Inspection on 14/01/08 for Highfield Grange

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Grange 16/01/07

Highfield Grange 27/07/06

Highfield Grange 29/11/05

Highfield Grange 29/04/05

Highfield Grange 04/01/05

Highfield Grange 19/05/04

Highfield Grange 09/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Highfield Grange John Street Wombwell Barnsley South Yorkshire S73 8LW Lead Inspector Sue Turner Key Unannounced Inspection 14th January 2008 09:15 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 Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Grange Address John Street Wombwell Barnsley South Yorkshire S73 8LW 01226 341123 01226 756 986 none None Barnsley PCT 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) Mrs Susan Christine Thickett Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The ten single bedrooms with a partition screen must be used as double bedrooms. The occupants of these double rooms must be given the option to move to single bedrooms when available. Flats 1, 2 & 5 must be used for intermediate care only. Flats 3 & 4 must be used for long-term care/short stay only. Staffing levels must be maintained at, at least, the minimum levels required by the April 2002 published `Residential Forum, Care Staffing in Care Homes for Older People` by 1/5/2003. These levels do not include managerial, nursing, administrative or ancillary hours, which must be over and above these levels. The area used for day care must be available for use by the home’s service users from 1600hrs to 0700hrs, Monday to Friday and at all times Saturdays and Sundays. The registered manager works 5 days (37 hours) per week as the registered manager. Three of the forty registered places can be used as either intermediate or short stay care for persons aged 55 - 65 years. 16th January 2007 5. 6. 7. Date of last inspection Brief Description of the Service: Highfield Grange is registered as a care home providing personal care and accommodation for 40 older people. Care at the home is provided on an intermediate basis. Barnsley Primary Care Trust owns the home. Accommodation is all on one level and divided into five flats. The home is registered for thirty single and five double bedrooms. A range of communal areas are provided. A commercial type kitchen and laundry serve the home and there are domestic type kitchenettes on each flat. Sufficient bathing facilities are provided. The home stands in its own grounds and has garden areas that were well maintained and accessible. There are car-parking facilities. Highfield Grange is close to Wombwell town centre. Main bus services run close to the home. Information about the home is available in the entrance hall to the home. A Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 5 service user guide is provided in each bedroom. The latest Commission for Social Care Inspection (CSCI) inspection report and the complaints procedure are also available in the entrance hall. There was no fee for intermediate care residents. Additional charges were made for hairdressing, private chiropody, toiletries, papers and magazines and manicures. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Sue Turner and Mike O’Neil, regulation inspectors. This site visit took place between the hours of 9:15 am and 3:45 pm. Susan Thickett is the registered manager and was present during the visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of this report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. We received six questionnaires from people using the service, two from relatives, two from staff and five from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to six staff, two relatives and eight people. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in January 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “The staff are lovely, please do not close the home, we need places like this”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 7 “The staff are brilliant, they do everything I ask”. “I can get anything I want here”. “The staff are so obliging”. “I can’t say anything bad about them”. Health professionals said: “Care staff are well liked by people and take time to chat with them and alleviate any worries they may have, making them feel at ease and comfortable in their surroundings”. “My clients have nothing but praise for the service”. “The home is clean and smells nice”. Relatives said: “My mother has spent five months at Highfield Grange. Throughout that time, I have been impressed with just how well she has been looked after”. “Highfield Grange houses a fair cross section of people. Staff do seem to meet peoples varying needs around age, disability and gender”. “The home maintains morale with common sense and a sense of humour”. “The home maintains standards of cleanliness in both the building and people”. The inspectors observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. Medication at the home was stored securely. Staff that administered medication confirmed that they had undertaken training in medication administration; to equip them with the skills needed to carry out the procedure safely. People said that they had a choice of food and that the quality of food served was “well cooked” and “enjoyable”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 8 People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe staying at the home. The home was clean and tidy and no unpleasant odours were noticeable. Agreed levels of staff were being maintained. A recruitment procedure was in operation to ensure the safety of people staying at the home. What has improved since the last inspection? People had been made aware of the homes terms and conditions. Information about these were seen in peoples files and in bedrooms. Where appropriate peoples care plans contained details of their needs in regard to their wishes on death and dying. Medication procedures had been reviewed and ‘tightened’ and therefore: • • • There were no gaps in the recording of medication. All information for medication requested was recorded. Medication was administered as prescribed. Where a resident refuses their medication, this was recorded and advice from the GP sought and recorded. The date medication was received into the home was recorded. The medication record provided clear information as to when medication received had been commenced. • • The menu board clearly displayed the alternatives/choices that were available at meal times. The complaints record included the investigation detail, outcome and any action taken as a result of the complaint. When double rooms were used as singles, extra furniture had been moved out of the room so that more space was made available. People said that the temperature in their bedrooms was ‘sufficient and ‘warm enough’. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 9 Staff recruitment records contained two written references, one from the last employer. Any gaps in employment history were recorded on the application forms. The financial records checked were accurate and correlated with withdrawals and deposits made. The temperature gauge on the bath was being checked regularly and the water provided at the outlet was at a safe temperature. 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. The summary of this inspection report can be made available in other formats on request. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 10 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 Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient information to inform people about their rights and choices. This information needs updating. Pre admission information ensured the home was able to meet peoples health, social and care needs. EVIDENCE: The homes had a Statement of Purpose and Service User Guide. These were available in the entrance hall for anyone visiting the home and in each person’s bedroom. They included useful information about the home and the services offered. They had not been updated since 2004 and some information was out of date. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 12 Information about the homes terms and conditions were seen on files. As the home only provided intermediate care there was no charge to the person. This information was highlighted in the files seen. Four out of six people who returned questionnaires said they had received a contract. One person said this was not applicable to them and the other didn’t reply. People were admitted to the home for intermediate care, often coming straight from hospital. Professionals and staff from the home assessed people’s needs on admission and throughout their stay. The aim of the home is for people to regain control of their lives and return home. Staff talked about the ways in which they supported people to regain their independent living skills. Evidence of this was seen in peoples care plans. Equipment was provided to promote mobility, continence and self-care. Relatives said: “My friend was taken on a home visit last week to see if she could manage”. “My sister is being taken home next week, to assess what help she will need when she can return home”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s plans of care did not contain all of the required information, which could result in people not being supported as needed or as they preferred. Medications were well managed, which ensured that people were protected from medication administration errors. People and their relatives were very complimentary about the way staff cared for them. EVIDENCE: Three peoples plans of care were seen. These contained information on aspects of personal, social and health care needs. The plans contained some good profile information, including records of medical treatment and risk assessments for falls, nutritional screening and moving and handling. On the whole information provided was easy to track. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 14 Peoples care needs were listed on generic care plans. The information on these was not specific to each individual. Some personal information had been added to these, but many could have been more person centred. In some cases the persons needs did not correlate with details in the care plans. People and staff said that GP’s, dentist, opticians and chiropodists visited the home as requested. Nurses, physiotherapists and occupational therapists were also available on site. Evidence of any professionals involvement in peoples care, was not recorded in care plans. Staff said that they recorded any health care visits in a diary. The inspectors spoke to the manager about the importance of recording, in people’s files, any health care visits or contacts and any changes made to people’s care following these. Relatives said: “The staff are very willing to answer any questions we have about our sisters care”. “Each time I come people look like they’re being well cared for”. People said: “Staff are more than OK they are excellent”. “The physiotherapist has given me some exercises to do and staff remind me to do them”. The AQAA stated that a full medication audit had been carried out at the home. Procedures for the ordering, administering and disposal of medications had been tightened. New medication cards, ordering and receipt books were in place. Medication checked at the site visit was stored securely. All medications administered had been signed for. Staff said that they had undertaken training, which gave them the competencies to administer medications. Staff said that, if appropriate, people were enabled to maintain control of their medication, with self-administration risk assessments in place. Staff spoken to were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Five professionals were asked if the service respected people’s privacy and dignity. Three answered “always” and two said “usually”. One professional said: “The home deals with all people as individuals and with respect and dignity”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 15 People said that they felt well cared for, staff treated them with respect and they were able to spend time in their room if they wished. A relative said: “Highfield Grange is a very friendly place, the staff treat people with respect and dignity”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. Activities on offer promoted choice and maintained interests. Meals served were of a good quality and offered choice, which ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 17 The activities plan included games, light exercise and hair and beauty. On the day of the site visit, there was no planned activity, however staff were seen spending time with people on a one to one basis. Due to people’s primary need being able to go and live at home, this was time well spent and people benefited from this individual time and attention. On the day of the visit a lunch of pork steak, potatoes and vegetables and treacle sponge and custard for pudding was served. The meal was well presented and looked appetising. Special dietary needs were catered for. The ambience in the dining room was pleasant and relaxed. Tables were set nicely with matching cutlery and crockery, condiments and tablecloths. The dining room was spacious and airy. Staff were seen assisting people in a caring and supportive way. People said that the meals at the home were always of a high standard with plenty of choices available. When talking about the food people said such things as: “I’m happy with the food”. “They know what I don’t like and they don’t give it to me”. “I can’t grumble about the food”. “The meals are jolly good, I have no complaints”. Relatives said: “The food is excellent and very healthy”. “Drinks are only given at set times, I think drinks should be encouraged throughout the day, perhaps a jug made up that people have access to”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People and relatives said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint since the last inspection. The manager had responded to this and an outcome had been reached. We had not received Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 19 any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. Policies and procedures relating to Adult Protection were in place at the home and staff spoken to were aware of their responsibilities for reporting and responding to any potential abuse. Staff said they had undertaken training in adult protection, but for some this was several years ago and they had not had any updated or refresher training. Ancillary staff said that they hadn’t had adult safeguarding training. The inspectors believe that they should be included in this training as they do have daily contact with people who stay at the home. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained, clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home was clean and tidy. Staff should be commended for the extremely fresh smelling environment. A rolling programme of refurbishment and redecoration was in place. This ensured that the home was aesthetically pleasing and free from hazards. Lounge and dining areas were domestically furnished. Pictures, cushions, ornaments and flowers enhanced the homely feel. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 21 Each flat had an enclosed garden area. The gardens looked well maintained and people said, weather permitting they enjoyed walking and sitting in the gardens. Bedrooms checked were comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. Controls of infection procedures were in place. Staff were observed using protective aprons, hats and gloves. Laundry facilities were sited so that soiled clothing was not carried through food preparation or food storage areas. In the flats coats and handbags were seen on the chairs around the kitchenette table. Staff said that they were their belongings. This area was used as a dining area at teatime. Staff were provided with separate facilities. Staff’s belongings made the room look untidy and introduced a risk of cross infection. One relative said: “The day room should have a board with the date and day etc, which would help people”. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers and recruitment procedures promoted the protection of people. Newly employed staff had completed induction training, however some staff required refresher and specialist training to ensure their skills were kept up to date. EVIDENCE: People and relatives spoke highly of the staff team and questionnaires returned identified staff always listened and acted on what people said. People said that staff were “always” or “usually” available when needed. Good relationships between staff and people were evident. People said that they were satisfied with the level of care they received and that staff knew how to care for them. Observation of staff responding to assistance as required was good. Relatives said: Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 23 “During my frequent visits, I’ve noticed that staff seem to deal competently with just about anything that happens”. “All the staff work as a team, it seems to be a very close knit team and everyone is concerned about peoples welfare”. “Some staff are not able to deal with the mental health difficulties that my mother has”. Three records of employment were checked. These included information including interview assessment, verification of identity, references, health checks and evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Application forms fully recorded previous employment. One file didn’t include a photograph and the two other files had very poor quality copies of photographs. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended. For some staff updated and refresher training in mandatory topics, for example, Moving and Handling, Adult Protection and Fire was necessary. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were due to commence this training shortly. It was positive to note that domestic staff had also completed NVQ training. Staff interviewed said that when they started work they received induction training in the first two months of their employment. One staff file checked identified that the member of staff had received induction training when they commenced work. Staffs training records were kept individually. The inspectors asked to look at three training records. For one person a training record could not be found. The others seen contained some certificates, but little information was found for updated training and courses. When asked how they knew which staff needed what training, the officer in charge said they relied on the staff member to tell them. Some staff spoken to were unable to remember which courses they had completed. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s approach benefited people and staff. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. People’s health and safety had been put at risk, in some areas. EVIDENCE: The manager had many years experience within the caring profession. She had commenced her NVQ Level 4 in Management and Care. . She was committed Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 25 to ensuring that people staying in the home were consistently well cared for, safe and happy. People spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The manager and provider had ways in which to check out the quality of the service that they were providing. Regular staff meetings were arranged. Management audits for health and safety, the kitchen, cleaning, record keeping and medication were completed. The responsible individual visited the home on a regular basis, a report was written following the visits and any identified actions taken. The home carried out yearly satisfaction surveys, copies of these were on display and comments had been acted upon. People were able to maintain control over their finances if they wished and had the capacity to do so. The home handled money on behalf of others. This was checked for three people. Account sheets were kept. Staff signed any deposits made and people signed when they made withdrawals. Monies kept balanced with what was recorded on the account sheet. Discussions with staff confirmed they were aware they should have supervision although this had not taken place. Equipment at the home was serviced and maintained. The manager confirmed that the maintence person checked the fire system each week. However this was not always recorded in the fire log. Staff said they had undertaken fire drills and practices; again these were not always recorded. Fire records were very inconsistent. It was difficult to establish who had received fire training and/or if there were gaps in staff fire training. The fire risk assessment had not been reviewed since January 2004. The document stated that it must be completed again in January 2005. This was highlighted at the previous inspection but no further action had been taken. Following the site visit the manager promptly confirmed that the fire risk assessment had been updated and issues highlighted were being actioned. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 26 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 2 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 27 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. 2. Standard OP1 OP7 Regulation 6 15 Requirement The Statement of Purpose and Service User Guide must be updated. The action to be taken by care staff documented in the plan of care must be specific to each person’s specific health, personal and social care needs and individual choices and preferences. (Previous timescale of 31/03/07 not met). The individual plan of care must contain clear information of all medical appointments attended or requested, together with the outcome of the result of that visit. (Previous timescale of 31/03/07 not met). To ensure that people are safeguarded from any form of abuse all staff must receive updated/refresher training in Adult Protection. Staff files must include a recent photograph. All staff must be provided with the relevant specialist and DS0000038647.V355757.R01.S.doc Timescale for action 01/03/08 31/03/08 3. OP8 15 31/03/08 4. OP18 18 31/03/08 5. 6. OP29 OP30 19 (1) (b) (i) 18 31/03/08 31/03/08 Highfield Grange Version 5.2 Page 28 7. 8. OP30 OP38 17 (2) 17 mandatory training for the role they are to perform. Up to date staff training records must be kept at the home. To ensure that people’s health and safety is maintained, fire records must be accurate and up to date. 31/03/08 14/01/08 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. Refer to Standard OP26 OP36 Good Practice Recommendations Staff’s coats, handbags and personal belongings should not be kept in the flats. Supervision should take place at intervals recommended by standard 36. Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Highfield Grange DS0000038647.V355757.R01.S.doc Version 5.2 Page 30 - 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. 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