Inspection on 20/05/08 for Highfield Nursing and Residential Home

This inspection was carried out on 20th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highfield Nursing and... 03/05/07

Highfield Nursing and... 29/06/06

Highfield Nursing and... 06/01/06

Highfield Nursing and... 08/08/05

Highfield Nursing and... 04/01/05

Highfield Nursing and... 07/07/04

Highfield Nursing and... 31/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Highfield Nursing and Residential Home Mandeville Road Saffron Walden Essex CB11 4AQ Lead Inspector Jane Greaves Unannounced Inspection 20th May 2008 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 Nursing and Residential Home DS0000015401.V364982.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 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 Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Nursing and Residential Home Address Mandeville Road Saffron Walden Essex CB11 4AQ 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) 01799 524936 01799 526116 Tronicgold Limited Manager post vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (60), of places Physical disability (3), Physical disability over 65 years of age (25) Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 50 years and over, who require nursing care by reason of a physical disability (not to exceed 3 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 25 persons) Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 60 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 11 persons) The total number of service users accommodated must not exceed 60 persons 3rd May 2007 Date of last inspection Brief Description of the Service: Highfield Nursing & Residential Home was opened in 1990 and consists of a two-storey building with newer purpose built single storey accommodation. It is located in a quiet cul-de-sac within walking distance of the centre of the North Essex town of Saffron Walden. Highfield is accessible by road and rail and the nearest station is in Saffron Walden. Parking is available in the visitor’s car park and in the adjacent road. There are 42 single en-suite bedrooms and 9 double bedrooms. 8 of the double rooms are en-suite. There are two passenger lifts. The home has several small courtyard gardens that are attractive and accessible to wheelchair users. All ground floor rooms that face onto the courtyard garden have French windows to give the residents access to the gardens. Highfield Nursing & Residential Home provides nursing and personal care with accommodation for up to 60 residents. Tronicgold Ltd privately owns Highfield NH, which is part of Carebase Ltd. At 20th May 2008 the range of fees paid for care and accommodation at Highfields Nursing Home ranged from &541.77 in shared accommodation to £1038.20 dependant upon level of need. Highfield Nursing and Residential Home DS0000015401.V364982.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 was an unannounced ‘key’ site visit. At this visit we considered how well the home meets the needs of the people living there and how staff and management support people to have a lifestyle that is acceptable to them. The level of compliance with requirements made at the previous inspection was assessed. The site visit took place over a period of 7 ½ hours. A tour of the premises was undertaken, care records, staff records, medication records and other documentation were selected and various elements of these assessed. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. Prior to the site visit the manager had completed and sent in to the Commission for Social Care Inspection the home’s Annual Quality Assurance Assessment (AQAA). This provided detail of how the service feels they are performing against the National Minimum Standards, and how they can evidence this. Before the site visit a selection of surveys with addressed return envelopes had been sent to the home for distribution to residents, relatives, involved professionals and staff. The views expressed by visitors to the home during the site visit and in survey responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection. The opportunity for discussion or clarification was given. We would like to thank the manager, staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: Relatives and residents representatives had positive things to say about the care and support people living at Highfields received. Comments included: “I guess it would never be ones choice to end up in a care home either for the resident or the family. But, in our case if we have to be anywhere I feel we have as good as can expect. We really have very little to complain about. Staff are excellent and have become friends to us” Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 6 “The service provides a tranquil atmosphere with caring staff” “The home is warm, provides good meals and 99.9 of the time X is treated with kindness and respect. In the main X and the family are pleased with the home”. The management style is very inclusive and involves the relatives of people living at the home in various steering groups to drive forward the quality of the service provision. 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 Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 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 Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that the care home can support their personal and healthcare needs. EVIDENCE: A Statement of Purpose and Service Users’ Guide were available. The AQAA stated that the manager was working with a steering group made up of relatives of people living at Highfields to develop a Service User Guide providing information in a clear and easily understood ‘user friendly’ manner. This will help people make a choice of care home for themselves or a relative. The manager reported in the AQAA that the homes website and brochure need updating to reflect the change and the range in the services provided. In the relatives and representatives survey conducted as part of the home’s annual quality assurance process 82 of respondants answered positively to the question ‘Did you find the Highfield brochure informative and was it able to answer all your questions?’ Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 9 Pre-admission assessments identifying peoples’ personal and social care needs were available on the files of two people who had recently moved in. These were well completed and informed the home all about them, what they hoped for and the support they needed. The AQAA stated that people were encouraged to visit before they moved in so that they can see the home and get information. One person who had recently moved into the home did so at very short notice, but evidence was available to show that their representative had visited before this happened. Surveys received by the commission as part of this inspection process included the comment “From our initial meeting, which took over an hour, we felt we were part of a partnership caring for our relative”. Intermediate care was not provided at Highfields. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The staff are successful in delivering appropriate care, although this may not always be documented or recorded appropriately. EVIDENCE: The previous inspection of this service identified that care plans did not include any evidence of monthly reviews being undertaken and therefore were not reflecting peoples changing needs. The manager reported, and staff members confirmed, that members of the nursing team had been nominated as key workers for each resident and were responsible for undertaking reviews of peoples’ care needs and documenting any changes made to the care plans necessary to meet the identified needs. However care plan reviews were still not routinely documented in all care plans so we could not be sure that peoples’ changing needs had been identified and that appropriate actions were being taken to keep people safe and healthy. The manager reported in the What we could do better section in the AQAA ‘We could review care plans regularly with varied frequencies according to need’. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 11 Risk assessments were present in the 3 care plans viewed however the way information was presented was not always effective as it was not always clear what actions had to be taken to reduce or remove the risks. Areas of risk assessed included maintaining a safe environment, falls, mobility and nutrition. Daily recording related to personal care or healthcare needs with no reference to peoples’ spiritual, social or emotional needs. Daily records were mainly clinical with little recording of the holistic approach that is evident at the home. All people living at Highfields had the choice of which GP attended to their healthcare needs; the manager reported there were five surgeries involved with the home. One person said, “Healthcare support here is absolutely marvellous, you only have to mention that something is bothering you and a doctor is called. ” Family members responded via surveys that they were generally happy with the healthcare provided for their relatives. Comments included “The nurses are very good at telling me any change in X’s health or if a doctor has been called” and “I can only speak for my relative’s needs. X is being looked after in a proper manner, I have no complaints” The staff skill mix in the home ensured that the health care needs of people were being met. Qualified nursing staff administered medication. There was no evidence to confirm that refresher training had been provided for staff members to ensure their skills and competencies were up to date however, the organisation’s peripatetic clinical manager spent time working with the home in the early part of 2008, she focussed on medication practices and procedures, the whole administration cycle. The manager reported plans for improvement in the AQAA as being ‘Improve processes and procedures of administration of medication’ and ‘Train nurses and seniors in the safe administration of medication’. Medication Administration Records (MARs) were completed appropriately with no gaps in recording and medications were stored securely in trolleys to facilitate safe transporting around the home. Trained staff were observed giving out lunchtime medications, approaching each person individually and assisting them to take their tablets. One Nurse observed administering eye drops to a person at the dining table, did not offer the person a tissue, the drops trickled down her face and into the person’s mouth. The nurse then walked away from the table leaving the resident with her spectacles lying on her dinner plate. During a physical tour of the home that was undertaken at the beginning of the visit it was noted in the communal ‘Garden Lounge’ in the dementia unit that there were records relating to peoples’ personal and physical well being on a cabinet in full view of visitors and other people living at the unit. One person spoken with reported that she felt that staff members were good at respecting her dignity with personal hygiene practices such as bathing. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 12 One person was observed being transferred from armchair to wheelchair with the use of a hoist in the communal lounge. Staff used a privacy screen whilst this was being performed to ensure the persons’ dignity was respected. All shared bedrooms had fitted privacy curtains. Relatives surveys included the comment “There is the odd occasion when X’s opinion is not respected eg in what she is to wear for the day. There have been a few occasions when X has been without false teeth: this has not been rectified until visitors have called in – one occasion after lunch”. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to have a lifestyle that matches their expectations through good opportunities for activity, and nutritional, enjoyable food. EVIDENCE: The routines of daily living and activities were flexible and varied to suit peoples’ expectations, preferences and capacities. In the entrance hall and in each person’s bedroom there was a ‘menu’ detailing the dates and times of the varied activities and entertainment available through the week. These included quizzes, craftwork, crosswords, flower arranging, outside entertainment such as singers and one to one time for those people not wishing to partake in group activities. The activity co-ordinator was seen greeting all the residents and asking if they would like to take part in the day’s scheduled activity. There was not a lot of interest on this day however it was reported that the attendance levels varied greatly. Pre-admission assessments included detail of peoples’ interests before entering the home however this was an area not continued within the care plans. The activities officer had a great deal of information about individuals and their likes and dislikes however there was not a system for recording the outcomes of activities sessions and how people reacted to different forms of stimulation. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 14 Consequently this information did not feed into the care plans and was not considered at reviews. The manager reported in the AQAA in the plans for improvement section that the service will provide a training programme for the activities organiser to introduce focus on quality and person-centred activities and to create a stronger link between the activity officer and the care team. There was a hairdressing salon with visiting hairdresser and beauticians 3 days per week. During the day people were observed having manicures and enjoying a chat with the beautician, one lady spoken with was very pleased with the wash and set she had just had. It was reported that the hairdressers work with the people living at the home and their families to choose individual styles and cuts to suit individuals. Observation confirmed that people were supported to bring personal items into the home with them if they wished to do so, ranging from ornaments, photographs and pictures to items of furniture. Visiting at the home was open and people could receive visitors at any time. During the site visit people were always made welcome and offered refreshment. One visitor said, “We are free to come and go, there is a home from home feeling”. On surveys it was said “I can come into the home what ever time I like and its always the same.” The service had a varied menu that included a vegetarian alternative meal of the day. The Chef reported that if people were really not happy with the options on offer for the day he provided individual meals for them. The kitchen was efficiently run and well equipped. The Chef reported he had autonomy over ordering food supplies and dealing with equipment maintenance as necessary. The dining room was not large enough to seat all people living at Highfields. People observed eating in their rooms at this visit confirmed that it was their wish to do so. We dined with residents at this visit and noted the experience was social and chatty for some whilst others sat and ate in silence. Staff members were helpful, cheerful and sensitive to peoples’ needs; the food was well presented and tasty. Comments from people living at the home included “Food is A1, very good indeed, great variety”, “ Food is not very clever, it is ordinary” and “The food is very good, I have a special diet and the chef really does a good job”. The manager reported that a corporate menu was to be rolled out across all the homes in the group however the service will have the autonomy to take what parts of the menu that are appropriate to the people living at the home and build around that. For example it was reported that people living at Highfields did not enjoy pasta meals so alternatives would be chosen by residents to replace these. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 15 Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to raise concerns about the service and feel safe living at the home however the staff’s training provision and the home’s recruitment practices do not always promote peoples’ safety and well being. EVIDENCE: The manager’s AQAA stated that all staff and volunteers were trained in matters relating to safeguarding vulnerable adults and that Highfield promoted and applied zero tolerance with regard to any form of aggression, violence or discrimination. Training records provided subsequent to this inspection visit indicated that 37 of the 58 staff members had current training in adult safeguarding. Of the 21 staff that were recorded as not having received this training 13 were reported to be new to the service, however, start dates for those staff members ranged from October 2005 to date. Staff members spoken with were aware of adult safeguarding procedures and were able to tell us what they would do if they had any concerns. Family members reported they felt their relatives were safe at Highfields and one resident told us “I couldn’t feel any safer living anywhere else”. Recruitment practices did not always include all the checks necessary to promote the safety and welfare of people living at the home. (Detail at standard 27) Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 17 The service had received three written complaints since the previous inspection visit. All had been dealt with in timescales according the the home’s policies and procedures, one had been substantiated, one had been unsubstantiated and one partly substantiated. The manager reported that any concerns raised verbally were dealt with immediately before they could ecscalate however these issues were not always recorded. A discussion was held with the manager about the importance of recognising all complaints and using them as a positive tool to drive forward the quality of the service provision and to be able to identify patterns of complaints. Family members reported in surveys “Any problems we have had have been dealt with very efficiently”. A “Comments” book in the foyer invited visitors to give feedback regarding the home and the service. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a pleasant and clean home that is suitable to meet their needs. EVIDENCE: Highfields provided a comfortable and homely environment for people to live in. The site visit included a complete tour of the premises, it was noted that the home was clean and tidy, and generally well decorated and maintained throughout, with no evidence of any unpleasant odours. Carpets and furnishings were of a good quality however it was reported that the pattern of the carpets in the communal areas did cause some people to think that there were biscuits on the floor, this could cause a potential risk to peoples’ safety when bending to try to pick them up. Living areas were arranged around pleasant courtyards that were easily accessible and attractive with some seating, hanging baskets and planting. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 19 It was noted that one person’s room close to the kitchen is very noisy, especially around mealtimes, with the sound of pots, pans, cutlery, crockery and staff chatting. The bathrooms were in good order and included aids and adaptations to meet the needs of the people using the service. There were sufficient toilets to enable immediate access. There was a competition in progress amongst the sixteen homes within this care home group to create a ‘special garden’ in the outdoor space adjacent to the dementia unit. To date the walls were painted pale blue, there were colourful lanterns, a wall fountain and some sensory planting. This was work in progress at this visit. Hoists and wheelchairs were seen stored in the corners of the communal lounges and in some corridors, the staff and manager acknowledged that this was not altogether suitable however there were no designated storage areas for such equipment. Surveys received from family members prior to this visit varied in their opinion of the home’s cleanliness. Comments included “Good standard of cleanliness”, “Cleaning of rooms, carpets and chairs could be improved” and “Cleanliness could be a little more thorough”. People living at the home were happy with the way their home is kept clean; their comments included “It is lovely and clean, the staff work so hard” and “You can’t fault it, it seems to be lovely all day long”. Rota’s confirmed that housekeeping staff were employed daily at the home from Monday to Friday however there was no evidence to show that there was consistent weekend cover available for cleaning duties. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Highfields can expect to be supported by staff who have a good level of basic training but who may need refresher training to ensure their skills are maintained. Recruitment practices do not always ensure residents are protected from risk of harm. EVIDENCE: People living at the home were complimentary about the care and support they received. “ One or two who are perfect. X is an absolute marvel some you need to tell what to do, not X, she knows exactly what to do” and “Very happy here, they are very good indeed” Relatives’ views were varied about the care and support provided. “The staff are excellent and have become friends to us”, “The staff seem very busy and there is not always a member of staff in the lounge when residents are getting anxious”, “The staff at Highfield do an excellent job” and “Staff should take more time to chat with residents who get lonely or bored” were some of the comments made. Staffing levels were maintained at nine care staff plus two qualified nurses during the morning period, seven care staff plus two qualified nurses during the afternoon and evening, and three care staff and one qualified nurse at night. This means that at night there were 4 people to attend the needs of 60 Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 21 people in a home that is very spread out and arranged in corridors around two courtyard areas and on two floors. This is equivalent to 1 person to 15 residents some with higher dependency levels than others, a discussion was held around the potential risks should an incident arise at night. A deputy manager had been appointed and was due in post imminently. Domestic, laundry and catering staff were provided and an administrator and full time handyman were also employed. Staff and managers spoken with felt that the daytime staffing numbers were sufficient to meet the needs of the people living at Highfields. Some relatives reported, “Sometimes it takes the staff a while to respond to the bell” and “On occasions X’s bell could be answered more quickly”. Observation on this day was that call bells were answered promptly and residents spoken with were generally happy with staff response times. The home employed some overseas staff with nursing and midwifery qualifications from their country of origin however they weren’t recognised as being trained to NVQ level 2. The manager was in the process of exploring what needs to be done to obtain NVQ accreditation for these nursing staff working as care assistants. The manager’s AQAA stated that the service had a ‘robust recruitment process that meets all legal and regulatory requirements ensures that all staff are thoroughly checked out and suitable for their job before commencing employment’. 3 staff files were viewed at this visit. For a returning member of staff there was no evidence that a reference had been obtained for a post held since leaving this service previously and there was no evidence of a check made against the Protection of Vulnerable Adults register before this person recommenced working at Highfields. A work permit for a person recruited from overseas indicated that she was working at another home within the organisation. The home had recently had an internal audit of staff files by the Organisation’s HR department. The file of one person recently recruited to the home contained all the information necessary to confirm that all the pre-employment checks had been made prior to the person starting to work at the home in order to safeguard the well being of people. The procedures were confirmed during conversation with this person. A staff training matrix was provided at the site visit however it was found not to be an accurate reflection of the training provision in the home, an updated matrix was provided subsequent to the visit. The matrix showed us that 40 of the 58 staff employed to work at Highfields had received training/refresher training in moving and handling and Fire safety Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 22 and 36 of the 58 staff had attended Health and Safety training. The service does not routinely provide infection control training for the staff team. The manager acknowledged that Induction programme is not currently in line with the Skills for Care common induction standards. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Highfields can be assured that the management is working towards improving the service and that their opinions are central to how the home develops. EVIDENCE: Although the manager has significant previous care experience and has achieved the Registered Manager’s Award (This is a recognised qualification for people who manage care homes.), as yet they have not been registered with the Commission for Social Care Inspection. Records showed us that the manager has attended training in the Protection of Vulnerable Adults and dementia care since the previous inspection of this service however has not attended recent training in fire safety or health and safety. Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 24 The AQAA form completed by the manager previous to this visit contained clear and relevant information that was supported by a wide range of evidence. The AQAA told us about changes they have made and where they still need to make improvements. It shows clearly how they are going to do this. The data section of the AQAA was not fully completed Feedback from staff included “She is a really good manager to work for, she is firm but fair” and relatives comments included “There is a good management team, which seems to be respected by the staff. Often firm – so you can see the sense of leadership and direction. Good continuity of staff, many of them have been here for many years” The manager has a very inclusive attitude to running the home involving residents’ families with various working groups to continuously improve the outcomes for the people living at the home. The service has an annual quality assurance process involving the residents’ representatives that covers every aspect of peoples’ lives at Highfields. Any areas of shortfall were identified and summarised in an action plan. It is company policy that the home does not look after personal monies on behalf of the people that live there. This is the responsibility of families, repre4sentatives or advocates. If any personal items such as toiletries are required the staff contact family members and items such as newspapers, chiropody, hairdressing and beautician are invoiced to the relatives and representatives quarterly. No major health and safety issues were noted at this site visit. From training information available staff are not all up to date in moving and handling, fire safety and health and safety training. Fire records viewed were satisfactory. Regular fire drills and testing takes place and evidence was available to show that equipment checks takes place. It was advised that a staff matrix of people attending drills be maintained, so that it can be easily identified that all staff attend drills on a regular basis. Highfield Nursing and Residential Home DS0000015401.V364982.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 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 3 Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans should be reviewed regularly and appropriate changes made as necessary to ensure peoples’ needs are met as they would wish. Care plans must contain details of the actions needed to ensure all the residents’ personal, social, emotional, spiritual and nursing needs are met. Previous agreed timescales 30/09/06 and 31/07/07 were not met. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 27 Highfield Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Nursing and Residential Home DS0000015401.V364982.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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