Inspection on 24/01/09 for Highfield House

This inspection was carried out on 24th January 2009.

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

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfield House 25/02/08

Highfield House 26/04/06

Highfield House 15/12/05

Highfield House 22/04/05

Highfield House 07/09/04

Highfield House 05/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Highfield House London Road Stroud Glos GL5 2AJ Lead Inspector Ms Lynne Bennett Unannounced Inspection 24 and 26 January 2009 10:00 th th Highfield House DS0000016465.V373131.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 House DS0000016465.V373131.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 House DS0000016465.V373131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield House Address London Road Stroud Glos GL5 2AJ 01453 758618 01453 767911 stroudcarehomes@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stroud Care Services Limited Nicola Carlill Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/02/08 Brief Description of the Service: Highfield House is a detached house with accommodation for seven adults with a learning disability who may display behaviour that challenges the service as well as people diagnosed with mental health concerns. The home is situated close to the centre of Stroud and residents are able to access public transport easily. They also have access to an estate car. Highfield House is one of three homes owned and managed by Stroud Care Services. The home is staffed 24 hours a day, seven days a week. People living there have single rooms with en suite facilities and access to a lounge and a kitchen/diner. There are substantial gardens which are tiered to the rear of the home, although at the time of the visit these were out of use due to the building of new flats. Fees range from £1,100 to £2,200. Each person is given a personal copy of the Statement of Purpose and Service User Guide. Further copies of these documents are available from the office in the home. The last inspection report is also kept in the office. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place in January 2009 and included two visits to the home on the 24th and 26th January by one inspector. The registered manager was present during the second visit. She had completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing some information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). All people living in the home were met and two discussed their care plans and other records with us. Surveys had been returned from six members of staff, three of whom were spoken with during the visits. We (The Commission for Social Care Inspection) talked to three people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these three people. This is called case tracking. Other records looked at included staff files, quality assurance records and health and safety systems. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: People said they were happy with their rooms and the en suite facilities. People living in the home said that they liked going to the pub, shops and cinema. One person had a job helping out at a local charity shop. Staff were observed interacting positively with people living at the home supporting them to cook lunch, do household chores and to go shopping. Staff said they have access to a training programme giving them the opportunity to gain the knowledge and skills they need to support people. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 7 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 House DS0000016465.V373131.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 and 4. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed and produced in a format appropriate to people’s needs using photographs, text and pictures. The Statement of Purpose did not provide information about the needs of the people living in the home or whether the environmental standards met the National Minimum Standards, this information needs to be included. Two people who had moved to the home from another home in the group had the wrong Statement of Purpose on their files. Since the last inspection one new person had moved into the home and three others had transferred from other homes in the group. Robust admission information was in place for the new person including an assessment of need and care programme approach supplied by their placing authority and an assessment which had been completed by the home. There was evidence that visits had taken place and records were kept confirming this. A new record was being put in place for use by people living in the home providing them with the Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 9 opportunity to give feedback about new people wishing to move in. A checklist provided evidence that people had been given information about the home. A letter from the placing authority confirmed that discussion had taken place with the home that the person’s needs could be met prior to admission. For those people who had transferred from other homes there was evidence of consultation with them and other people involved in their care prior to the move and visits to the home. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are being assessed and they are being supported to make decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. EVIDENCE: Since the last inspection Essential Lifestyle Plans had been put in place which gave people living in the home the opportunity to be involved in identifying their needs and wishes and developing their care plans. Some people choose not to be actively involved in this but others embrace it. Two people talked through their care plans and said how they discussed these with their key workers on a regular basis. The third person said that they were not interested in their records but did say they chat to their key worker about what they would like to do. Each person had a daily working file containing care plans, risk assessments and reactive and management strategies where needed. Where people had mental health needs they were receiving the appropriate support and reviews Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 11 as required under the Care Programme Approach. Plans were being monitored and reviewed each month with a quarterly report being produced by the person with their key worker. There was evidence that when annual reviews were due the person was being involved in preparing the report for this meeting which for some included representatives from the placing authority and their family. The Essential Lifestyle Plans provided a holistic analysis of people’s needs and wishes and plans referred to their physical, social, intellectual and emotional needs. People had signed their plans and other records on their files. Comprehensive daily reports were being kept providing a snapshot of each person’s day. Additional monitoring forms were in place to complement care plans and risk assessments. People said they were being supported to make decisions about their day-today lives and encouraged to be involved in their home, gain skills to be more independent and to be involved in their local community. Access to advocacy would be provided if needed and one person said they had weekly sessions with a counsellor. The AQAA stated, “Advice had been sought on Independent Mental Capacity Advocates and advocacy.” House meetings had been tried at the home but people said they had not proved successful. One person said that they represented the home at a group meeting with other people using Stroud Care Services. Minutes of the first meeting were in the home and it was evident that action was being taken to implement issues discussed at these meetings. Risk assessments had been developed from hazards identified in Essential Lifestyle Plans and placing authority assessments enabling people to take risks to gain further independence minimising the risks of possible harm. A missing person’s procedure was in place and each person had a missing person’s form that included a photograph and their description. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. They are encouraged to take responsibility for managing budgets for one meal a day and snacks enabling them to develop skills in independent living. EVIDENCE: People had identified what they like to do and how they would like to spend their day. From this an activity schedule had been put together of suggested activities. A list of possible activities had also been drawn up which was used as a prompt for people to suggest things they may like to do on a day-to-day basis. This created more flexibility for those who did not have regular activities such as college or voluntary work. One person said they were going to increase the days they helped out at a charity shop and that they also enjoyed going to the local college. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 13 People were observed deciding how to spend their time, going into town shopping or for a walk and planning the evening’s entertainment. They said they went to a cinema and for a meal out at the weekend. They had also enjoyed bowling, day trips and regularly went to a local working men’s club. Daily records indicated what people had chosen to do and whether they had been offered activities, which they had refused to participate in. People said they were supported to maintain contact with family and friends. One person had a holiday planned with family and met up regularly with friends. Most people had mobile phones but also had access to the home telephone. People said they take responsibility for cleaning their rooms, doing their laundry and helping around the home. Daily records indicated what they had done each day. Each person had a front door key and they said they had the number to the keypad on the front door so that they had freedom to come and go as they pleased. Restrictions around the use of the kitchen were still in place, this being locked overnight when staff went to the sleep in room. The rationale for this was recorded and staff said this was under review. Most people had facilities in their rooms to make drinks. People living in the home said they helped to shop for provisions and took it in turns to prepare the evening meal. One person had completed a food hygiene course but was going to do a refresher course. People were being supported to cook their own meals if they wished. They all had their own cupboard in the kitchen and a weekly allowance to buy their own provisions for snacks and breakfasts enabling them to learn how to budget. Records of meals eaten were being recorded on daily notes. During the visits freshly prepared meals were being cooked and fresh fruit was available. Food in fridges was stored correctly and labelled with the date of opening. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and wellbeing are being met helping them to stay well. Medication processes are in place that safeguard people from possible harm and enable them to take responsibility for their own medication. People’s wishes in respect to end of life have been discussed with them. EVIDENCE: Each person had a health action plan in place, which included an end of life plan. Essential Lifestyle Plans had identified people’s likes and dislikes and any support they needed to manage their mental health. All people were able to manage their personal care needs with occasional prompting for some from staff. The AQAA said, “staff support service users with personal issues with dignity and respect.” Talking to staff confirmed a person centred approach to their care and they were observed interacting with people positively during the visits. Each person was registered with a GP and had access to other healthcare professionals locally. One person was in the process of changing their GP to a local surgery and another person had a dental appointment during a visit. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 15 Records were being kept of all appointments and the outcome of these, with any action to be taken. People with mental health needs were being supported through the Care Programme Approach and had regular access to their Community Psychiatric Nurse. Contingency plans were in place should they be needed at times of crisis. New systems had been put in place for the administration and supply of medication. Staff had completed training in the safe handling of medication. Medication audits of their competency were in place. The temperature of the medication cabinet was being monitored. Stock was being kept to a minimum and stock checks were in place on the administration records. One record had handwritten entries, which the member of staff had initialled. Another member of staff should check this and countersign the record. Homely remedies were being kept and the Doctor had authorised their use. A signature list of staff administering medication was in place. One person said they were being supported to manage their medication. Records confirmed that staff were supervising self-medication and enabling the person to manage their own records. The next step was to store medication in their room and a safe had been provided. This is excellent practice. Each person had an End of Life plan, which indicated that their key worker had discussed their wishes about how they would like to be treated should they become unwell and their wishes about dying. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. People should be safeguarded from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure which was accessible to people living in the home. One person had made a formal complaint and a record of the outcome of this and response from the registered manager was on the complaints file. People said if they had concerns they would talk to the registered manager or staff. The representative attending group meetings with Stroud Care Services said that any concerns would also be discussed at this meeting with the Area Manager. Minutes of this meeting confirmed that they were being addressed. Staff had attended a variety of training in the safeguarding of adults, some with the local adult protection team, an internal session, as part of their induction programme or National Vocational Qualification Award. Staff spoken with had a good understanding of abuse and had confidence that the registered manager would challenge poor practice. Staff said that they completed Positive Response Training (PRT) which provided them with the knowledge and skills to understand how to support people when challenging the service using a non aversive approach. Staff confirmed that the use of physical intervention was rarely used and that diversion and distraction Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 17 techniques were effective. Any incidents were being recorded and staff were offered debriefs to explore these with the management and PRT trainers. Systems for the management of people’s personal finances were examined. Care plans indicated that all people living at the home managed their own finances. They also had responsibility for managing part of their own budget with the support of staff. Satisfactory records for this were being kept and regular checks being completed. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The grounds to the front of the home are unsafe and do not comply with the home’s risk assessments which were in place to endeavour to make the area safe and free from potential hazards. EVIDENCE: At the time of the visit five new flats were being built adjacent to the home, and were impacting upon areas around the home to the front and rear. This work was nearing completion but had meant that during the building people had not had access to the garden to the rear. A small patio area had been left for their use. The intention was to rebuild the garden to the rear giving them access to the garden on several levels. Builders were using the grounds to the front of the home to access the flats. The ground was uneven and very muddy creating a hazard for people having to use the steep drive out of the home. The registered manager had put a risk assessment in place that identified that a path would be partitioned off on the drive. This area was supposed to be kept clean by the builders and gravel or sand applied to keep the area dry and safe for walking on. This was not in place during the visits and staff indicated Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 19 that although an area had been marked on the drive it was never fenced off. During the visit builders were cutting stone creating clouds of dust that a person living in the home was observed having to walk through. The registered manager said that there were no arrangements in place with the builder to discuss what work would be done each day and how this would impact on people living in the home. Accident records indicated that two members of staff had fallen on the driveway during this time. We contacted Stroud District Council who the registered manager said carried out regular checks on the building of the flats, to ascertain whether they had any concerns about site safety. They confirmed they visited the site regularly and if they had any concerns about site safety these would be reported to the Health and Safety Executive. We discussed concerns about the driveway and area to the front of the home with the providers during the last inspection and we were assured that this area would be made safe when renovations to the home had been completed. This was not done at the time. A letter expressing our concerns was sent immediately to the Responsible Individual. The general décor of the home was good, with evidence that communal areas had been redecorated. There were concerns about damp in the lounge and a bedroom and these were being addressed. All rooms had en suite accommodation including a shower. The registered manager had plans to refurbish the bathroom. When the building is completed people living in the home would have the use of an office and another room. The laundry was clean and tidy. Colour coded mops had been provided and hazardous products were stored securely. A downstairs toilet was being kept locked for use by visitors and staff. The rationale for this was clearly recorded and people living in the home said this had been done in consultation with them. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34, and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Improvements need to be made to recruitment and selection processes to make sure people are safeguarded from possible harm. EVIDENCE: The staffing levels at the home were being maintained at two per shift with one person sleeping in. One person was in receipt of 1:1 support each day and staff said that at times this could impact on other people living in the home if the mix of staff was not right – such as new staff, female staff or staff from another home. Comments from surveys indicated that some of the people living at the home prefer to be supported by male carers. The registered manager was aware of this when planning the rota for the home. Lone working risk assessments for female staff were in place and guidance clearly indicated their roles and responsibilities. New staff confirmed that they had an induction programme and a copy of this was examined. It states that it is equivalent to TOPSS foundation programme. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 21 This should be reviewed to reflect the Skills for Care Foundation programme. Information was given to the registered manager about the Learning Disability Qualifications. A National Vocational Qualification programme was in place and staff were accessing this to complete their awards in Health and Social Care. The DataSet indicated that 57 of the staff team have a NVQ award. Recruitment and selection files were examined for three new members of staff. Each had completed an application form and a checklist was being used to evidence that proof of identity had been obtained. All three people had a satisfactory Criminal Records Bureau check in place and one person had been appointed before this was received. A pova first check had been completed and a risk assessment was in place describing the duties they could perform. A full employment history had been obtained for two people but there were gaps in the record for one person. During their interview they had been questioned about this but had given an explanation of 6 months of a 3-year gap. This needs to be fully explored with people. It was clear that the processes were in place to prompt interviewers to obtain this information. Reason for leaving former positions in care had been provided for some people but one person had worked in several care homes prior to joining the home and there was no explanation from their previous employers of the reason why they left. The references they had listed did not come from care employers. At least two references were being obtained for new staff before appointment. People living in the home said that they had received training in interviewing techniques and had helped out at several interviews. This is good practice. The home had access to a training co-ordinator. A number of staff had trained to deliver training to the staff team including Positive Response Training, Moving and Handling and Equality and Diversity. The registered manager confirmed that some training was being sourced externally such as Mental Health, Safeguarding of Adults, Medication and Infection Control. A training matrix was in place and each quarter the training co-ordinator cascaded to the home a list of training and people needing refresher courses. Copies of certificates were kept on staff files. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance systems must be put in place involving people who live at the home. Amendments to fire risk assessments will ensure that the health, safety and welfare of people is promoted and protected. EVIDENCE: Since the last inspection we had registered the manager. She has considerable experience with people with a learning disability and mental health problems. She has the Registered Managers Award and a NVQ Level 4 in Health and Social Care. She said that as part of her continuing professional development she had completed a course in supervision and appraisal skills. She provided the AQAA to us in time and had completed it satisfactorily. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 23 The majority of requirements issued at the last inspection within her control had been implemented. She had highlighted concerns about the health and safety of the home during current building work to her line manager and to the proprietors of the home, and had put risk assessments in place outlining how hazards should be minimised. The area manager said that a quality assurance system had been identified and that a range of audits involving people living in the home would be put in place. Monthly-unannounced Regulation 26 visits were taking place and reports being produced. These were examined. Some people living in the home had completed surveys in 2008 about the service they were receiving. Feedback from regular meetings with key workers and representation on Stroud Care Services Joint House meeting provided the opportunity for people to participate in the quality assurance process. Stroud Care Services were also considering ‘Investors in People’ as an additional quality assurance tool. Systems for the monitoring of health and safety were in place. Staff were maintaining daily records for fridges, freezers, water outlets and hot food temperatures. Food in fridges was labelled with the date of opening. Portable appliance testing had been completed and certificates confirmed servicing of other appliances in the home. Staff had completed mandatory training in fire, first aid, moving and handling, food hygiene and infection control. A fire risk assessment was in place and an evacuation procedure. The procedure needs to be reviewed to reflect the Regulatory Reform (Fire Safety) Order 2005, that people should be fully evacuated from the building. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 24 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 4 3 4 4 X 5 X 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 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 X Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 6 Requirement The Registered Person must make sure that the Statement of Purpose needs to be reviewed to include reference to the numbers, range of needs and sex of people living at the home. It must also include the number and size of rooms in the home. This is to make sure that people have access to information they need about the home. The grounds to the front of the home must be made safe to make sure that people are able to use the driveway and gain access to the house without fear of injury. This is to safeguard people from possible harm. The reason for leaving former positions in care must be verified. This is to make sure that staff are recruited through a robust procedure reducing risks of harming or abusing people. A quality assurance programme must be put in place with the production of an annual report. (This is repeated from the previous inspection although DS0000016465.V373131.R01.S.doc Timescale for action 30/04/09 2. YA24 13(4) 02/02/09 3. YA34 19 30/04/09 4. YA39 24 30/04/09 Highfield House Version 5.2 Page 26 work was in progress to comply with this.) 5. YA42 23(4A) Fire evacuation procedures must comply with guidelines issued by the Fire Service. This is to protect people from harm. (This has been repeated from the last inspection.) 30/04/09 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. 5. Refer to Standard YA1 YA20 YA24 YA32 YA35 Good Practice Recommendations When people transfer to the home from another home in the group they should have access to information about Highfield House. Handwritten entries on medication administration records should be checked and countersigned by a second member of staff. Arrangements should be made to discuss with builders their plans for the day that may impact on people living in the home. The induction programme should reflect the Skills for Care foundation programme. Staff should complete the Learning Disability Qualification. Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Highfield House DS0000016465.V373131.R01.S.doc Version 5.2 Page 28 - 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. 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