Inspection on 27/07/06 for Highfield Grange

This inspection was carried out on 27th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Grange 14/01/08

Highfield Grange 16/01/07

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 Mrs Jayne White Unannounced Inspection 27th July 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highfield Grange Address John Street Wombwell Barnsley South Yorkshire S73 8LW 01226 341123 01226 756 986 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) None Barnsley PCT 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.V294503.R01.S.doc Version 5.1 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. 29th November 2005 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. Information received prior to this inspection identified there had been a change to the use of beds in flat five where residents on that flat and flat three are admitted for respite or short stay. The manager was informed a variation of registration needed submitting. Residents on flat one and two were admitted for intermediate care and residents on flat four were long term residents and those admitted for short stay and respite care. Barnsley Primary Care Trust owns the home. Accommodation is all on one level. There 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 DS0000038647.V294503.R01.S.doc Version 5.1 Page 5 Highfield Grange is close to Wombwell town centre. Main bus services run close to the home and the home is a short distance from the town centre. Information about the home is available in the entrance hall to the home and a service user guide is provided in each bedroom. The latest CSCI inspection report is also available in the entrance hall and the service user guide informs residents where this can be obtained. The pre-inspection questionnaire identified the full fee for permanent, respite and short stay residents was £315.00, however, this is based on a financial assessment completed by social services. The stay for residents on intermediate care is free. Additional charges were made for hairdressing, private chiropody, toiletries, papers and magazines. This information was supplied in the pre-inspection questionnaire compiled by the manager on 26 April 2006. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over eight and a quarter hours from 9:00 to 17:15. As part of the inspection process ten questionnaires were sent to residents, ten to relatives/advocates, five to GPs and six to social and health care professionals to obtain their opinions of the home. Residents returned six questionnaires, two questionnaires were returned by intermediate care assessors, four by GPs and seven by relatives and/or advocates of residents. On the day, opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, visitors and/or advocates, staff and the manager. Seven of the staff on duty were spoken with about their knowledge, skills and experiences of working at the home, together with eight of the twenty four residents about their views on aspects of living at the home and two advocates about their opinion of the home. Also taken into account was other information received by CSCI about the service since the last inspection. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspectors wish to thank the residents, staff and managers for their time and co-operation throughout the inspection process. What the service does well: The home had a warm and welcoming atmosphere and residents were comfortable to give their opinion of the service. The majority of residents that were spoken to said their needs were met and they were happy with the care offered to them. Residents’ and advocates general comments about the home included “really, really a lovely little place”, “peaceful”, “highly satisfied with care provided at Highfield Grange”, “ok here”, “well looked after”, “staff alright”, “quite happy” and “enjoyed my stay except for being ill for a couple of days”. The focus of the home was to admit residents’ for intermediate care, respite and short stays although there were residents that lived at the home on a permanent basis. The intermediate care provided residents with rehabilitation to enable them to return home and it was evident that this service worked well. Although residents did not visit the home to assess its facilities before admission one resident said “ I’d always heard good reports from people who have stayed at Highfield Grange, so I knew everything would be fine”. Residents were provided with access to health care services to promote and maintain their health care needs and comments included “always appropriate Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 7 care”, “if anyone needed the doctor, it was arranged, even the same day the doctor would call”, “nothing but praise for the staff, they were spot on. Always ready to help in every way, during the night, all the time”, “always receive assistance when I need it” and “they keep their eyes on you and ask all the time if you’re alright. Always so pleasant with everyone, always ready with a word of comfort if anyone felt a bit down or lonely”. One GP comment card that was returned identified the home as “one of the best home’s in the area”. The staff spoken with had a good knowledge of residents care needs and were able to demonstrate the services that the home provided. Residents were treated with respect and dignity and their right to privacy upheld. Discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Comments included “not bothered about participating in some social activities available”, “the staff always joined in activities. Were very good, keeping the limbs moving, different games etc, everyone seemed to get on well and enjoy their stay”. Residents were able to maintain contact with family and friends and members of the local community as they wished. Residents received a diet that satisfied their requirements in a pleasant dining area. Comments included “most people seemed to enjoy the meals, they were nicely presented, good choice. The cooking side was very good and I would recommend it. All praise to the chefs” and “food good – home baking brilliant”, “good meals and choice – four or five choices at tea”. The building and its environment was on the whole clean and well-maintained. Staffing hours calculated using the residential staffing forum calculation confirmed minimum staffing levels at the home were met. Systems in place to deal with monies/valuables held by the home on behalf of residents’ were comprehensive and safeguarded residents’ interests. What has improved since the last inspection? The manager had introduced a pro-forma to complement the terms and conditions that informed the resident how their fee would be calculated as this is not readily available when the resident moves into the home. All sluice room doors were locked which ensured residents safety was maintained. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 8 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. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 9 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.V294503.R01.S.doc Version 5.1 Page 10 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): The outcomes for standards 2, 3 & 6 were inspected. All residents had details of the terms and conditions of their stay. The majority of residents in the home were part of an intermediate care, short stay and respite service. Residents on short stay or respite service did not have an assessment for each admission although details within the previous care plan were now reviewed. An intermediate care assessor completed a basic assessment of need for those residents requiring intermediate care. Both processes did not facilitate residents being able to visit the home or a manager visiting the resident prior to their admission. Admissions for long term stays were no longer facilitated. Residents’ admitted solely for intermediate care were provided with the appropriate facilities to maximise their independence and return home. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three residents case files were inspected for a contract/terms and conditions of their stay. All residents had been provided with the terms and conditions of their stay. The manager had introduced a pro-forma to give residents some information on how their fee will be calculated. It was discussed with the manager to include the minimum and maximum fee they may be charged. One resident who was spoken with was clear on what they had to pay by using a voucher system. The philosophy of the home was in the main to admit residents who needed rehabilitation so they could return home and respite and short stay residents. The nature of the intermediate care service is process driven and does not facilitate residents being able to visit the home prior to admission. The admission procedure for those residents admitted for intermediate care was that the intermediate care assessor would complete a basic contact assessment. Admissions for long term stays were no longer facilitated. Short stay and respite residents did also not visit the home prior to their admission, but those spoken with had been at the home before. Four of the six questionnaires identified residents were asked if they wanted to move to the home and all questionnaires said they received enough information about the home before they moved in to decide if it was the right place for them. One comment on a questionnaire was “always heard good reports from people who have stayed at Highfield Grange, so I knew everything would be fine”. Intermediate care was provided, which provided residents with short-term intensive rehabilitation to enable them to return home. Specialist health staff including nurses, physiotherapists and occupational therapists supported this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 12 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): The outcomes for standards 7, 8, 9 & 10 were inspected. Residents’ had an individual plan of care that in the main contained comprehensive details of resident’s health and personal care needs, but omissions and lack of detail were evident. Residents were provided with good access to health care services to promote and maintain their health care needs. There were residents responsible for their own medication, but residents were not protected by the procedures in place for the receipt, recording, storage and return of medicines. Residents were treated with respect and dignity and their right to privacy upheld. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 13 EVIDENCE: Three individual plans of care were inspected on a sample basis. Although residents admitted for short stay and respite care did not have an admission assessment completed every time they were admitted, the resident’s file demonstrated the plan of care was reviewed and updated on admission. The plans contained some good profile information, including records of medical treatment and risk assessments for moving and handling. Risk assessments for falls were not in place on those files inspected and on one the nutritional screening form had also not been completed. There continued to be omission of residents’ wishes in the case of death. Further care was needed to ensure there is no discrepancy of information, for example, the administration of supplement drinks and lack of information about where this is to be recorded resulting in it being recorded nowhere and no-one sure whether the resident had, had one that day although they thought they would have. In addition, although there had been intervention by a nurse for assistance with a pressure area and recorded in the district nursing notes for that resident, that the resident required assistance with a pressure area was not referred to in the plan of care. For permanent residents, although the care plan demonstrated information within it was updated, for example, removal of one aspect of care provided, it did not include action to take by carers that superseded it. Neither did the plan contain clear evidence all information was reviewed on a monthly basis. Further detail was needed to ensure comprehensive information was provided for care staff to follow a plan of care for a resident other than wash and dress. All residents spoken with were happy with the care provided and comments included “always appropriate care” and “if anyone needed the doctor, it was arranged, even the same day the doctor would call”. All residents’ questionnaires identified residents thought they received the support and care they needed together with any medical support they required. All questionnaires returned identified staff listened and acted on what residents had said and that staff were always or usually available when residents needed them. Additional comments included “nothing but praise for the staff, they were spot on. Always ready to help in every way, during the night, all the time”, “always receive assistance when I need it” and “they keep their eyes on you and ask all the time if you’re alright. Always so pleasant with everyone, always ready with a word of comfort if anyone felt a bit down or lonely”. One GP comment card that was returned identified the home as “one of the best home’s in the area”. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 14 It was positive to note residents were enabled to maintain control of their medication including monitoring their own blood sugars. Risk assessments were in place for those resident’s who self-administered their medication, but this did not identify in detail where that medication was to be stored and in one instance this was found to be insecurely stored, which may put other residents at risk. Prescribed supplement drinks were also found insecurely stored in refrigerators on one of the flats, which could affect other residents’ well-being if they mistook them as a carton of drink and drank them. Three residents’ medication records were inspected on a sample basis. A new recording system had been implemented. The recording of some medication was ambiguous with a number of possible explanations. The information to support this include, the amount of medication received on admission was recorded, however, the number of medicines administered prior to the recording of further medication received meant either further medication had been received and had not been recorded or the resident had been without medication, but the medication continued to be signed for as administered. There were a number of gaps in the medication record. The amount of medication returned when a resident was discharged was not recorded. The amount of prescribed supplement drinks were recorded when received but further administration was not, even though discussions with the assistant resource centre manager (ARCM) and manager confirmed they should be. All residents spoken with 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. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. There were areas where the privacy and dignity of residents was respected, for example, knocking on residents’ doors before entering and closing toilet doors when in use. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 15 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): The outcomes for standards 12, 13, 14 & 15 were inspected. Discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Residents were encouraged and assisted to maintain contact with their family, friends and the local community as they wished. Residents received a diet that satisfied their requirements in a pleasant dining area. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 16 EVIDENCE: Six questionnaires returned by residents identified five always thought there were activities arranged by the home that they could take part in, one sometimes. Additional comments included “not bothered about participating in some social activities available”, “the staff always joined in activities. Were very good, keeping the limbs moving, different games etc, everyone seemed to get on well and enjoy their stay”. Residents were observed to spend time in the lounges, whilst others chose to spend their time in the privacy of their bedroom. Discussions with residents demonstrated they spent their time in different ways, two said they’d played dominoes and ludo that morning and one said they liked knitting and reading in bed and watching Coronation Street. There was a pleasant enclosed garden area, which was popular with residents and their advocates on the day as the weather was hot. There was good interaction between residents and visitors with children and residents playing imaginary games together and a group of gentleman were observed in the entrance to the home reading the newspapers and listening to the radio. The manager had, had problems with the TV licence to ensure all residents could have a television in their room but was addressing this and she said it was expected that this should be facilitated in the next financial year. Residents confirmed that they maintained good links with their family and friends and that they could visit “at anytime”. Meal times were 8:30 for breakfast, 12 noon for lunch when the main meal of the day was served, 16:30 for tea and 19:30 for supper with some flexibility around these times. The menu for the day was displayed in the dining room. All questionnaires identified residents enjoyed their meals at the home. Additional comments included “most people seemed to enjoy the meals, they were nicely presented, good choice. The cooking side was very good and I would recommend it. All praise to the chefs” and “food good – home baking brilliant”, “good meals and choice – four or five choices at tea”. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 17 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): The outcomes for standards 16 & 18 were inspected. Residents were confident their complaints would be listened to and acted upon, however, the complaints procedure did not contain the name, address and telephone number of the Commission for Social care Inspection. There was an adult protection procedure and all staff had received adult protection training. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 18 EVIDENCE: The complaints procedure ensured that residents and/or their advocates were aware of how to make a complaint and who would deal with them. All questionnaires identified residents knew who to speak to if they weren’t happy and how to make a complaint. Additional comments included “there was always somebody available, who would listen and if possible would put things right” and “if there was anything to complain of I would inform my neighbour next time she visited”. All residents spoken with said they were satisfied with the care provided and had no complaints. One advocate commented “I am not a frequent visitor but have no reason for concern on my visits”. The provider dataset identified no complaints had been made, however, one complaint had been made to the home since the provider dataset had been submitted. The detail had been passed on to the responsible individual but it was discussed with the manager that information at the home needed to demonstrate the investigation methodology, the outcome, any action taken as a result of the complaint and the dates the complainant was responded to. There was an adult protection policy and procedure that promoted the protection of residents from harm or abuse, but some staff that had been recruited had not been checked against the protection of vulnerable adults register (see staffing section). Staff confirmed that they had attended adult protection training, which enabled them to identify and report any allegations or incidents of abuse to residents. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 19 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): The outcomes for standards 19, 25 & 26 were inspected. The building and its environment was on the whole clean and well-maintained, but the use and layout of the double rooms need addressing to ensure they meet residents’ needs. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 20 EVIDENCE: Residents’ that were spoken with said they thought the home was comfortable and were pleased with their living environment. The home was clean and tidy, which promoted a comfortable and homely environment. The home was decorated in a comfortable and welcoming manner, including homely touches of pictures and ornaments. Furnishings and furniture were of a good standard. One room had an unpleasant odour and this was reported to the manager to address. One resident comment card also indicated “some rooms and passages could be a little fresher (aroma wise). Of the questionnaires returned five always thought the home was fresh and clean, one usually. Residents had access to all indoor and outdoor facilities. There is a condition of registration that the ten single bedrooms with a partition screen must be used as double bedrooms. Discussion with one resident, staff and observation of the rooms registered identified the layout was still for two single rooms with only the partition screen pulled back making the difference of a double room. This meant the layout of the rooms was not suitable for those residents occupying them on a single basis because of their needs. One resident commented “I’m no better off than in a single room because I don’t go in the other half” and staff said using the hoist was still difficult in those rooms because of the furniture still in them. Laundry facilities were sited away from food preparation areas. Discussions with laundry staff confirmed the laundry system on the whole works well with each flats laundry being washed separately. Both the laundress and care staff were able to describe systems that were in place to control the spread of infection. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 21 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): The outcomes for standards 27, 28, 29 & 30 were inspected. Staffing hours met that identified by the residential staffing forum for older people. This is a condition of registration. The recruitment files did not demonstrate the recruitment process was sufficiently comprehensive in order to ensure the protection of residents. Staff were trained to equip them with the knowledge and skills for their roles within the home, to enable them to care for residents in a safe way, however, improvements are required with the administration of medication. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 22 EVIDENCE: The majority of residents and advocates spoken with spoke highly of the staff team and comments included “can’t complain about any of the staff”, “amazed at staff compared to hospital – more time for you”, “lovely staff”, “most staff nice – some abrupt”, “very kind here – it’s the best thing about it – couldn’t do any better” and “staff alright”. All questionnaires returned identified staff listened and acted on what residents had said and that staff were always or usually available when residents needed them. Additional comments included “nothing but praise for the staff, they were spot on. Always ready to help in every way, during the night, all the time”, “always receive assistance when I need it” and “they keep their eyes on you and ask all the time if you’re alright. Always so pleasant with everyone, always ready with a word of comfort if anyone felt a bit down or lonely”. Good relationships between staff and residents were evident. Residents stated 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. The staffing forum provided to identify the total care hours to be provided for the week of the inspection calculated those hours as 797.72. The manager provided the total of care staff hours provided and this was 673. Sufficient ancillary staff were employed to ensure standards relating to food, meals and nutrition were fully met and the home on the whole was maintained in a clean and hygienic state. Subsequent to the inspection, the manager provided an amended staffing forum calculation that identified the original calculation provided was incorrectly calculated and the total care hours was in fact 527.49 hours. The inspector accepted this amendment as factually correct. A recruitment policy and procedure was in place but it did not sufficiently protect residents at the home. Correspondence had been sent to identify to the manager and her line manager what was required by the Care Home Regulations 2001 and National Minimum Standards for Older People. They submitted the PCT recruitment policy/procedure to demonstrate it met those requirements but inspection of the policy/procedure by the inspector identified it did not. This has lead to recruitment requirements not being met and this continues. One staff file was inspected and indicated a full employment history was not obtained, the memo supplied to state a CRB has been obtained and the person can commence employment does not include the date the CRB was issued, disclosure number or that a protection of vulnerable adults check had been requested. This does not demonstrate the CRB was issued before the member of staff commenced employment and that they are not listed on the protection of vulnerable adults register. The manager confirmed there were staff working where a protection of vulnerable adults check had not been requested and demonstrated this. The manager agrees to contact the human resources section to identify the action to be taken. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 23 Subsequent to the inspection the manager informed the CSCI all staff were to undergo another criminal records bureau check including a protection of vulnerable adults check. The manager was informed new staff cannot commence employment until a POVA first check has been requested and this can be demonstrated. Discussions with staff identified a training programme for staff was in place to enable them to meet the assessed and changing needs of residents, however, the staff files inspected did not demonstrate documentary evidence of the qualifications and training they had received. It was also noted that the training needed to be updated, as did some of the training of the four staff that were spoken with. The provider dataset identified training in the past 12 months has included fire, moving and handling, palliative care, NVQ Level 2 & 3 in Care, food hygiene, record keeping and first aid. Staff confirmed that they had attended various training courses that included health and safety, moving and handling, fire, emergency aid, food hygiene, infection control, MRSA, protection of vulnerable adults, dementia, violence and aggression, palliative care and NVQ 2 in Care. The provider dataset identified eighty per cent of care staff had achieved their NVQ level 2 in Care or equivalent and five staff hold a first aid certificate. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standards 31, 33, 35, 36 & 38 were inspected. The atmosphere in the home was one of openness and respect for residents. To formalise this process it is essential a quality assurance system be put in place that seeks the views of residents about the quality of the service provided. Systems in place to deal with monies/valuables held by the home on behalf of residents’ were comprehensive and safeguarded residents’ interests, however, inspection of the payment of fees and personal allowances could not be inspected as this was completed by the treasury department of Barnsley Metropolitan Borough Council. Staff were receiving supervision albeit not at the intervals recommended by the standard. The safety and welfare of residents’ were not wholly promoted and safeguarded, as comprehensive recruitment practices were not in place and the receipt, recording, storage and return of some medicines was poor. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 25 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The atmosphere in the home was one of openness and respect for residents. This was demonstrated by the fact that on the whole residents and relatives spoke highly of the management and staff team. Discussions with the manager demonstrated she cared about the residents and was familiar with their needs, but had not yet completed her NVQ Level 4 in Management and Care. The provider dataset identified training in the past 12 months has included NVQ Level 3 & 4 in Management. The quality assurance system at the home consisted mainly of management audits. Other quality systems were being introduced and included a record keeping and medication audit. The manager said a system to include residents in the quality assurance process and what they thought about the quality of service that was being provided was being introduced in October 2006. The line manager for the service did complete regulation 26 visits. Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. The companies treasury department dealt with all finances that related to the permanent residents. They acted as appointees for residents, gave the resident their personal allowance, banked monies of residents when required and maintained the records of those transactions. Monies held by the home for three residents were inspected. The procedure for dealing with any monies was very comprehensive and at least two signatures were obtained when money was exchanged with residents’ and/or their advocates. Written records and monies balanced. There was a secure facility for the safekeeping of monies and valuables on behalf of the resident. Discussions with staff confirmed they were receiving supervision, however, it was not at the recommended intervals identified in the standard. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 26 The home did have a health and safety policy. When the building was inspected no fire exits were blocked. Fire training and/or drills for staff were in place, however, the inspection of fire records identified three staff had not had fire training in the past six months and only one of those members of staff had been present on a fire drill, although it was noted that the names of staff present on all drills was not recorded. Hazardous products were safely stored. The provider dataset identified servicing was in place for the gas and electrical systems and equipment, as were water temperature checks for compliance with legionella. It was noted there had been 39 admissions to A & E but these had not been reported to the CSCI. Sluice room doors were noted to be locked at all times which maintained the safety of residents and there was sufficient equipment and aids and adaptations provided to meet the needs of the residents and good moving and handling techniques were observed, which maintained the safety of residents and staff. Also please see outcome for standard 9, medication practices and standard 29 recruitment practices. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 27 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 X 3 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 1 Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 28 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 OP7 Regulation 15 Requirement Care plans must contain details of residents’ care needs in regard to their wishes on death and dying. Previous timescales of 31/03/05, 30/06/05 & 28/02/06 not met. All care plans must contain a completed falls and nutritional risk assessment. All care plans must identify the intervention for pressure area care. All medication must be safely stored including the medication self administered by residents. Previous timescale of 28/02/06 not met. Supplement drinks must be treated as medication and recorded and stored as such. Previous requirement of 30/06/05 & 28/02/06 not met. All medication received in the home and returned to residents on discharge must be recorded. There must be no gaps in the recording of medication. DS0000038647.V294503.R01.S.doc Timescale for action 31/08/06 2. 3. 4. OP7 OP7 OP9 15 & 17 15 & 17 13 31/08/06 31/08/06 31/08/06 5. OP9 13 31/08/06 6. 7. OP9 OP9 13 & 17 13 & 17 31/08/06 31/08/06 Highfield Grange Version 5.1 Page 29 8. OP16 22 9. OP16 22 10. OP25 12, 13 & 23 11. OP29 19 12. OP29 19 13. OP29 19 14. 15. OP30 OP29 OP30 19 18 16. OP33 24 The complaints procedure must include the name, address and telephone number of the Commission. The complaints record must include the investigation detail, outcome, any action taken as a result of the complaint and include dates when the complainant has been responded to. The rooms registered in the conditions of registration, as double rooms must be used as such with furniture removed when being used on a single basis to meet residents’ needs. All staff employed at the home must have an enhanced level CRB check, including a POVA register request. Where an original and/or copy of a CRB clearance is not on file information on the file must demonstrate the date the CRB was issued, the disclosure number, the level of the check, that a POVA register check has been requested and is clear and the date this was undertaken if it was prior to the issuing of a full CRB. The staff files must demonstrate a full employment history including a satisfactory written explanation of any gaps in employment. The staff files must demonstrate documentary evidence of any qualifications and training. An audit must be undertaken of staff training and where that training needs updating arrange for those staff to undertake the training. A quality assurance system must be established and maintained to review the quality of care DS0000038647.V294503.R01.S.doc 31/08/06 31/08/06 31/08/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 Highfield Grange Version 5.1 Page 30 17. 18. 19. OP38 OP38 OP38 23 23 37 provided including stakeholders of the service. All staff must have fire training and undertake fire drills at the required intervals. The fire drill record must include the names of staff that were present on the drill. All notifiable incidents identified in the regulations must be reported to the CSCI. 31/08/06 31/08/06 31/08/06 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. Refer to Standard OP3 OP7 OP31 OP36 Good Practice Recommendations That an admission assessment is completed each time a resident is admitted for short stay or respite. That care plans for permanent residents demonstrate their care plans are reviewed on a monthly basis. That the manager obtains an NVQ Level 4 or equivalent in Management and Care. That supervision takes place at intervals recommended by the standard. Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Highfield Grange DS0000038647.V294503.R01.S.doc Version 5.1 Page 32 - 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!