Inspection on 14/12/05 for Highfield House Residential Home

This inspection was carried out on 14th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Highfield House Residential Home 01/03/10

Highfield House Residential Home 18/09/07

Highfield House Residential Home 26/09/06

Highfield House Residential Home 08/03/06

Highfield House Residential Home 15/03/05

Highfield House Residential Home 20/12/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Highfield House Residential Home London Road Halesworth Suffolk IP19 8LP Lead Inspector Deborah Seddon Unannounced Inspection 14th December 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highfield House Residential Home Address London Road Halesworth Suffolk IP19 8LP 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) 01986 872125 01986 872125 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (39), of places Physical disability (1) Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Care can be provided to three named service users with dementia (as detailed in the application for variation dated 12 April 2005). 15th March 2005 Date of last inspection Brief Description of the Service: Highfield House is situated close to the town of Halesworth in Suffolk. The home is owned by BUPA and is registered for 39 older people and 1 person with a physical disability. Highfield is not registered to provide nursing care. The home offers 32 single rooms and 3 double rooms, 28 rooms have en-suite toilet facilities and 12 have an en-suite bath or shower. Highfield House offers two lounges, one with a television and one quiet room and two dining rooms. The home is situated within extensive grounds, with a summerhouse, sensory garden, patio and terraced areas. The home has easy access to the shops and is on the local bus route. Mrs Deidre Coby has been appointed the home’s manager and is currently in the process of becoming the registered manager for Highfield with the Commission for Social Care Inspection (CSCI) Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours on a weekday in December 2005. During the inspection time was spent talking with six residents and two visiting relatives. Time was also spent with members of staff, which included the manager, deputy manager, catering manager, maintenance person and senior care assistant. A tour of the premises was made. Records looked at included staff rotas, staff files, training plans, handover sheets from the night staff to the day staff, residents care plans and a quality assurance analysis. What the service does well: Highfield provides residents with a friendly and relaxed environment to live in with their own possessions around them. All areas of the home are nicely presented and are comfortable, clean and tidy. Visitors are encouraged to visit at any time and several relatives and friends were seen visiting during the inspection. Feedback from residents and relatives and the quality assurance survey was very positive in that they were satisfied with the service they receive. One relative commented, “All staff are very good here, they are very kind”. Another relative commented “ Highfield is ideal for my relative as they love trees and gardens and during the summer they will sit in the garden and read”. Residents comments included“ lovely home, incredibly nice staff” and “staff are marvellous, food nice, it is all very good, I am quite happy here”. Residents spoken with felt that they lived in a home where staff respected their privacy. Staff were observed knocking on residents doors and waiting before entering their room. The catering arrangements within the home provide residents with a nutritious and balanced meal on a daily basis, with a good variety of choice. Residents spoke highly of the food provided. Residents care plans are very detailed and easy to follow. The inspector was able to track the care needs of the resident through the care plan and see evidence that the individual care needs were being monitored and reviewed on a regular basis. The health needs of the residents were responded to quickly and appropriately. The ‘Personal Best’ programme was seen to be working well within the home. Several of the staff had achieved personal best certificates and badges in recognition of their improved performance and development, which in turn benefits the resident’s quality of service. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 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. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Residents cannot expect to have a completed detailed assessment of their needs prior to moving into the home, however residents can expect that the home will implement a plan that identifies resident’s needs and how they are to be met. EVIDENCE: The care plans of three service users were seen. Only one care plan had a completed pre admission assessment, another had been partially completed. There was no evidence seen on the third care plan of an assessment being completed. The assessment that had been completed included information about the resident’s mental health, recreation and social care, safety, communication, falls, personal hygiene and the reason for admission amongst other areas. One service user’s plan stated that they were admitted to the home because they were weak due to deterioration in their condition. The plan stated that they needed care through the night and had a full description of how to meet their needs. The plan also stated the resident’s wishes were that they required ‘no further treatment’. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, Residents can expect to have their personal and physical needs identified, monitored and met and have access to healthcare services. They can expect to be protected by the home’s procedures for administering medication. Residents can expect to have their privacy and dignity upheld and their wishes respected in the event of death. EVIDENCE: During the inspection the care of three residents was tracked. This involved looking at their care plans and spending time with the residents individually and with two relatives of the residents who were visiting. The care plans covered all aspects of the resident’s health, personal and social care needs. One resident’s care plan had evidence of a Behavioural Assessment Scale Of Later Life (BASOLL) being completed prior to the resident moving into the home. This included the amount of self-care that the resident could safely manage, which had been incorporated into their care plan. Evidence was seen that the care plans were being reviewed on a regular monthly basis. Residents had signed a form to share information and to discuss and oversee the implementation of their care plan. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 10 The care plans contained detailed risk assessments to promote the residents health. These included falls, moving and handling, pressure area care and nutritional assessments. One resident’s falls risk assessment seen had recently been updated to reflect a change from medium to high risk. The assessment contained a list of interventions to promote the resident’s independence. An evaluation sheet referred to the resident making good progress using their Zimmer frame. The moving and handling assessment supported the falls assessment highlighting the risk of the resident tripping or falling due to their frailty and confusion whist using their Zimmer frame. Another care plan seen had a detailed assessment for pressure care using the Waterlow assessment tool. The resident had scored a high risk and evidence seen showed the resident had been issued with a Respose mattress and a cushion for their chair. A record of pressure area checks was being made daily by a senior member of staff and detailed comments recorded, for example “areas of residents body susceptible to pressure sores and infection checked and thoroughly washed and cream applied”. There was evidence in the notes that the district nurse visits residents in the home when required. To support the pressure care assessment the resident had a nutritional assessment in place. The resident had a low score and as a result was having their weight monitored on a regular basis. Records show that they were maintaining an average weight, with a small weight loss in recent months, however records showed that the resident ate well and had been more active between October and November. Evidence was seen that the General Practitioner (GP) visits the home on a regular basis. A record of visits was seen on each resident’s care plan. These contained the details of the visit and any changes to resident’s health or medication. An entry was made following the GP visit to one resident prescribed antibiotics for an infection in their leg. It was recorded that there was a history of pain and swelling in this leg and the resident was advised by the GP to keep it elevated. The resident was observed sitting with their foot up on a footstool. The hand over notes between the night staff and day staff were seen and made reference to the possibility of a resident having a urine infection. The senior member of staff on duty informed the inspector that a urine sample had been taken to the surgery during the morning for testing. The notes also referred to a resident that had broken their dentures, arrangements had been made for a carer escorting another resident to the opticians would be taking the teeth to the dentists to get them repaired. The care plans contained detailed risk assessments to promote the residents health. These included falls, moving and handling, pressure area care and Each medication administration record (MAR) chart had a front cover with the residents name, date of birth, GP, room number and a photograph for identification and any known allergies. The member of staff administered medication appropriately and in line with good practice. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 11 A requirement was made at the previous inspection for the date of opening of eye drops was recorded to ensure that they were not being used after their expiry date. Evidence was seen that the date had been written on the box containing the eye drops and those checked were with within date. One resident who had recently moved into the home told the inspector that they enjoyed their privacy, preferring to stay in their room. They said, “ Staff respect my decision, but still inform me of events in case I wish to join in any of the activities”. The resident spoke of receiving help from male care staff with their personal care. A male carer had been allocated to assist them with a bath, at first they said “I found the situation embarrassing, however I feel that the male carer is very good and leaves me in private to wash my private parts”. Residents care plans reflected the importance of respecting resident’s privacy and dignity with plans in place. One resident had a dressing plan ‘to ensure that the resident is smartly dressed and tidy in their appearance’ and another had a washing and personal hygiene plan stating that the resident is to be encouraged to wash own areas of body within reach to promote independence. Evidence was seen that residents spiritual needs are recorded on the admissions forms in their care plans. Information was seen giving directions to the home to contact their solicitor and social worker and wanted to buried, another resident had expressed their wishes to be buried next to their spouse. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15, Not all residents living in the home can expect to have a lifestyle that matches their needs, however residents can expect to receive a good standard of fresh and appealing food with a wide variety of choice as part of their daily diet. EVIDENCE: Activities advertised on the notice board in the entrance hallway showed a range of activities coming into the home during December, which included a local drama group who were putting on a pantomime of Aladdin. Carol singers from local primary and middle schools, and a separate carol concert was arranged for Christmas Eve. A Christmas party was arranged for the 23rd December. A church service is held in the home every third Sunday in the month. One resident spoke of the activities improving. The home has appointed a new activities co-ordinator who has arranged a lot more things to do, which included ball games, a game based on the television series ‘only fools and horses’, trivial pursuit and monopoly. They also spoke of a minibus trip to Southwold. A relative of a resident told the inspector that the home was ideal for their relative as they loved trees and gardens and that during the summer they will sit in the garden and read. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 13 The home is registered for one resident who is physically disabled and under the age of 65. A resident told the inspector that they had recently moved into a larger room. In their old room they had had a dish for receiving sky television and enjoyed watching comedy and discovery channels, but had cancelled their subscription, as they were unable to have a dish fitted to the outside of the home. The resident said “I spend my time joining in activities, reading, and completing crosswords or listening to music”. They showed the inspector their collection of music compact discs. The inspector asked if they had the opportunity to shop for these themselves so that they could choose from a large selection in the shops, however they said “my key worker will get them for me” they also said that “I drink on occasions, I like lager and the occasional whisky.” However they said they did not go out to the pub very often. A discussion was held with the manager about appropriate age related activities being offered to this resident. Relatives and friends of residents were observed visiting throughout the inspection. The inspector had the chance to speak with two relatives visiting and both were very positive about the care their relatives receive in the home. One relative often visits to join their spouse for lunch. Another relative commented “Lovely home with incredibly nice staff” and that their relative was happy and settled living at Highfield. The menu for lunch was in a frame and displayed outside the dining room. The menu consisted of carrot and coriander soup or fruit juice, followed by a choice of roast chicken and stuffing or smoked haddock, accompanied by a choice of roast potatoes, cauliflower and peas. For dessert residents could choose from pears with vanilla sauce, ice cream or assorted cheese and biscuits. The catering manager showed the inspector the menu for teatime, which consisted of a choice of assorted sandwiches or beans on toast and followed by a choice of fresh fruit, a selection of cake and crème caramel. The catering manager had made provision for residents following a diabetic diet, providing, fruit cocktail, angel delight or yogurt. They use diabetic ingredients to make foods, such as cheesecake, which have no added sugar. Residents are given a choice in advance of their meal; three residents had requested alternatives to the teatime menu. The catering manager had made a note of their choices. Food seen was nicely presented, smelt nice and looked appetising. Residents said they were enjoying the food. The catering manger showed the inspector records of previous meal sheets and three day monitoring forms that they use to monitor the food and fluid intake of residents not eating properly. The catering facilities were clean and tidy and were being closely monitored by the catering manager who has completed a city and guilds qualification in catering and housekeeping. Temperatures and records were being completed in line within the guidelines of food hygiene standards. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed on this occasion. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25, 26, Residents can expect to live in a well-maintained environment and welcoming environment, which provides a good range of communal and personal accommodation with their own possessions around them. EVIDENCE: Highfield House is situated in close proximity to the town of Halesworth, originally a private Georgian dwelling it has been converted and extended to provide residential accommodation. The home offers a range of communal areas, which includes two dining rooms, two lounges and two conservatories. Surrounding the house there are landscaped gardens, terraces and patio areas, which are all well maintained and accessible to residents. Residents also benefit from a sensory garden in the summer months. Twenty-eight rooms have en-suite toilet facilities and twelve have an en-suite bath or shower. There are additional toilets accessible to residents on the ground floor. Additionally the home has assisted bathrooms with Arjo parker baths installed. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 16 On arrival the inspector was invited into the building by a person delivering a parcel and had to wait several minutes before anybody knew that they were on the premises. This was raised with the manager who explained that a new security code entry system was being installed that day. The main door to the house opens into a porch and the security system was being fitted to the inner door providing a safer system of access into the home. The inspector spent time talking with the maintenance person who is also the health and safety co-ordinator. They are responsible for undertaking and completing all risk assessments within the home. They have experience of the building trade and are responsible for the upkeep of the décor throughout the building. They were able to show the inspector a programme of redecoration. BUPA have completed a review of all the care homes with regards to the latest fire safety standards. They have identified work to bring each home up to standard. The maintenance person told the inspector that Highfield House is expecting a contractor to come into the home to replace fire door seals and to install additional smoke detectors. Risk assessments have been undertaken on windows in the rooms of residents residing above ground floor. Remedial action has been taken where residents were at risk of falling through the windows. Sash windows have been fitted with bolts, which prevent sash windows opening further than 8”. The risk assessments are monitored and where any action is taken a record is made and signed by the maintenance person. Five residents have bedrails fitted, which have been risk assessed and the appropriate equipment has been purchased to ensure that the rails, protectors and beds are compatible. Evidence was seen that these are reviewed on a monthly basis. The home provides aids and equipment to residents. They also have a pool of wheelchairs and three hoists. The maintenance person makes a visual check of the wheelchairs, hoists and slings monthly and showed the inspector a service report by Arjo who service all baths and hoists in February 2005. During the tour of the building the inspector noticed that all radiators were fitted with radiator guards and that all residents bedroom doors were fitted with self-closing fire doors. Resident’s rooms seen looked clean, tidy and comfortable and personalised with some of their own belongings. One resident showed the inspector a selection of ornaments they had brought from home and said they had their own television. Another resident who uses a wheel chair had recently moved into a larger room and was pleased they had more space to manoeuvre. The inspector was invited into another resident’s room where they were relaxing in their own recliner armchair and looking out of the patio window. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 17 They told the inspector that they had brought their own bed and lamp as well as the chair. They spoke of being happy with their room and “staff were marvellous, food nice, it is all very good, I am quite happy here”. The home was observed to be clean and hygienic and free from offensive odours. Liquid soap dispensers and paper towels are situated in all the bathrooms and staff have access to disposable gloves and aprons. The laundry room was seen and had two large washing machines each with a sluice facility and two large tumble dryers. The home’s procedure for dealing with soiled linen is to use the red bags, which dissolve in the washing machine. Signs were located in the sluice room informing staff of the procedure for dealing with clinical waste. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, People living in the home can expect to be cared for by a team of staff who are available in sufficient numbers and supported to provide a greater level of individual care to meet their needs through the ‘personal best’ scheme. Residents can also expect to be protected by the homes recruitment procedures, however they cannot expect to be protected from potential harm until all staff has received training in the protection of vulnerable adults, first aid and food hygiene. EVIDENCE: The home provides 24-hour care and the staff roster confirmed that the home operates with five staff on an early shift and 4 staff on a late shift. Four care staff were working between the hours of 8am to 6.30pm and one member of staff was working 8am to 2pm. Three care staff were working between the hours of 6.30pm to 10pm and one member of staff working 2 to 10pm. Three night staff work between the hours of 10pm to 8am. There is a senior member of staff on each shift included in the numbers. The care staff are supported by a catering team, consisting of a manger, cook and three assistants. The catering manager and the cook were both on duty on the day of the inspection; the catering manager uses this opportunity to complete paperwork and ensures that the kitchen has a thorough cleaning. The home employs one maintenance person who was working between the hours of 8am to 4.30pm. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 19 The manger provided the inspector with a copy of the home’s training matrix. Which was divided between statutory and non-statutory training. The home has 50 of staff qualified with a National Vocational Qualification (NVQ). Out of 21 care staff, 8 have completed NVQ 2, with three in the process of completion. Two staff have completed their level 3. The home employs 15 ancillary staff, 2 had completed their NVQ level 1 and 1 has completed level 2. The recruitment and selection process for new staff was inspected. Two staff files seen contained all the necessary checks, including a criminal records bureau check (CRB), protection of vulnerable adults (POVA 1st) and two satisfactory references. Both files seen had a completed terms and conditions of employment and evidence that the staff had completed or was in the process of completing the sector skills council for social care (TOPPS) induction and foundation training. In the front entrance hallway the home has an album displaying all staffs training certificates, including the BUPA ‘Personal Best’ certificates. The personal best programme is designed to offer residents a greater level of individual care. A senior member of staff informed the inspector that this provides staff with the opportunity to build their own plan of improvement and development. The staff and supervisor set out the plan and once the staff member has achieved their goals they are awarded a certificate and a badge. Staff can go on to achieve further personal best certificates and if they obtain a gold for outstanding achievement they are awarded a luxury holiday and a sum of money from BUPA. The training matrix identified basic food hygiene, abuse training and first aid as non-statutory training, however these are safe working practices that all staff must receive training for in line with the requirements of the national training organisation (NTO). The matrix showed that not all staff had received recent up to date training in all three areas. However, the matrix did reflect that all staff had received recent training for moving and handling, health and safety, dementia, nutrition, pressure area prevention and fire awareness. Five staff had attended catheter care training and eight designated members of staff had received training for the administration of medication. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 38, The results of the quality assurance survey show that residents and relatives are happy with the service they receive. To ensure the health and safety of residents, staff and visitors, risk assessments need to be expanded to give more detailed information of the potential hazard and give specific actions to minimise or eliminate the risks. EVIDENCE: BUPA has a quality assurance and monitoring systems in place. The inspector was shown the result of the most recent quality assurance survey. The survey covered all areas of the service covering a range of topics, for example, the quality of service provision, friendliness of staff, staffs knowledge of residents needs, promptness of staff response, meals, administration, laundry services, cleanliness and maintenance of the home and grounds. The results in percentages reflected that users of the service and relatives were very satisfied with the service they receive. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 21 A recommendation made at the previous inspection in March 2005 was for an appropriate receipt book to be used when receiving monies for safe keeping from residents. The manager showed the inspector the receipt book and evidence was seen that this was being used to provide proof of receipt of monies being received on behalf of the resident. Time was spent discussing the risk assessment process with the maintenance person. They hold the responsibility for co-ordinating health and safety within the home. The risk assessments seen covered a range of topics however there needs to be more explanation of the risks and potential hazards to residents, staff or visitors to the home and more detailed specific actions to minimise or eliminate the risks. The maintenance person had attended a course on risk assessments but this was along time ago, and they felt that they would benefit from refresher training to bring them up to date with current legislation and extend their knowledge of the risk assessment process. The maintenance person showed the inspector the fire logbook, which had detailed records of the fire system and fire equipment being tested and serviced on a regular basis. A record of staff training including fire drills was also recorded. As part of their role as health and safety co-ordinator the maintenance person is responsible for fire safety training. BUPA have produced a training pack, which is very comprehensive and gives staff an overview of all aspects of fire safety and their responsibility to follow the appropriate fire procedures within the home. Records were also seen for the provision and maintenance of the window restrictors and monitoring of water temperatures. The maintenance person had been on a portable appliance-testing (PAT) course and was responsible for testing all portable electrical appliances within the home. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP3 Regulation 14,Sch 3 (1)(a) Requirement Pre admission assessments must be undertaken and fully completed, signed and dated prior to the resident moving into the home. Staff must receive training the protection of vulnerable adults to protect residents from potential harm or abuse. Timescale for action 30/03/06 2 OP30 13(4) (c) 13 (6) 30/03/06 3 OP38 13 (4) Risk assessments must be 01/03/06 expanded and contain more detailed information of the potential hazards to residents staff and visitors. They must give specific actions to minimise or eliminate the risks. Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 24 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. Refer to Standard OP10 Good Practice Recommendations Consideration should be given to the resident’s choice and preference with regards to receiving personal care from staff of the opposite gender and have written consent within their care plan to support their decision. Residents should be consulted and have a programme of activities that include local, social and communal activities appropriate to their assessed needs. 2. OP12 Highfield House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 House Residential Home DS0000024415.V277333.R01.S.doc Version 5.1 Page 26 - 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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