Inspection on 25/02/08 for Highfield House

This inspection was carried out on 25th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Highfield House 24/01/09

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 09/07/2008.

CARE HOME ADULTS 18-65 Highfield House London Road Stroud Glos GL5 2AJ Lead Inspector Ms Lynne Bennett Unannounced Inspection 25 and 26 February 2008 10:15 th th Highfield House DS0000016465.V359289.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.V359289.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.V359289.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 ****Post Vacant**** 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.V359289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2006 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. 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 head office, which is in the grounds of the home. The last inspection report is also kept in the office. Highfield House DS0000016465.V359289.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. 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. This inspection took place in February 2008 and included two visits to the home on 25th and 26th February. The service was dormant for sixteen months during which time there was a complete refurbishment that included adding en suites to bedrooms and replacing the heating system and some windows. In January 2008 a new manager and staff were appointed. At the time of the inspection there were two people living at the home and four staff were supporting them. The acting manager had left two weeks previously and was due to be replaced in the week following the inspection. In the interim a deputy manager was overseeing the management of the home. The Annual Quality Assurance Assessment (AQAA) had not been returned to us (The Commission) by the time of the inspection. Surveys had been provided for people living at the home and staff but these had not been returned. People living at the home were spoken with and observed during the visits. Staff were also spoken with. The proprietors were present during part of the visits. Feedback was received from placing authorities. A range of records were examined including care plans, staff files, health and safety records and medication systems. What the service does well: What has improved since the last inspection? Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 6 All requirements issued at the last inspection in April 2006 had been met. The refurbishment of the home had provided all single bedrooms with en suites that include a shower, toilet and wash hand basin. New carpets have been fitted throughout and the home had been redecorated. 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.V359289.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.V359289.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): 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, including visits to the home, enabling them to make a decision about whether they wish to live there. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: Comprehensive systems were in place for the admission of new people to the home. The admission records for a person admitted in January were examined providing evidence that admission procedures were being followed. Stroud Care Services had completed an assessment in addition to obtaining an assessment and care plan from the placing authority. Information had also been supplied from their former placement. Visits to the service had been noted and the outcome of the visits recorded. The person said they had settled in well and were getting to know staff and the area despite initial anxieties. Comments from a placing authority indicated that they had been asked to supply an assessment and care plan upon referral and they felt that the admission process had been thorough. One person had chosen to move back into Highfield from another home in the group. They had lived at Highfield House prior to the renovations. This had Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 9 been done in agreement with their care manager who has regular contact with them. Each person had a statement of terms and conditions. These need to be reviewed to ensure they provide all information about fees and additional costs and are relevant to Highfield House. We have agreed with Stroud Care Services that the registration of the home will be for people with a learning disability and for people with a mental health problem. A new certificate will be issued in the future to reflect this. The Statement of Purpose indicates that the staff will have the skills and competencies to provide care for this group of people. Highfield House DS0000016465.V359289.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A regular review of assessments will make sure that care plans and risk assessments reflect people’s changing needs. People are involved in making decisions about their lifestyle. EVIDENCE: The care of the two people living at the home was case tracked. This involved reading their care plans, examining financial and medical records, observing their care and talking to staff about the care they provide. There was no reference that people had been asked about their preferences for the gender of staff to support them with their personal care. Each person had two files one for general information and the other for a person centred plan. Assessments were in place from which their care plans had been developed. The assessment for one person had been reviewed in March 2006 and needs to be reviewed. During the visits staff were reviewing sections of this person’s file to ensure that information related to the home in which they were now living. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 11 Care plans were being monitored on a monthly basis with a review checklist attached to each plan and an additional monthly summary of the outcomes for people. These indicated that people had worked with staff to develop their care plans and risk assessments. Care plans were in place for a range of needs including communication, self-care, community activities and domestic skills. Care plans clearly indicated where a risk assessment, reactive strategy or behaviour management plan was in place. Care plans for a new person appeared to be duplicated. One set of plans indicated a number of restrictions in place such as declining to give medication if the person had refused to take it between 8.30 –9.00 and refusing to give money if household chores had not been completed. Discussions with staff indicated that a multi agency review had looked at ways in which the person could be encouraged to take responsibility for helping around the home and to take their medication on a regular basis. The other set of plans were more proactive in their approach to this and appeared to be less confrontational. Behaviour records indicated that incidents had occurred when the former approach had been taken. The proprietor stated that the plans would be reviewed and the inappropriate plans removed. There were a number of restrictions within the home including restricted access to the kitchen when people were in an anxious state. Records were in place describing the rationale for this. This had been implemented and an incident form completed at the time. The front door has a keypad restricting use of the door although one person was observed being able to leave and enter the home via the back door. Care plans and risk assessments must include the rationale for the lock on the front door. People were observed being supported to make choices about their daily lives whether to go out, what to eat and how to spend their time. One person said they decide when they wish to go into Stroud and another person had planned to go out but changed their mind. Staff respected this decision. Risk assessments were in place for a range of activities and hazards with evidence of regular review. A risk assessment for one person indicated that they should have support whilst out in the community but records of a recent multi agency meeting indicated agreement that they would be able to go into Stroud without staff supervision. They were observed doing this during the visits and staff stated that they were informed how long they would be and where they were going. The risk assessment needs to be amended to reflect this. A missing person’s procedure was in place that indicated when staff should contact the police. Both people had a missing person’s form in place providing a description and pen picture. One needed to have a photograph added. Staff commented that this was going to be done. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 12 Care plans for both people indicated problems with invading people’s personal space and inappropriate behaviour towards female staff. One person had a risk assessment in place providing guidance to female staff about how to minimise any risks to them. This was not in place for the other person. Female staff described the action they take to divert and discourage people from being inappropriate, this followed guidance as noted in the risk assessment for one person. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 13 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 are able to make choices about their life style and supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with friends. People are involved in menu planning whilst retaining choice and flexibility on a daily basis. EVIDENCE: People were observed using their local community facilities going to shops and for walks. They said they also like to go out for meals to garden centres and pubs or fast food outlets. One person had been to the cinema. They occasionally go to a social club to meet up with friends or visit one of the other homes. Each person has an activity schedule in place but this was observed to be very flexible. They have an individual activities budget allocated on a weekly basis. Daily diaries keep a record of their routines and activities. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 14 People were being encouraged to help out around the home with varying degrees of success. They will occasionally help out with household chores. One person was observed helping to make a lunch and they both helped themselves to drinks and snacks. The home has some ground rules which people were being asked to sign up to when they move in. One of these includes restricted access to the kitchen overnight due to risks to one person. A smoking area has been designated in the garden for people who wish to smoke. Risk assessments were in place in relation to this. Staff said that the people living in the home were involved in planning the menus for the week. One person said they were having pasta for tea and had chosen to have German sausage with a glass of lager for lunch. Budgets appeared to be stretched but staff said they were manageable. They said that the provisions budget was subsidised if needed. The proprietor commented that budgets had not initially been effectively managed with large equipment purchases being made from the provisions budget but that this had been resolved. People were involved in the weekly shop that they did on a Friday. There were fresh vegetables in the fridge and cheese and ham. There were inconsistencies in the labelling of opened produce in the fridge. Two items had not been labelled. There was frozen food in the freezer. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 15 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): 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. People’s health and wellbeing are being met helping them to stay well. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. EVIDENCE: The support people require managing their personal and self-care was noted in their care plans. One person neglects their personal appearance and hygiene and staff will need to monitor this and endeavour to support them to improve their standards of personal care. Accident and incident records were in place and being used by the home. We had been notified of an emergency admission to hospital. People have been registered with a local doctor. Records confirmed that those people on a Care Programme Approach have regular access to their Care Manager or Community Psychiatric Nurse. One person had a meeting with their Care Manager at the time of the visit. Records were being kept for other Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 16 appointments with an optician, chiropodist and outpatient appointments. Staff were checking these during the visit. One person had refused to register with a dentist and chiropodist and this was noted in their care plan. The deputy manager said that they had intended to put Health Action Plans in place and was given contact numbers to obtain a copy. Systems for the administration of medication were examined and found to be satisfactory. The medication cabinet was due to be replaced with a cabinet that complies with “The Handling of Medicines in Social Care” produced by the Royal Pharmaceutical Society of Great Britain. The home had a medication policy in place and had the most recent copy of the British National Formula. Staff confirmed that they complete training with a local pharmacy as well as part of their NVQ in Health and Social Care. They were also audited by the home to assess their competency at regular intervals. Stock records were being maintained on the medication administration record. Most handwritten entries had been signed although one for an antibiotic had not been signed. It is good practice for any handwritten entries to be countersigned by another person. One person had regularly refused medication and there was a procedure in place on their care plan should this continue for referral to a crisis team. Pro Re Nata or ‘as necessary’ medication was being given. Protocols for their use were not seen but had previously been in place. Staff were recording correctly when this medication was given. The temperature of the cabinet was not being taken or recorded. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 17 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. People are aware of the complaints procedure. Systems are in place to safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure in place. All people living at the home have a copy of this that includes our contact details. People spoken with said they would talk to staff or their Care Managers about any concerns they may have. A record log was being kept in the home and indicated that no complaints had been received. The complaints procedure was not displayed in the home at the time of the visits. Staff records confirmed that they had attended training in the ‘alerters guide’ provided by the local Adult Protection Team. Staff complete protection of adults/abuse training as part of their NVQ awards in Health and Social Care. Staff confirmed that they complete training in Positive Behaviour Management (PBM) and were being taught a low arousal approach to managing challenging behaviour. Reactive strategies were in place for people who may challenge the service and these state that physical intervention was to be used as a last resort. Records were in place that assess any incidents and provide staff with the opportunity to reflect on the triggers and approach taken. The proprietor stated that a Psychologist was to be employed one day a week to review reactive strategies and to support people on a 1 to 1 basis. A member of the Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 18 management team was completing training in PBM so that this can be delivered internally. Until she is qualified staff were receiving training from an external training agency. Highfield House DS0000016465.V359289.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 and 30. 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. Accommodation of a high standard has been provided for people which was let down by poor hygiene and cleanliness. EVIDENCE: The home has been refurbished to provide people with single rooms with en suites that include a shower, toilet and hand wash basin. Rooms had been redecorated providing accommodation of a high standard. Some rooms were still being painted at the time of the inspection. One person invited us to have a look at their room that they had decorated with their personal belongings. They said they were happy with their room and the fixtures and fittings. It was noted that their bedding and pillow were soiled and stained. This was brought to the attention of the proprietor who said it would be replaced. Communal areas were pleasantly decorated and fitted out with good quality fixtures and fittings. The downstairs toilet had been refurbished and an Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 20 additional bathroom provided on the top floor. Communal hand washbasins had access to liquid soap and paper towels. The laundry area was satisfactory. Colour coded mops had been provided. Some mops need replacing; the mop heads were dirty. As mentioned some redecoration was still taking place and the proprietor stated that the parking area to the front of the property was to be tidied up and cleaned. These were having an impact on the cleanliness of the home. One person likes to spend time in the garden and walks through the kitchen in dirty shoes. Staff were observed cleaning the home trying to ensure that kitchen floors and toilets were kept clean. The carpet near the front door was replaced during the inspection and carpets had been spot cleaned. A general maintenance programme was in place for the home. A full time maintenance person was employed between the three homes for day-to-day repairs. Staff have temporarily moved the sleeping in room due to disturbances to themselves and a person living at the home. A duvet had been hung at the window to give some privacy. Curtains need to be supplied. People were observed accessing the grounds around the home. A smoking area had been identified on the patio to the rear of the home. This was overgrown in parts with brambles and bushes. These need to be pruned. Highfield House DS0000016465.V359289.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. 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. Peoples’ needs are met by a competent staff team, who have access to a mainly satisfactory training programme that needs to ensure staff have knowledge about the diverse needs of people living at the home. People have been put at risk by unsafe recruitment processes. EVIDENCE: Three staff had been transferred from other homes in the group and one new member of staff had been appointed to the home. Staff spoken with confirmed that they were completing NVQ awards in Health and Social Care. Arrangements were being made during the visits for the assessor to meet with candidates to discuss their work. The new member of staff said that once the induction programme had been completed then he would be registered on the NVQ programme. Copies of the completed induction programme were kept on staff files. The home should consider making the new Learning Disability Qualification (LDQ) accessible to staff. Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 22 Staff were observed treating people with respect and being approachable and accessible. They said that they were looking forward to the new manager starting at the home so that the service could be developed further. Recruitment and selection files were examined for the new member of staff. He had been appointed without a Criminal Records Bureau check in place although a PoVAfirst check had been completed. A risk assessment was produced on the second day of the visit detailing what he could and could not do. During the first visit to the home he was left on several occasions without supervision and at one point in the home alone whilst the team leader went to another home. Discussions with the proprietor earlier in the visit had centred on concerns that according to the rota he was left in the home unsupervised between 8.00 and 11.00 am and that he was scheduled to sleep in. It was stated that the rota had just been changed so that additional cover could be provided until 10.00 pm each evening and that he would not be sleeping in until his CRB was returned. It was stated that there was usually someone in the head office (in the grounds of the home) between these times. An immediate requirement was left with the proprietor to state that whilst working without a CRB new staff must be supervised at all times by a named person and that they must not escort people away from the home unless accompanied by another member of staff. Failure to comply may lead to the CSCI considering enforcement action to secure compliance. The proprietor confirmed that the CRB certificate arrived two days after the visits to the home. In addition to this there was no evidence that proof of identity had been obtained for this person or a current photograph. There were copies of three references that had been obtained prior to appointment and a full application form. There was a gap in employment history between 1990 and 1995 that needed to be explored. An occupational health questionnaire had also been completed. There was no evidence that copies of training certificates had been obtained at the point of appointment. Training records on staff files confirmed that they have access to mandatory training in 2007, Mental Capacity Act training, alerter’s guide and Positive Behaviour Management. Copies of certificates were kept on file. Staff confirmed that refresher training was being provided. Some staff had attended training in mental health awareness and the proprietor stated that the Psychologist would be providing training in mental health focussing on the needs of people living at the home. Highfield House DS0000016465.V359289.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. 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. People living at the home will benefit from a manager who has a dynamic and creative approach, and who will provide clear direction and leadership. Quality assurance systems need to be established involving people living in the home. People are being put at risk by inconsistencies in the recording of health and safety systems. EVIDENCE: At the time of the inspection there was no manager in post. A new manager was due to relocate to the home from another home in the group in March 2008. She was in the process of registering with us to become the registered Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 24 manager for the service having submitted a CRB check through the registration team. The Annual Quality Assurance Assessment had not been returned prior to the inspection having missed the deadline for return by almost two weeks. A group manager had recently been appointed and was due to start in post in April 2008. The proprietor confirmed that she would be registering as the responsible individual for the organisation. Regulation 26 visits had not taken place since the home opened and the quality assurance programme had not yet been put in place. Health and safety systems were inspected indicating inconsistencies in the recording for: • • • Checking of fire systems Recording of fridge and freezer temperatures Recording of hot food temperatures Water temperatures had been tested for the kitchen sinks but temperatures for other outlets around the home now need to be tested on a regular basis. A risk assessment was in place to state that thermostatic valves were not needed because people living at the home were not at risk of scalding. Temperatures still need to be monitored and to fall within safe parameters. The evacuation procedure for the home indicates a stay put procedure for people who will not leave their rooms. This no longer complies with the Regulatory Reform (Fire Safety) Order 2005. There were two sets of fire extinguishers around the home, side by side. Those extinguishers fixed to the walls were last serviced in November 2007 whilst the freestanding extinguishers had not been serviced since August 2005. These latter extinguishers should be serviced or removed if not needed. Portable appliance testing was being completed on the second visit to the home. It had been due to be completed in January 2008. Highfield House DS0000016465.V359289.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 X 2 3 3 3 4 3 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 3 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 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 2 2 X 2 X 2 X X 2 X Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 26 No 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 14(2) Requirement Assessments of people living at the home must be regularly reviewed to reflect their changing needs. This is to make sure that the home can continue to meet their needs. The reasons for restricted access (lock) to the front door must be recorded with evidence of agreement of the people living in the home. Risk assessments must be put in place for: • Accessing the community without staff supervision • Minimising hazards from inappropriate behaviour towards female staff. This is to make sure that people are safeguarded from possible harm. The home must regularly check the temperature of the medication cabinet. This will make sure that medication is fit for purpose. Clean bedding must be provided for people. Where there are incontinence issues appropriate DS0000016465.V359289.R01.S.doc Timescale for action 31/05/08 2. YA6 17(1)(a) Sch 3.3(q) 13(4) 31/05/08 3. YA9 31/05/08 4. YA20 13(2) 30/04/08 5. YA26 16(2)(c) 30/04/08 Highfield House Version 5.2 Page 27 6. YA28 23(3)(a) 7. YA34 18(2) 8. YA34 19 Sch 2 9. 10. YA39 YA39 24 26 11. YA42 23(4A) bedding must be provided. This is to make sure infection control is managed. Curtains must be provided for staff in their sleeping accommodation. This is to promote privacy and dignity at the workplace. New staff working without a CRB check in place must be supervised at all times and must not escort service users away from the home. This is to make sure that people are protected from possible harm or abuse. Any gaps in employment history must be explored. Proof of identity must be obtained including a current photograph. Evidence of relevant qualifications and training must be obtained. 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. Unannounced monthly visits to the home must be in place and copies of the written report kept in the home for inspection. This is to make sure that the organisation monitors the quality of service provided by the home. Fire evacuation procedures must comply with guidelines issued by the Fire Service. This is to protect people from harm. 30/04/08 26/02/08 29/02/08 31/03/08 31/03/08 31/03/08 Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 28 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 YA5 YA6 Good Practice Recommendations Terms and conditions for the home should be completed in full – including the fees and any additional costs. Care plans should be reviewed to ensure that there is no duplication. Care plans should include reference to people’s preferences for the gender of staff providing personal care. Any limitations on facilities, choice or human rights as discussed in a multi agency forum must be recorded. The missing person’s record should include a photograph of the person. Opened produce should be labelled with the date of opening. Monitor and support a person to maintain higher standards of personal care and hygiene. Health action plans should be put in place for people living at the home. Handwritten entries on medication administration records should be countersigned. Protocols for the administration of PRN or as necessary medication should be in place. A copy of the complaints procedure should be displayed in the home. The grounds around the home should be made safe. Building materials and equipment not needed should be disposed of and overgrown bushes and brambles should be pruned. Mop heads should be replaced at regular intervals. Staff should complete the Learning Disability Qualification. Health and safety records for recording of fridge and freezer temperatures, water temperatures, hot food temperatures and fire systems should be monitored to ensure that they are being completed at the appropriate times. 3. 4. 5. 6. 7. 8. YA7 YA9 YA17 YA18 YA19 YA20 9. 10. YA22 YA28 11. 12. 13. YA30 YA35 YA42 Highfield House DS0000016465.V359289.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, 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.V359289.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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