Inspection on 13/07/05 for Highdell Nursing Home

This inspection was carried out on 13th July 2005.

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

Highdell Nursing Home 26/02/07

Highdell Nursing Home 16/05/06

Highdell Nursing Home 16/01/06

Highdell Nursing Home 26/01/05

Highdell Nursing Home 06/07/04

Highdell Nursing Home 07/01/04

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

CARE HOMES FOR OLDER PEOPLE Highdell 43 Westfield Lane Idle Bradford BD10 8PY Lead Inspector Val Francis Unannounced 13th July 2005 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 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. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highdell Address 43 Westfield Lane Idle Bradford BD10 8PY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 610442 01274 610442 Mr Stephen Richard Pelkowski Mr Stephen Richard Pelkowski Care Home with Nursing 25 Category(ies) of Dementia (25 Mental Disorder (25) registration, with number of places Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26.01.05 Brief Description of the Service: Highdell Nursing Home is situated in the village of Idle, Bradford and provides accommodation for up to 25 people with psychiatric problems. Qualified psychiatric nurses and care staff provide twenty-four hour care. Accommodation at the home is provided on two levels with a recently installed lift offering access to the upper floor. This is in addition to the provision of a stair lift. There are single and double bedrooms, some with en-suite facilities. The home has two lounge areas plus a separate dining room.Parking is available to the front of the home and there are gardens to the rear and side. Although the home is situated in a quiet area the bus routes to Bradford and Shipley are easily accessible. Shops and local amenities are within walking distance. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection, over a day, which started at 12mid-day and completed at 5.40pm. On arrival at the home the inspector met the Matron who was in charge. The registered manager was not at the home, he however joined the inspector and facilitated in the inspection process later on. A Comment card was given to the manager for his feedback on the way in which the inspection was carried out. Comment cards for both residents and visitors and the new CSCI service users information leaflets were also left. During this inspection, residents’ records and care plans were assessed, and observation was made of staff interaction with residents and their relatives. Residents, their visitors and staff were spoken with about the care given at the home. What the service does well: Care is provided to residents by staff that are friendly and supporting. The inspector spoke to visiting relatives who said that the staff are friendly and welcoming. During the inspection the inspector saw staff making sure that residents were wearing suitable clothing and head wear for the outside weather. Staff applied sun cream to residents head and arms that could be burnt by the sun. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 standard(s) 3 No residents are admitted before having an assessment of needs. EVIDENCE: Residents are admitted to the home after an assessment carried out by the manager. Other assessments from social workers and health care professionals are also carried out, this includes discussions with the service user, relatives and other relevant professionals. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 standard(s) 7 and 8. Whilst there were care plans in place they did not reflect all the residents needs. EVIDENCE: Three residents care plans were seen; looking at how individual care needs would be met using the assessment information. The inspector felt there was some good information in care files on meeting care needs, but felt that residents would benefit from care plan approach that was person centred. Putting the person first and not the dementia but recognising the needs and emotions of the residents are important. The manager was advised that although risk assessments were carried out for residents who were at risk of developing a pressure sore and he and his staff work closely with the District Nurses for supply of pressure relieving and incontinent aids, a plan of care must be in place to show the actions to be taken to prevent pressure sores. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 10 Several people had bed safety rails fitted, but there was no plan of care, which would give staff all information to care for the resident with a bed safety rail fitted. An agreement of consent was needed from the resident or their relatives for the use of bed safety rails. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 standard(s) 12 and 13. Social Activities needs to be more defined to keep residents from being bored. EVIDENCE: Day to day activities are arranged using community facilities for one to one or groups. Arrangements are made for entertainment to be brought into the home. During the visit the inspector saw some residents who appeared to be bored One person had family visiting; others were walking around the ground floor corridor. The manager said staff involve residents in activities on a one to one basis. Activities are displayed on the notice board; two residents go out shopping and using the local community facilities and out on day trips to places of interest alone, without staff assistance. Most of the residents have contact with relatives and friends, some who have family abroad have contact via telephone calls. It was evident from discuss with one set of family visiting at the time that they are made welcome by staff. The manager said when possible the home manages to get some visitors from the local church. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 standard(s) 18 There are systems in place to protect residents from abuse. EVIDENCE: All staff have had one day training on Adult Protection, and access to the home’s policy and procedures for handling abuse in the home, the multi agency procedure and the Department of Health No Secret Document. Some amendment was needed to the home policy procedure so that it is line with the multi- agency procedure. CRB checks are carried out for all new staff and two references taken before the start of employment. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 standard(s) 19,25 and 26 The environment would improve with a good cleaning programme and with redecoration and the replacement of furnishing, carpets and curtains. EVIDENCE: The location of the home is suitable for the purpose. Since the last inspection the building work for the extension is now completed. Although there has not been an increase in the number of residents the building now provide more single rooms, than shared rooms. The temperature throughout the building appeared to be comfortable for the time of year. Although it is the home’s policy to check water temperature monthly, it was some time since the last check was carried out. Emergency lighting is throughout the home that would allow people to see, if there was a power cut. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 14 The communal rooms were found to be dirty and needed cleaning and redecoration. The carpet in the non smoking lounge had worn and was fraying this being a potential trip hazard to residents, staff and visitors. The carpet in the smoke room was worn in some areas, and carpet near the chairs was sticky; easy chairs and wheel chairs on the whole were dirty and filled with food debris. The varnish on the dining room chairs was cracking and worn in areas. In general the inspector found that the communal sitting rooms were looking stark and lacked the warm and inviting atmosphere portrayed by staff to the people living at the home. Laundry facilities are alright for the present resident group. Although staff have had infection control training this now needed to be updated to make sure that that they are aware of the current thinking about infection control. The food storage containers in the kitchen needed washing and window ledges needed cleaning. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. Staffing level needs to improve with the employment of domestic staff and increase in cleaning hours, to ensure that care staff have time to spend with residents. EVIDENCE: Although there were no care or nursing staff vacancies at the time and staffing levels appeared to be enough for residents during the day, some consideration is needed to increase the staffing levels during the night to accommodate the lay out of the building and the location of residents bedrooms. The lack of domestic staff in the home was reflected in the standard of cleanliness of the building. The home management also needs to look at the amount of allocated hours for domestic staff, so that there is enough time available to clean the home without care staff spending time cleaning that should be spent with residents. Two members of care staff have a National Vocational Qualification (NVQ) level 2. There is no work base assessor to assess staff during their NVQ training. All new staff receive induction training. More specialist training is needed so that staff gain skilss to meet the needs of the people they care for. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 The standard of cleanliness and the lack of proper facilities for hand washing and drying creates the risk of spread of infection. EVIDENCE: The manager said staff have one to one supervision sessions approximately every two months, looking at their training and development for their personal needs and for the care of the residents. Plans are in place to involve the matron in staff supervision. Staff have had moving and handling training, which is carried out annually, There is Health and Safety policy procedure in place. Plans were in place for two members of staff to do the basic food hygiene course, with a view for an updated course for all other staff. There were records that health and safety checks are carried out. A copy of the electricity and gas safety check certificates were not available. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 17 The wc room identified to the manager needed cleaning, toilet brushes needed changing, no paper towel or liquid soap was available. There were no records to indicate that risk assessments for the building were carried out. There are some health and safety matters that were seen during the inspector’s brief walk around the building. These are found in standard 19. All accidents and incidents are recorded and the appropriate agency is informed. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 2 1 STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x 3 x 2 Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Resdents must have a care plan that clearly identfies all their assessed needs and how they would be met. There must be a plan of action to be taken to prevent pressure sores occurring. A plan of care with an action plan must be in place, in regards to the use of bed safety rails. The water temperature checks must be carried out on a monthly basis and records kept of these checks. The standard of cleanliness through out the home especially the communal sitting rooms, ktichen and toilets must improve. wheel chairs must be cleaned. a plan with timescale for replacement and redecation in the home, must be sent to the CSCI area office liquid soap and paper towels must be provided in all wcs. The toilet brush identfied must be removed. the domestic hours must be provided for seven days a week. Timescale for action 30th August 2005 30th August 2005 30th aughust 2005 30th August 2005 30th August 2005 2. 3. 4. 7 7 25 15 & 13 (4) (b) 15 & 13 (4) 23 5. 26 23 6. 7. 26 24 12 23 30th August 2005 30th August 2005 30th August 2005 30th August 2005 30th september Page 20 8. 9. 10. Highdell 38 26 27 13.(3) 13 18 (1) J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 2005 11. 12. 13. 28 38 28 23 the home must have 50 of staff with an NVQ qulfication by March 2006. risk assessments for the building must be carried out. December 2005. 30th september 2005 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 7 7 12 Good Practice Recommendations resident/ relatives should sign an agrrement to indicate there consent for bed safety rail in place. all effort must be made for social acitivites to be carried out for residents to meet their individual needs. Highdell J52 J03 S19894 Highdell V226102 130705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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