Inspection on 03/11/05 for Highcroft

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Highcroft 21/03/07

Highcroft 19/05/05

Highcroft 28/02/05

Highcroft 06/09/04

Highcroft 30/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Highcroft 7 Eastfield Park Weston Super Mare North Somerset BS23 2PE Lead Inspector Alison Murray Announced Inspection 3rd November 2005 09:30 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 Highcroft DS0000020244.V249442.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. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highcroft Address 7 Eastfield Park Weston Super Mare North Somerset BS23 2PE 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) 01934 622247 01934 626100 Mr David Harold Willcox Mrs Ann Willcox Mrs Ann Willcox Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate 23 persons aged 50 years and over who require nursing care of whom up to 3 persons may be 65 years and over and in need of personal care only. Staffing Notice dated 18/04/1997 applies Manager must be a RN on Parts 1 or 12 of the NMC register. 2. 3. Date of last inspection 19/05/05 Brief Description of the Service: Highcroft Nursing home provides nursing care for up to 23 persons, aged 50 years and over. The home is situated in a quiet cul-de-sac in Weston-super-mare and is opposite a small private park. Accommodation is offered in single and double rooms, which are decorated to a high standard and in keeping with the period of the house. Some rooms have ensuite facilities. The main lounges look out across the gardens and town and a larger room is available on the lower ground floor for family celebrations and special events. A passenger lift offers easy access to all areas of the home. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very positive announced inspection. The inspector spent over 6.5 hours in the home. A total of 9 residents and two visitors were consulted individually. All the other residents were observed in the communal areas of the home. Staff were not formally interviewed, but observed as they went about their work. Staff and resident records, were reviewed along with the home’s policies and procedures. What the service does well: What has improved since the last inspection? Mr and Mrs Wilcox have continued with their programme of refurbishment and redecoration. Work has been completed to a very high standard. Highcroft offers very good all round accommodation. The newly created patio area to the rear of the home is much appreciated by residents and their visitors. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 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. Highcroft DS0000020244.V249442.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 Highcroft DS0000020244.V249442.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): 1, 2, 3, 4 and 5. Residents’ needs are thoroughly assessed before admission to the home. They and family members are given good information about the home, and the services it offers. EVIDENCE: Mrs Willcox said that she visits prospective residents, either at home, or in hospital to carry out an assessment of their needs. Records for two recently admitted residents showed that this is a comprehensive assessment. In conversation, these residents, and a relative said that Mrs Willcox had discussed care and social needs with them. They felt they were given very good information about the home, and the service it offers. The statement of purpose and service user guide have been updated since the last inspection. They are both well presented, and contain the relevant information. One lady was admitted the day before the inspection. She said that everyone had made her very welcome. Although she has complex nursing needs, she felt comfortable that the staff knew how to meet these. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 9 Mrs Willcox writes to each prospective resident, or their relative to confirm that their needs can be met within the home. This letter clearly states that the first four weeks of their stay is a mutual trial period. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 10 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 and 11 The health and personal care needs of residents are very well met. There is a friendly, informal atmosphere in the home, with evidence of a good rapport between residents and staff. EVIDENCE: The standard of care documentation was very good. Care plans were written for each area of identified need. They provided staff with clear guidance to meet residents’ needs. This guidance was based on current good practice, and confirmed the involvement of other health professionals. Staff demonstrated a sound awareness of residents’ needs. A large number of residents were aware of the content of their care plans. One lady said that staff in the home had organised a specialist wheelchair for her; during the inspection another person received a visit from the community physiotherapist. Staff in the home had arranged this. A visiting relative said that she was kept informed of any changes in her mother’s condition. A total of 9 residents were consulted individually, and others observed in the communal areas of the home. All were neatly dressed, and attention had been paid to their hair and nail care. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 11 There was a calm, relaxed atmosphere in the home. The residents said that the staff were ‘lovely’, with several naming specific favourites. They gave numerous examples of staff members going out of their way to be helpful. A relative said that she had been particularly impressed that, with the encouragement of the staff, her mother’s mobility had increased significantly since her admission to Highcroft. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 12 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 and 15 The programme of planned and informal activities offered at Highcroft, meets the needs and expectations of the residents. Family and friends are made welcome. Residents really enjoy the meals provided. EVIDENCE: On the morning of the inspection, an independent activities organiser was leading a group of residents in a reminiscence session. This was well structured, and the residents clearly enjoyed the mixture of music, quiz and chat. Staff and residents said that this was a ‘normal day’. Residents’ interests were recorded in their care records. Mrs Wilcox said that she aimed to provide a mixed programme of activities to suit individual tastes. A number of residents were looking forward to a trip to the theatre. They said that they were able to choose which activities to attend. Residents also enjoyed one-to-one, low key activities. During the inspection, a staff member encouraged one resident to do her exercises. Others sat and read newspapers, or chatted with the residents. Residents said that their family and friends were able to visit at any time. A relative confirmed that she was always made welcome. Mrs Wilcox said that residents and their families were encouraged to use the lower floor dining room for private parties. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 13 All the residents consulted said that the standard of food provided at Highcroft was good. Since the last inspection, a new chef has been appointed to work in the home. Residents said that his cakes and pastries were particularly good. They appreciated his attention to detail in presentation. Mrs Wilcox said that she places a strong emphasis on home cooking and fresh local produce. The lunchtime meal looked and smelt appetising. Staff were observed to provide discreet assistance where required. Residents told the inspector that they appreciated being able to have sandwiches and snacks in the late evening if they wished. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 14 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 complaint procedure in the home is satisfactory. Staff demonstrate a good awareness of adult protection issues. EVIDENCE: There are comprehensive policies and procedures in place. Mrs Willcox has placed a ‘comments box’ in the entrance hall, so that residents or visitors may raise anonymous concerns. Residents and a visiting relative all confirmed that they knew how to use these procedures if the need should arise. Several commented that they felt comfortable raising informal concerns with Mrs Willcox. They added that these had always been ‘Sorted out’ very promptly, and there had been no need to make a formal complaint. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 15 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 and 26 Highcroft offers very good all round accommodation. The standard of housekeeping and laundry services are commendable. EVIDENCE: Since the last inspection, work has continued to refurbish and redecorate the home. Furniture and fittings were of a very high standard, and complement the character of the property. All the rooms were well proportioned, light and airy. Some of the first floor rooms have access to a decked balcony. A number of residents commented how much they enjoyed sitting out here. Since the last inspection, a patio has been created to the rear of the home. This is a very attractive area, and offers wheelchair access to the back gate. Mrs Willcox said that this had proved very useful. Residents said that the flower beds surrounding the patio had been planted with spring bulbs. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 16 The standard of housekeeping and laundry service was particularly good. The home was spotlessly clean and tidy. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 17 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 and 30 Staff have the knowledge and skills to care for the residents in the home. They are actively keen to develop and extend this knowledge. Recruitment procedures are generally sound, but pre-employment checks need to be carried out in respect of all staff. EVIDENCE: There were 21 residents in the home during the inspection. Conversations with staff and regular visitors indicated that staffing levels were appropriate to the needs of residents. Staff said that they were kept busy, but still had time to chat with the residents. Visitors said that they did not have a problem finding staff to speak to. Call bells were answered promptly during the inspection. The records kept in relation to three recently appointed staff were inspected. Two of these demonstrated a thorough recruitment procedure. The third record reviewed contained only one written reference. Although this person had provided a copy of a CRB disclosure from her previous employment, staff at Highcroft did not wait for a PoVA First check before she started work in the home. Mrs Willcox explained that this staff member had worked at Highcroft in the past. She had kept in touch with staff and residents since then. Staff are enthusiastic about training opportunities offered to them. By the end of the year, Mrs Willcox anticipates that over 60 will have achieved at least level 2 NVQ in care. Training records confirmed that staff had attended Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 18 courses on a range of issues relevant to the needs of the client group. At present, the training records do not indicate the duration of training sessions. In discussion during the inspection, Mrs Willcox identified a way of amending the form to include this information. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 19 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, 34, 35, 36, 37 and 38 The home is effectively and efficiently managed. Systems are in place to enable staff, residents and visitors to comment on the way the home is run. EVIDENCE: Mrs Willcox has considerable experience in care home management. Staff, residents and relatives commented that the home is very well run. Mrs Willcox and her staff have developed extremely comprehensive quality assurance and monitoring systems. Staff have taken on the responsibility of overseeing the different aspects of these audits. Those consulted were enthusiastic about this process. They said that it gave them an opportunity to ensure that they were delivering the best care possible to the residents. An action plan is written to address any shortfalls in the service. These action plans are regularly reviewed and updated. Their findings are fed back to residents and relatives at regular meetings. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 20 Mrs Willcox issues regular satisfaction surveys to both residents and their relatives. These surveys, and comment cards received by CSCI as part of the inspection process indicated a high level of satisfaction with the service offered at Highcroft. All the documentation seen during the inspection was of a high standard, and securely stored where appropriate. Regular health and safety checks were carried out. Requirements made at the last inspection were met within the agreed timescales. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 21 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 X 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 3 3 3 3 3 Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 22 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. 1 Standard OP29 Regulation 19.1 Sch. 2 Requirement Two written references and a PoVA First, or CRB check must be in place before new staff start work in the home. Timescale for action 03/11/05 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 Staff records should include the duration of any training attended. Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Highcroft DS0000020244.V249442.R01.S.doc Version 5.0 Page 24 - 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!