Inspection on 01/12/05 for Highfield

This inspection was carried out on 1st December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highfield 04/07/06

Highfield 27/02/06

Highfield 22/02/05

Highfield 26/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Highfield Highfield 51 Alpha Road Birchington Kent CT7 9EG Lead Inspector Elizabeth Hendry Announced Inspection 1sr December 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 Highfield DS0000023437.V268173.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. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highfield Address Highfield 51 Alpha Road Birchington Kent CT7 9EG 01843 842116 01843 842190 melanie4baker@hotmail.com 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) Mr Egerton Lionel Keith Eckersley Mrs Anne Margaret Eckersley Mrs Melanie Baker Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Highfield Residential Home is a detached three-storey building with service user accommodation situated over three floors. The home is located within ten minutes walk from local shops and public amenities including public transport, library and church. There is an enclosed rear garden, which is laid to lawn. There is off street parking to the front of the property for approximately six cars. The home provides personal care and support for up to 21 older persons. The home aims to respect service users privacy and dignity. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first annual inspection, which took place during the course of a day. Time was spent meeting and talking with all residents, members of staff and management. Policies, procedures and records were examined, and a tour of the home was undertaken. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that staff involved in the management of service users medication are consistent in the use of abbreviations when recording instances of refusal. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 6 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. Highfield DS0000023437.V268173.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 Highfield DS0000023437.V268173.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): 1,3 and 6 The homes Statement of Purpose and Service User guide are excellent. They provide Service Users and prospective service users with the information they need to make a decision about moving into the home. Service users move into the home knowing their needs will be fully met. No intermediate care is provided within the home. EVIDENCE: Service users spoken to confirmed that prior to moving into the home, they were provided with a service user guide, which clearly identified what services and facilities were available. The Statement of Purpose and Service User guide contained detailed information regarding the layout of the accommodation, staff qualifications and experience, management of the home, and services provided. Service users spoke of being involved in a pre admission assessment undertaken by the manager of the home, all service users spoken to felt confident that their needs would be met prior to accepting a place at the home. The registered manager confirmed that no intermediate care is offered at the home. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 9 Highfield DS0000023437.V268173.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): 8,9 and 10 Service users health care needs are fully met. The systems for medication administration require review to ensure that service users medication needs are fully met. Staff treat service users with respect and dignity at all times. EVIDENCE: Staff spoken to had a clear understanding of the needs and limitations of all residents within the home. The healthcare needs of all residents are fully met, staff closely monitor all residents to ensure their healthcare needs are met, and any problems identified are quickly addressed. The home frequently accesses services from district nurses, physiotherapists, psychologists and chiropodists. Medication administration records were checked and referenced against medication held within the home. Drugs stored tallied with medication administration records. Inconsistencies in the use of abbreviations were identified in the recording of non-administration of medicines. The registered manager confirmed that all staff involved in the administration of medication were nearing completion of a comprehensive safe handling of medication Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 11 course, and that a review of the homes medication recording systems was currently taking place. Service users spoke of staff treating them with respect and dignity at all times, confirming that personal care is provided in a sensitive manner. Staff were observed communicating well with all residents. Highfield DS0000023437.V268173.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 and 15 Service users are fully supported to participate in activities and develop interests. Staff encourage service users to maintain contact with family and friends and participate within their local community. Dietary needs of Service Users are well catered for with a balanced and varied selection of food available that meets the Service Users tastes and choices. EVIDENCE: The registered manager confirmed that there is a wide range of activities available within the home, these include, dominoes, keep fit, bingo, and arts and crafts. Visits to the local community and maintaining interests involved in prior to moving into the home are actively encouraged. All activities are optional and dependent upon personal choice and preferences. Service users spoken to said that their friends and family are made to feel very welcome when visiting the home. Service user questionnaire received prior to the inspection were complimentary of the running of the home and facilities on offer. Menus viewed illustrated a varied, nutritious selection of meals, with full choices available. Service users spoke highly of the meals provided at the Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 13 home, and that staff were aware of their personal likes and dislikes with regards to food. The registered manager confirmed that hold and cold drinks and snacks are available at all times upon request. Highfield DS0000023437.V268173.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 homes complaints policy and procedure is good, ensuring Service users receive quality care at all times. Arrangements for the protection of service users are satisfactory protecting them from possible risks of abuse. EVIDENCE: The home has an open door policy, which encourages staff and service users to raise concerns with the added confidence that appropriate measures will be taken. Service users spoken to said that they would feel comfortable to raise concerns without fear of reproach. A copy of the homes complaints policy and procedure was viewed within the service users guide and statement of purpose and was found to contain detailed information in a manner that is easy to understand and act upon. No complaints have been made to the home since the last inspection. The registered manager confirmed that all staff are asked to read the homes adult protection policy and procedure upon commencement of their employment. At the time of the inspection no additional training is accessed. Those members of staff who have either completed or are undertaking NVQ level 2 complete units on abuse awareness. Highfield DS0000023437.V268173.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 The standard of the environment within the home is good providing Service Users with an attractive and homely place to live. Infection control measures are in place, which promotes the wellbeing and health of service users and staff. EVIDENCE: A tour of the home was undertaken, a good standard of decoration and furnishing was found throughout the home. The majority of fixtures and fittings were domestic in nature. To the rear of the property there is a large garden area, which provides additional seating and living space for the residents during the summer months. Service users were seen to have personalised their bedrooms. The home has a planned maintenance and redecoration programme. The home was found to be clean and no offensive odours were present. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 16 The registered manager confirmed that all staff are undertaking a comprehensive infection control training course in addition to the basic training provided during induction. Highfield DS0000023437.V268173.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, 29 and 30 Staffing levels within the home are high providing consistent care to the service users. Service users receive care from qualified and well-trained members of staff. Recruitment policies for staff are not consistently followed. EVIDENCE: High levels of staff were on duty during the inspection, staff rotas examined showed good levels of staff were on duty at all times to ensure service users needs could be fully met. Service Users spoke highly of all members of staff commenting that nothing is ever too much for them. Staff files viewed showed a commitment from both the management of the home and staff to undertake and achieve a variety of training, including NVQ Level 2, relevant to the home and service users needs. Staff files viewed were found to contain enhanced criminal records bureau checks, however the absence of some written references and proof of identity was identified. The registered manager confirmed that this would be addressed as a matter of urgency. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 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): 31,38 Service Users benefit from a well managed home. The health and safety of the service users and staff are promoted. EVIDENCE: The manager has a clear understanding as to the goings on within the home. Service users spoke of the manager playing an active role in the home on a daily basis, and providing an open door to discuss personal issues and worries. The homes accident report book was viewed and was found to comply with the Data Protection Act 1998. The gas safety certificate and electrical safety report was viewed and found to be out of date. Fire safety equipment inspected was found to have been recently checked and in working order. Health and safety notices were in place throughout the home, offering guidance to staff. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 19 Radiator covers were in place throughout the home, and all hot water outlets are thermostatically controlled. Highfield DS0000023437.V268173.R01.S.doc Version 5.0 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 21 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 14/12/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Ensure consistency in the use of abbreviations when recording medicines, ensure all medicines entering or leaving the home are recorded, ensure all handwritten entries are countersigned, internal creams are to be stored away from external creams.) The registered person shall make 01/03/06 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm of abuse. Ensure all staff files contain all 01/02/06 detailed in schedule 2. Copies of valid electrical and gas 01/02/06 safety certificates to be forwarded to the commission. Requirement 2 OP18 13(6) 3 4 OP29 OP38 19 23 Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Highfield DS0000023437.V268173.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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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