that there were always sufficient numbers of staff on duty to cater for their needs. Two staff files were viewed by the inspector and the required documentation was not available in either file. Whilst both the files included evidence that a criminal records bureau check was in place, two written references were not available. The application forms were inadequately completed and contained very little information about employment histories and dates of employment. These issues must be as addressed as the residents’ safety could be compromised if this information is not available. There was evidence of staff training including induction in a separate file and the staff spoken with confirmed that they received regular training in fire,first aid moving and handling and medication administration. Twenty five per cent of the staff had completed a National Vocational Qualification in care at level two or above, including the manager who has obtained a level four in care. Several more staff were about to commence the training. The National Vocational Qualification is a qualification for care staff to ensure that they Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 17 receive appropriate training in the needs of the resident group whom they are caring for. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 18 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, 33, 35, 36, 38 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents live in a home, which provides for their needs, with basic safety in place. EVIDENCE: The manager was available throughout the visit to the home . The manager has worked in the home for six years as the the manager of the service. She has completed a National Vocational Qualification in care at level four and has achieved a National Vocational Assessors award which enables her to assess the staff in the home for their qualifications. She has a good relationship with the new owner and there have been no changes made in the home since he took it over in February 2006. The manager used to hold regular meetings with the residents but now finds that one to one discussions with them and their families achieves a better result in ensuring that the home is providing the service that they need and Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 19 require. A quality questionaire is going to be distributed to residents and families to gain their views. The recruitment policy needs some urgent attention, with the obtaining of relevant documentation such as written references and adequate and completed application forms. Criminal Records Bureau checks have been obtained which does offer some protection for the residents. The staff were being given appropriate training to look after the residents both in care needs and health and safety issues. This was confirmed by available documentation, the manager and by staff spoken with, however whilst some of the staff had a little knowledge of the safeguarding of adults, the knowledge was limited and training in this area must be provided. There is currently no evidence of staff supervision having taken place. Residents finances are handled by their families with the home holding some monies on their behalf for incidental expenses. This is handled by the manager with good records in place and two signatures for each transaction. There are records of expenditure available in the home. The residents are well protected by the financial policies in the home. Residents needs are met with a good working relationship with the district nurses who will supply equipment for the use of the residents, which ensures that the residents receive appropriate support. There are appropriate records in place confirming that all health and safety requirements are being met to maintain a safe environment for residents and staff. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 20 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? None 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 OP29 Regulation 19(b) Requirement The registered person shall obtain two written references and a fully completed application form for all staff prior to their employment. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP30 OP9 OP12 OP26 OP36 Good Practice Recommendations The registered person establishes robust training for ‘Safeguarding adults’ The registered person ensures that the staff are aware of the requirements for witnessing the administration of controlled drugs. The registered person gives consideration to the provision of appropriate activities for the resident group The registered person establishes a cleaning programme to eliminate the odour found in the main lounge. The registered person establishes a programme of staff supervision. Highbury Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Residential Home DS0000066365.V304326.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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