Inspection on 29/11/05 for Highfield Grange

This inspection was carried out on 29th November 2005.

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 27/07/06

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 29th November 2005 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.V268586.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 Grange DS0000038647.V268586.R01.S.doc Version 5.0 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) 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.V268586.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 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 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 April 2005 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Highfield Grange provides personal care and accommodation for 40 older people. Sixteen of those places are registered for long and short stay residents and twenty four for intermediate care, however, the philosophy of the home is now such that all admissions are for intermediate or short stay residents. The home is all on one level and is registered for thirty single and five double bedrooms. The home stands in its own grounds and has a garden area that is accessible to residents. There are car-parking facilities. The home is close to Wombwell town centre. Main bus services run close to the home. The homes registered provider is Barnsley Primary Care Trust. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six and a half hours from 9:00 to 15:30. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, advocates, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to six of the staff on duty about their knowledge, skills and experiences of working at the home, three of the twenty nine residents about their views on aspects of living at the home and three advocates. What the service does well: What has improved since the last inspection? The homes statement of purpose had been reviewed to describe more accurately the services and facilities provided. The complaints procedure now contained details of the regulatory body to enable residents and/or their advocates to make a complaint directly through them should they wish. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highfield Grange DS0000038647.V268586.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 Grange DS0000038647.V268586.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): The outcome for standard 1, 2 and 5 were inspected. The statement of purpose/service user guide provided information for residents about the home. All residents had details of the terms and conditions of their stay, but this did not always contain the fee to be paid. The majority of residents in the home were part of an intermediate care service and this did not facilitate residents being able to visit the home prior to admission. Admissions for long term stays were no longer facilitated. Residents who were admitted to the home for intermediate care were helped to maximise their independence and return home. EVIDENCE: The statement of purpose/service user guide had been amended to provide a clear description of the double bedrooms provided and that they are not first and foremost single rooms. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 9 All residents had been provided with the terms and conditions of their stay, but the cost of their stay continued to not be identified. The reason for this, described in previous inspections was the financial assessment, completed by the local authority to determine the fee, had not been calculated before their stay. The nature of the intermediate care service did not facilitate residents being able to visit the home prior to admission. Admissions for long term stays were no longer facilitated. Short stay and respite residents also had not visited the home prior to their admission, but those spoken with had been at the home before. Highfield Grange DS0000038647.V268586.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): The outcomes for standards 7, 8 and 9 were inspected. Residents had an individual plan of care that identified health and personal care needs, but omissions and lack of detail were evident. Residents had good access to health care services, which met their assessed needs. There were residents responsible for their own medication, but this was insecurely stored. The recording and monitoring of supplement drinks prescribed and administered was poor. EVIDENCE: Three care plans were inspected on a sample basis. The files for residents who had stayed at the home before on short stay and/or respite basis did not clearly identify the readmission dates and that there had been a break and/or change in the service provided. This made information difficult to track. The files contained some comprehensive information but there were omissions and some information lacked detail, namely, residents wishes in case of death, discharge plans not completed for those being discharged home from intermediate care and dietary needs of residents not clearly identified on the care plan. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 11 The detail in the plan was supported by associated documentation including risk assessments. Discussions with staff identified a training programme had been implemented for record keeping requirements. Discussions with residents, observations and inspection of residents’ care plans demonstrated residents had appointments with a range of healthcare professionals. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. Risk assessments were in place for those resident’s who self-administered their medication, but this did not include the storage of that medication and this was found to be insecurely stored. Three residents’ medication records were inspected on a sample basis. Records of medication received into the home were handwritten and were not countersigned. Supplement drinks were not recorded as medication even though discussions with the assistant resource centre manager (ARCM) confirmed they should be. Staff had received medication training. It was positive to note that some care staff that were not responsible for medication had also received training to improve their knowledge base when caring for residents’. Highfield Grange DS0000038647.V268586.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): The outcomes for standards 12, 13 and 14 were inspected. Residents on the whole were generally happy with their lifestyle within the home. The daily routines within the home were flexible and promoted resident choice and decision making where possible. Residents were encouraged to maintain contact with their family, friends and the local community as they wished. EVIDENCE: 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. There had been an improvement in the activities provided for residents to promote stimulation. There was a pleasant enclosed garden area, which was popular when the weather was warm. Residents confirmed that they maintained good links with their family and friends and that they could visit “at anytime”. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 13 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 and 18 were inspected. The complaints procedure was clear and accessible. Complaints made by residents and/or their advocates were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure and all staff had received adult protection training. 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. The majority of residents were satisfied with the care provided. One resident raised a concern during the inspection and this was dealt with to the satisfaction of the resident. There was an adult protection policy and procedure that promoted the protection of residents from harm or abuse. 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.V268586.R01.S.doc Version 5.0 Page 14 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 outcome for standard 25 was inspected. For the most part the environment provided a safe place for residents to live. EVIDENCE: Water temperatures were being recorded. Care must be taken that all bathrooms have their water temperatures monitored. Water temperatures were checked on a sample basis and found to be satisfactory. The home had appropriate sluicing facilities, but one of these was found unlocked which presented a risk to residents’ safety. Discussions with staff identified not all staff had a master key to lock the sluice room door. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 were inspected. The transfer of a resident from one flat to another during the inspection facilitated the needs of residents being met by the number and skills of staff. The recruitment files did not demonstrate the recruitment process was sufficiently comprehensive in order to ensure the protection of residents. There was a comprehensive staff training programme in place to equip staff with the knowledge and skills to complete their role in a competent manner and meet the needs of the residents’. EVIDENCE: All but one resident and all advocates spoken with spoke highly of the staff team and described them as “first class”, “brilliant” and “there is nothing they could do better”. It was identified during the inspection one resident was accommodated on flat 5. This meant the resident was isolated, vulnerable and left unsupervised for long periods of time. In addition the lounge and dining area on the flat were locked, resulting in facilities being unavailable for the resident without moving to another flat some distance away. Discussions with staff and the manager identified this was because there was insufficient staff to provide care on the flat. In agreement with the resident and to the resident’s satisfaction the resident was transferred to another flat enabling them and all other residents’ to be appropriately cared for and supervised. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 16 Discussions with staff identified staffing on the four other flats had improved since the last inspection and that they now felt they had time to provide a quality service. What became apparent in discussions with staff was the lack of buzzers and master keys. Only three buzzers were available for all staff and they said at times this resulted in a delay with assistance for a resident. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included record keeping, protection of vulnerable adults, health and safety, moving and handling, fire, first aid, food hygiene, infection control, NVQs, medication. The manager provided information to confirm determine that fifty three per cent of care staff had achieved their NVQ level 2 in Care or equivalent. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 17 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 outcomes for standards 31, 33, 35, 36, 37 and 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 were in place to safeguard residents’ financial interests. Staff were receiving supervision albeit not at the intervals recommended by the standard. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The safety and welfare of residents’ were not wholly promoted and safeguarded, as comprehensive recruitment practices were not in place, medication that was self-administered was insecurely stored and a sluice room door had been left unlocked. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 18 EVIDENCE: The atmosphere in the home was one of openness and respect for residents. The quality assurance system at the home was haphazard. A comments/suggestions box and resident questionnaires were available in the entrance to the home, but the manager said there was rarely a response. Other quality systems were in place but not one that asked those who received the service what they thought about the quality of service provided. Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. The financial records of two residents’ were inspected. Written records of all transactions were maintained with a receipting mechanism and signatures of two persons. 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. A sample of the records that the home was required to keep were inspected. These have been commented upon throughout the report and where necessary requirements made. Records were securely stored. The home had a health and safety policy. Safety posters were on display. When the building was inspected no fire exits were blocked. The fire alarm, emergency lighting and fire fighting equipment were checked at the appropriate intervals. Fire training and/or drills for staff were in place. Servicing of gas and electrical systems and equipment were in place. Risk assessments were in place for the risk of legionella and water temperatures were checked and a record maintained. Notifiable incidents were being reported as required by the regulations. Also please see outcome for standard 9, medication practices, 25, environment and 29 recruitment practices. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 19 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 2 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 2 X STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 20 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 and social/leisure. Previous timescales of 31/03/05 and 30/06/05 not met. Care plans must contain sufficient detail including a discharge plan of care where appropriate and detailed dietary needs of the resident. All medication must be safely stored including the medication self administered by residents. Supplement drinks must be treated as medication and recorded and stored as such. Previous requirement of 30/06/05 not met. All sluice rooms doors must remain locked. Residents must only be admitted onto flats where facilities are available for them and they are appropriately supervised by staff. The manager must retain responsibility for the recruitment of all staff that commence work DS0000038647.V268586.R01.S.doc Timescale for action 28/02/06 2 OP7 15 28/02/06 3 4 OP9 OP38 OP9 13 13 28/02/06 28/02/06 5 6 OP25 OP38 OP27 13 12 & 18 28/02/06 29/11/05 7 OP29 19 28/02/06 Highfield Grange Version 5.0 Page 21 8 OP33 24 9 OP37 17 at the home and provide evidence that a thorough recruitment procedure has been followed in accordance with the requirements of the regulations. Previous timescales of 31/03/04, 31/12/04 & 31/03/05 not met. A system must be established 31/03/06 and maintained to review the quality of care provided including ensuring delegated tasks required by the regulation are met. Previous timescale of 31/12/04 and 31/08/05 not met. Records required by the 28/02/06 regulation must be kept up to date and accurate. 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 Refer to Standard OP2 OP7 OP37 OP36 Good Practice Recommendations Residents should know at the point of moving into the home the fee that is payable and by whom. The files of residents who are readmitted to the home as a result of short stay and respite placements should be clear and more organised. That supervision takes place at intervals recommended by the standard. Highfield Grange DS0000038647.V268586.R01.S.doc Version 5.0 Page 22 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. 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