Inspection on 13/03/06 for Highbury Rise

This inspection was carried out on 13th March 2006.

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 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 Rise 31/10/06

Highbury Rise 03/05/06

Highbury Rise 20/10/05

Highbury Rise 11/01/05

Highbury Rise 15/06/04

Highbury Rise 27/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Highbury Rise 6 Highbury Road Hitchin Hertfordshire SG4 9RW Lead Inspector June Humphreys Unannounced Inspection 13th March 2006 14:00 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 Rise DS0000019424.V286359.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 Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highbury Rise Address 6 Highbury Road Hitchin Hertfordshire SG4 9RW 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) 01462 437 495 angela@benslow.co.uk Benslow Management Company Limited Angela Taylor Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: Highbury Rise, provided by Benslow Management Company Limited, is a residential care home for 23 service users in the Old Age and Dementia Category. It was first registered with Hertfordshire County Council on 29th August 1985 and transferred to the National Care Standards Commission on 1st April 2002. The home is situated in a residential area of Hitchin, within easy walking distance of local amenities and shops. There is limited parking to the front of the building. Accommodation is provided on three floors consisting of single occupancy bedrooms with washbasin. There is one double bedroom. The toilet and bathroom facilities are nearby. Each floor is served by a passenger lift. There are a number of community areas including two small lounges and a large lounge/dinning room that overlook a small patio and back garden. The kitchen is next to the lounge/dinning room. The small administrative office is also on the ground floor. The laundry room is situated in the basement. The home provides the service of a hairdresser and chiropodist, for which an additional charge is made. Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on 13th March 2006. The registered manager and the deputy manager were present. There are 21 service users in the home, the majority of whom have dementia. The inspection included a tour of the premises and discussion with the management team. The inspector spent some time observing the interaction between staff and service users, who were all in the lounge of their choice. A number of service users participated in the afternoon social activity of Music and Dance. Those who preferred a quiet game of dominoes or an afternoon nap were in the smaller lounges. The service users appeared relaxed and contented. Those interviewed gave positive feedback in regard to the care and service provided. (Please see below for details of the inspection findings). What the service does well: What has improved since the last inspection? The registered manager has arranged for all staff to have training in Dementia and the Protection of Vulnerable Adults (POVA). There is a rolling training programme organised for staff in the coming year that is tailored to the needs of the current group of service users. The home is to discontinue providing toiletries for sale to service users. An alternative method will be arranged. Since the last inspection, there was an outbreak of scabies in the home. With the help of the Health Protection Agency and the General Practitioner, the outbreak was contained. Appropriate treatment was given to both service users and staff. Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 6 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 Rise DS0000019424.V286359.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 Rise DS0000019424.V286359.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): 1, 2, 3, 4. A pre-admission assessment is conducted before a prospective service user is admitted into the home. A trial period is arranged before the contract is signed. EVIDENCE: The pre-admission details of recent admissions were seen in the service user files. The registered manager confirmed that each service user was given a Service User Guide. The prospective service user is given a six weeks trial period before the contract is arranged and signed. The relative and/or representative are involved. Highbury Rise DS0000019424.V286359.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, 10. Service users are treated with respect and dignity and their right to privacy is upheld. The care needs of the service users are not reflected clearly in the written care plan. EVIDENCE: Members of staff were observed to be gentle and friendly as they assisted the service users who appeared confused at times. The majority of the service users suffer from dementia. Some time was spent looking at the various aspects of the service user file and written care plan tool adopted in the home. Although there is a file called Care Plan Assessment, the contents of this file does not reflect the specific care needs of the service users in the home. Although there was a comprehensive initial assessment at the time of admission, the written care plan and the written risk assessments were insufficient and inadequately written. In addition, there were new admissions (since the last inspection) where the service user’s initial care plan had not been completed with regard to aspects of care needs. Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 10 The management must ensure that all aspects of the care needs of a new service user are recorded as soon as they are admitted. In addition, the written care plan must reflect the care needs of the particular service user, be maintained, be kept updated and be accurate. All written care plans and reviewed care plans must be readily available for inspection. (Please see Statutory Requirements and Recommendations). Highbury Rise DS0000019424.V286359.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, 14, 15. The service users are given every opportunity to participate in all aspects of routine living. They are encouraged to join in the activities of the day. The meals provided are nutritious and wholesome. Choices are given daily. EVIDENCE: All the service users were up and about on the day of the inspection. They all have access to their favourite lounge and seating. A group of service users were observed participating in the afternoon activity of Music and Dance with members of staff involved. Those who prefer a quieter time were playing dominoes in the smaller lounge while others were having a quiet snooze in the front sitting room. Members of staff were readily available to assist the individual service user. The menu is displayed on the noticeboard in the main lounge. The menu is varied and choices are given. Service users are given drinks at regular intervals. Highbury Rise DS0000019424.V286359.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, 18. Service users and their relatives are confident that their complaints are listened to, are taken seriously and are acted upon. The management ensures that service users are protected from abuse. EVIDENCE: There were no written complaints since the last inspection. The management ensure that any concern raised is dealt with immediately and that appropriate changes are made to improve the service. Arrangements have been made for all staff to attend training in issues concerning the Protection of Vulnerable Adults. Highbury Rise DS0000019424.V286359.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, 22, 25, 26, The home is generally clean and comfortable. Service users have access to community spaces. All specialist equipment has been maintained and kept in good working order. However there are hazards to safety that need to be addressed by management. EVIDENCE: The home has a rolling maintenance programme. All the bedrooms examined appeared clean and they reflected the lifestyles of the occupants. One service user has had her bedroom carpet replaced since the last inspection. All specialist equipment has been serviced. The old commodes will be replaced with new ones on 14th March 2006. The wheelchairs appeared clean and well maintained. Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 14 Since the installation of the new boiler, the hot water temperatures recorded in two bedrooms were around 48 degrees centigrade. Where the temperature is too high, a thermostatic valve must be fitted to the washbasin. The water temperature should be close to 43 degrees centigrade. There are 4 radiators that require protective radiator covers to ensure a low surface temperature. The registered manager has agreed to make the necessary arrangements to ensure that these radiators are covered appropriately. Currently, the home has a service user who has a tendency to touch the uncovered radiator and its control panel. The registered manager must ensure that exit doors are clear from obstruction at all times. One coffee table, placed by an exit door in the lounge, was immediately removed to an alternative position when this was highlighted to a member of staff. (Please see Statutory Requirements). Highbury Rise DS0000019424.V286359.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, 30. The numbers and skill mix of the staff are adequate. A training programme for all staff is in place. EVIDENCE: On the day of the inspection, there were seven staff on duty, including the registered manager and the deputy manager. Team working was evident. The members of staff were observed to interact well with the service users in their care. The service users spoken to said that ‘the staff are helpful’. The registered manager has made arrangements for all staff to have training that includes Dementia and the Protection of Vulnerable Adults. The registered manager is organising a rolling training programme for the coming year to enhance the knowledge and skills of all staff to ensure that the needs of the service users are consistently met. A number of staff will be attending the Infection Control Programme organised by the Health Protection Agency. It is recommended that all staff have training in regard to writing care plans. (Please see Statutory Recommendations). Highbury Rise DS0000019424.V286359.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, 37, 38. There is a quality assurance and monitoring system conducted by the provider. The health, safety and welfare of the service users and staff are not always promoted and protected. However, the management took appropriate action during the scabies outbreak. EVIDENCE: On the day of the inspection, the inspector received a copy of the provider’s quality assurance and monitoring report. In the recent scabies outbreak (source unknown) the registered manager took appropriate measures to contain the situation with the help of the Health Protection Agency and the General Practitioner. All service users and staff were Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 17 treated with a prescribed lotion. The Commission (CSCI) was notified under the Care Homes Regulations 2001 (Regulation 37). The management must ensure safe working practices. The record-keeping aspect of the service is not consistently maintained. Risk assessments are not always carried out and recorded. (Please see Standard 7 and 19 and Statutory Requirements and Recommendations). Highbury Rise DS0000019424.V286359.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 3 3 2 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 x 3 2 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x x x 2 2 Highbury Rise DS0000019424.V286359.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 OP4OP7OP 37 Regulation 15,17(1) & 17(3) Requirement The management must ensure that all records for the protection of service users and for the effective and efficient running of the home are maintained, are kept up to date and are accurate, namely: (a) The written care plan must be in place as soon as a service user is admitted and it must be readily available for inspection. (b) The written care plan must reflect the service user’s needs in respect of their health and welfare and how these care needs are to be met. (c) All reviewed care needs must be reflected in the written care plan. (d) There must be written risk assessments, on safe working practices, in particular, concerning the risk from hot water and hot radiators. DS0000019424.V286359.R01.S.doc Timescale for action 31/03/06 Highbury Rise Version 5.1 Page 20 2. OP25OP38 13 (4) A thermostatic valve must be 31/03/06 installed to each washbasin where the hot water temperature is above 43 degrees centigrade. All radiators must have protective radiator covers to ensure a lower surface temperature. (The registered manager has agreed to make the necessary arrangements to remedy the situation). 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. Refer to Standard OP30 Good Practice Recommendations It is recommended that all staff have further training in regard to writing care plans. Highbury Rise DS0000019424.V286359.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Rise DS0000019424.V286359.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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