Inspection on 07/06/06 for Highfield Hall

This inspection was carried out on 7th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfield Hall 01/12/08

Highfield Hall 10/06/08

Highfield Hall 30/04/07

Highfield Hall 30/01/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Highfield Hall Highfield Hall and Court Stafford Road Uttoxeter Staffordshire ST14 8QA Lead Inspector Jane Capron Key Unannounced Inspection 7 June 2006 9:00 Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 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 Hall DS0000065382.V299547.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 Adults 18-65. 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 Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Hall Address Highfield Hall and Court Stafford Road Uttoxeter Staffordshire ST14 8QA 01889 563780 01889 566902 info@moorcare.co.uk 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) Moorcourt Developments Limited Mr Lee John Bentley Care Home 21 Category(ies) of Learning disability (21), Physical disability (2) registration, with number of places Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Kingston View - Six beds - Learning Disability (LD) Abbey View - Six beds - Learning Disability (LD) Highfield Hall - Nine beds - Learning Disability (LD) and Two beds Physical Disability 30th January 2006 Date of last inspection Brief Description of the Service: Highfield Hall is a care home for residents with a learning disability. The accommodation is provided in three adjoining units that make up two sides of a courtyard that provides parking. Opposite the home are offices, the company’s training school and the activity centre used by the residents at Highfield Hall and Highfield Court, another home on the same site. The Hall itself provides accommodation for nine residents with a learning disability although two also have a physical disability. The home is on two levels with four bedrooms downstairs and five upstairs. The home has all single bedroom accommodation which are of a good size and all have ensuite facilities. The home has a lounge with attached dining area, a small industrial style kitchen and a laundry. The home has a vertical lift. The residents in the Hall have ranging abilities but a number have high dependency care needs. They all moved together from a home owned by the same company that was closing. Abbey View provides accommodation for six residents. The accommodation provides single bedrooms with ensuite facilities. The home has a large lounge, a domestic style kitchen with a dining room adjoining it. The residents assist in running the home undertaking a range of daily living tasks including assisting with meal preparation. Kingstone View provides accommodation for six residents with varying dependency levels but all need regular supervision and support to undertake tasks. The home provides single bedroom accommodation, a lounge and a domestic kitchen/dining area. Both Abbey View and Kingstone View have their own small laundry facilities. There are grassed areas to the rear of all the units and all units share the services of an activity staff member. The home has the use of a mini bus. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 5 The aim of all the units is to encourage residents to be as independent as possible and to provide them with a full and varied lifestyle. Each unit has its own staff but all staff may work in each unit from time to time. There is one senior that has responsible for all the units on each shift. The level of fees range between £489 and £1300 per week (May 2006). Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a two-day period lasting approximately eight hours. The inspection included spending time at all three units. The inspection included: • Discussions with a number of residents to ascertain what it was like for them living at the home. • Discussions with a number of care staff from all units. • Discussions with the Care Manager. • Examination of a range of support plans. • Inspection of the medication procedure and sampling of the medication administration for a number of residents. • Sampling of the financial management records. • Checking of the recruitment procedures • Examination of the training provided to staff. • Observation of staff supporting residents. • Examination of a sample of residents’ bedrooms and communal areas. • Examination of a range of documentation related to the running of the home including records of staff meetings, residents meetings and records relating to health and safety. What the service does well: All residents spoken to liked living in the home. Residents liked their bedrooms and felt their privacy was respected. Residents had made their bedrooms their own with a range of personal items including pictures and ornaments. The accommodation throughout was of a good standard. Externally the home had access to a very large grassed area and this was being well used for sitting out and for activities. Several residents stated that they enjoyed playing football outside and enjoyed sitting and eating outside. Residents’ participation was being promoted. The home sought the views of residents through resident meetings in each unit and through resident surveys. One resident had put together a list of items he wanted to raise at the next meeting. The staff and residents were in the process of putting together a newsletter and one resident had written a number of articles that were to be included in the newsletter. Comments included ‘we are very happy in our new home’. Residents participated in a range of household tasks, the level varied according to individual ability. These activities included vacuuming and cleaning their bedrooms, helping with meal preparation, making drinks, putting the menu together and going shopping. All residents were going on holiday and they stated that they had been involved in deciding where they wanted to go. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 7 The home was meeting the primary healthcare needs of the residents. Records showed and residents confirmed that they saw the GP when they felt ill, they attended for eye and dental check ups and received chiropody services. The home was effectively working in partnership with health care professionals. Residents said they liked the staff and observation showed that there were positive relationships between staff and residents and that each unit had a relaxed and friendly atmosphere. What has improved since the last inspection? What they could do better: Whilst the home had made improvements there remained some areas where action was needed to ensure the home met the necessary standards. The home needed to further develop into appropriate formats the information it provided. There continued to be gaps in the support plans and risk assessments, which could lead to staff not providing the necessary support to residents. The home also needed to ensure that its procedures for managing residents’ money showed a clear audit trail to ensure that residents were being fully protected. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 8 Alterations were needed to the medication procedures to include a homely remedy procedure and to ensure that there were no gaps in the medication administration records. The home also needed to ensure that procedures were in place to correctly administer controlled medication. Whilst the environment throughout was generally of a good standard the carpet in the hallway of the Hall needed to be either cleaned or replaced. This would improve the standard of the accommodation for the residents. Whilst training had improved there were areas that staff needed to have further knowledge in to improve the service to the residents. These areas included autism, communication, and challenging behaviour. 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 Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had provided adequate information for residents and relatives to make an informed choice to move to the home but information needed to be in a more user-friendly format. Whilst residents had been assessed by the local authority this information was not always made available to the home, which could have affected the ability of staff to meet the residents’ needs had the home not been aware of most of the residents previously. EVIDENCE: The home had developed a Statement of Purpose and a service users guide but these were not in a user-friendly format. Residents and relatives did however feel that they had the necessary information and had the opportunity to visit the home and be fully involved in their relative’s move to the home. All residents had been assessed prior to moving to the home but the local authority had not always provided the home with the necessary information. As most of the residents had been known to the staff previously this did not have the negative effect it could have. In most cases the staff knew the information needed to meet residents’ needs. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 11 Residents and/or relatives were able to visit the home beforehand to make an informed choice over whether to move there. A number of the residents had visited a number of times and had chosen their bedrooms and had been involved in choosing their decorations. All residents were provided with contracts that identified the service to be provided. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst in most cases the support plans covered the necessary areas there were some areas such as behavioural management plans that needed to be developed to enable staff to have the full knowledge to support the residents effectively. Residents benefited from having their choices promoted and being included in a range of activities related to the running of the home. Some aspects of the home’s risk assessments needed further development to ensure that residents were more fully protected and were not being subject to any unnecessary restrictions. EVIDENCE: A sample of care plans showed that they covered most of the necessary information to meet the residents’ needs but there was a need in some instances to further develop the information on specific communication needs and also to develop behaviour management plans where residents exhibited difficult and sometimes aggressive behaviour. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 13 The care plans were being reviewed. The home had begun to start planning to introduce person centred planning techniques. The home had a range of risk assessments in place but there were some omissions including use of wheelchairs, bathing and seizures. Risk assessments were generally up to date. The home was promoting choice and decision-making. Residents stated that they chose what to do and were involved in a range of household activities including shopping and meal preparation. In Abbey View residents were fully involved in menu planning and doing the household shopping. In both the Hall and Kingstone View the preferences of the residents were taken into consideration when planning meals. All the units had residents meetings and one resident in Abbey View showed a list of issues he had put together for the next meeting. The level of involvement of residents in managing their own finances depended on each resident’s ability. Those residents in Abbey View were more involved in deciding how to spend their money than other residents. Staff were able to describe how residents made choices over such issues as what they wanted to wear, food they liked and activities they wanted to do and when they wanted to go to bed. Residents stated that they could choose when to get up and go to bed and residents in Abbey View stated that they were fully involved in day to day activities and made choices over their daily lives. The home had a system in place to gain the views of residents as part of reviewing its quality of service. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a varied lifestyle that is based on their choices. The residents have the opportunity to take part in a range of activities both in and out of the home and regularly access the community. The home provides residents with a varied menu that is based around healthy living and the resident’s preferences. EVIDENCE: Residents were being provided with a varied lifestyle. Each unit tended to organise their own activities although there were some joint activities. The activities were based on residents’ choices and preferences. All residents had the opportunity to take part in trips out of the home and groups of residents had gone out on both days of the inspection. Trips included those for a number of residents and trips for one or two residents together. Residents accessed a range of community resources including going shopping, swimming and using the gym at the local leisure centre and going to the library. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 15 Residents went to the hairdresser and accessed the usual range of primary health care services- the optician, the dentist and the GP. Additional activities included going to the Gateway club, out for meals and to the pub. Several residents went horse riding. A number of residents went to college and it is hoped this can be expanded. Internal activities included watching TV and DVDs, bingo, drawing and painting, baking and outdoor games including football and other ball games. Some of the residents take part in gently exercise. The home has a dedicated activity staff member who provided specific activities for residents on a small group basis. All residents were going on holiday. Residents in Abbey View stated they were going to Wales in caravans. The residents pay for this themselves. The home has access to transport and residents pay towards this. The home’s routines vary from unit to unit although all routines were quite flexible whilst considering the needs of the residents. Residents stated that they get up when they want and go to bed when they want. All bedrooms were lockable and several residents chose to lock their bedrooms. All the units had a relaxed atmosphere and observation showed positive relationships between staff and residents. There was good interaction between staff and residents. Relatives reported that they felt involved and were welcomed when they visited the home. They reported that they could visit their relative in private. Residents were supported and encouraged to maintain relationships with relatives and friends and residents visited friends in other units and at the other home on the site. The arrangements for meals differed between units. In the Hall there was a cook who provided the meals and where there was a more formal menu. This provided a choice and was based on healthy eating and on residents’ preferences. There was however flexibility and residents quite often went out for meals and ate outside when the weather was good. Residents that needed assistance with meals were provided with it. Within Abbey View and Kingstone View the care staff cooked the meals and with residents did the weekly food shopping. Residents were involved in aspects of meal preparation including laying and clearing the table, washing up. Residents were involved in menu planning. Meals were varied and were based on residents’ choice and preferences. Fresh fruit was available in all units. Within all units residents weight was being monitored and advice sought if where were concerns over weight gains or losses. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was meeting the health care needs of the residents but there were certain aspects of the medication procedures and practices that needed to be addressed to be sure that the residents’ medication needs were being met. EVIDENCE: The home had identified the personal care and health needs of the residents. The home was meeting the personal care needs of the residents. Residents were suitable dressed for the weather. Residents stated that the staff gave them the help they needed. Residents had a key worker and those spoken to were aware of the identity of their key worker. Observation showed that residents were receiving hair and nail care. Records showed residents were having eye and dental checks and that weight was being monitored. Discussions with health care professionals showed that the home was liaising effectively with them and were following up on issues discussed. Residents were receiving support from specialist health care staff including psychiatrists, OT and speech and language therapists. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 17 The home was storing medication appropriately and was receiving three monthly checks by the pharmacist. The home was in the main administering medication correctly but there were gaps on the records for one day and it did not have a controlled medication record in place. The home did provide residents with homely remedies but did not have a procedure in place for this. All staff administering medication had received training. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems in place to gain the views of residents and residents felt their views were listened to and acted upon. The home’s procedures and the staff training in adult protection had increased the protection for the residents. However the home needed to ensure that its method for recording residents’ finances provided a clearer audit trail. EVIDENCE: The home had a complaints procedure and this was known to residents and relatives. The procedure was on display and was in a pictorial form. The home had not received any complaints. The home was aware of the local advocacy service. In addition to the complaints procedure the home had resident meetings and questionnaires to gain the views of residents and relatives. The home had a procedure for the protection of the residents. All staff had received training in adult protection and staff were aware of the signs and symptoms that could indicate abuse. Staff were aware of the home’s procedure. The home had systems in place to record residents’ expenditure but this system needed to provide a clearer audit trail. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,38,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with good quality accommodation both internally and externally. The home was clean and tidy throughout and procedures were in place to control the spread of infection. EVIDENCE: The home was providing a good standard of accommodation in all units. The home was being well maintained. All units were suitably furnished in a domestic style although the carpet in the Hall needed cleaning or replacing. All units had lounge and dining room facilities. Bath and shower facilities were provided in each unit. The bathrooms in Kingstone had been upgraded since the last inspection. The bathroom in the Hall was suitable for residents that needed equipment to aid with bathing. Residents were keen to show their rooms and were clearly proud of them. There were of a satisfactory size with some bedrooms in the Hall being very large. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 20 All bedrooms had a window providing a view with many having a view over the rear wooded and grassed area. Nineteen of the bedrooms had ensuite facilities. Bedrooms had been well personalised with many having their own furniture. Bedrooms showed the individual personalities and interests of the occupant. All bedrooms had adequate storage facilities with some having excellent facilities i.e. two wardrobes and several chairs. All bedrooms were lockable. The home had good external space at the rear, backing onto a very large grasses and wooded area. Each unit had a seating area outside. The external area was well used in good weather with residents eating outside and using the area to play football and other games. Each unit was clean and tidy. The Hall had domestic staff support for cleaning and these staff were in the process of taking a NVQ qualification. In the other units the care staff with residents undertook the cleaning tasks. The domestic staff of the Hall had oversight of the standards within the other units. The home had cleaning schedules in place and staff received some infection control information as part of their induction. Each unit had laundry facility and these were suitable to meet the laundry needs of the residents. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided suitable staffing levels and the increase in training was enabling staff to be more effective in meeting the needs of the residents. The staff had a positive attitude and had developed good relationships with the residents. The home’s recruitment procedure was protecting the residents. EVIDENCE: The home had adequate staffing levels to meet the needs of the residents. Each unit had dedicated staffing although on occasions there was some working between units. At the Hall there were three care staff on duty throughout the day and two waking night staff. At Abbey View there were two care staff throughout the day and one waking night staff. At Kingstone View there were three care staff on duty throughout the day and one waking night staff member. One of the staff during the day was specifically to support one resident. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 22 The Hall always had a senior staff member on duty and that staff member had responsibility to provide support and oversight of the other units. In addition, the home had a fulltime activity staff member who worked with individuals and small groups throughout the week and supported residents to go on trips and to the Gateway Club. The home had used a high number of agency staff but this level had reduced as staff had been recruited and existing staff had picked up extra hours. It was noted however that some staff had been working excessive hours and this would affect their effectiveness to undertake their role and could leave the home with problems when these staff take leave or are unwell. The home needs to address this issue. Staff spoken to were well motivated and were fully aware of the individual needs of the residents. Residents and staff were observed to have positive relationships. The home had effective recruitment and selection procedures. Examination of a sample of personnel files showed two references were sought and that CRB checks had been completed. Staff were provided with a contract, job description and a copy of the General Social Care Council Code of Practice. Staff were provided with support. A system of supervision had been started and staff meetings for day and night staff were being held. The home’s training school was providing good support. Staff members had individual training files and the level of training had improved. Four staff had completed NVQ 2 and a further seven were in the process of doing the qualification. Five more were due to start in the near future. All staff had completed adult protection training; training in epilepsy and all new staff undertook induction training. All senior staff had completed training in medication. A number of staff had received some training in autism and this had led to an improvement in the service provided to one resident. There are still areas of training required to develop the service including challenging behaviour, makaton, person centred planning and further training in autism. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were benefiting from a home that was well led and where the manager had an open management style seeking the views of residents and staff. The home had systems in place to review the service provided to residents in order look at ways to further develop the service for residents. The home was providing a safe environment for residents and staff. The home was well supported by the external management systems put in place by the company. EVIDENCE: The manager had the necessary background and knowledge to manage the home. He was in the process of completing NVQ level 4 in care and management. He had undertaken training to ensure his knowledge was being kept up to date. He was well respected by staff and residents spoke positively about him. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 24 Staff found he had an open style of management and was always available to listen to their views. They felt he consulted with them and did not implement practices without discussion. Observation showed him to have a relaxed and friendly manner with residents and was fully aware of their needs. The home has several systems in place to assess the quality of the service. Surveys had been completed of residents and relatives as well as external agencies involved with the home. These contained positive comments. The home also has regular checks from the catering manager and the Responsible Individual. There was still scope for further development. The home has health and safety procedures in place and rsi kassessments for safe working practices. Staff have received the necessary training in food hygiene, health and safety, fire and moving and handling. Infection control training is planned for the near future. Checks on the fire records showed that the necessary checks were being undertaken. The home had the support of good external management that was located on the site. There were systems in place for financial budgeting and control, human resource planning and general support for the manager. The home had the necessary insurance cover in place. Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 3 Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement To ensure that support plans cover all the necessary areas in full including behavioural management plans and communication. To complete risk assessments in respect of activities in which residents engage e.g. bathing (Previous timescale not met) To investigate the possibility of more residents being involved in educational and fulfilling activities. (Previous timescale not met) To ensure that the home has an effective procedure for the administration of medication including controlled drugs. To ensure that the home develops a homely remedies policy To ensure that the records of residents’ finances provide a clearly audit trail. To clean or replace the carpet in DS0000065382.V299547.R01.S.doc Timescale for action 01/09/06 2. YA9 13(4)(b) 10/07/06 3. YA12 16(2)(n) 01/09/06 4. YA20 13(2) 19/06/06 5. 6. YA20 YA23 13(2) 13(6) 01/07/06 01/08/06 7. YA24 16(2) 01/09/06 Page 27 Highfield Hall Version 5.2 the hallway of the Hall. 8. YA33 18 To ensure that staff do not work 01/07/06 excessive hours that could affect their ability to effective undertake their role. To put plans in place to provide 01/09/06 the necessary training for staff to effectively undertake their role including makaton, challenging behaviour, and autism. 9. YA32 18(1)(a) 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 YA1 YA8 Good Practice Recommendations To develop information in a user-friendly format. To look at methods of increased decision making and participation of residents including those with specialist communication needs. To provide staff with training in person centred planning. To assess whether residents would be able to mange a front door key. 3. 4. YA32 YA16 Highfield Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Hall DS0000065382.V299547.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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