Inspection on 07/04/05 for Highgrove

This inspection was carried out on 7th April 2005.

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

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

Other inspections for this house

Highgrove 18/03/08

Highgrove 22/10/07

Highgrove 05/05/06

Highgrove 06/10/05

Highgrove 10/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Highgrove Stapehill Road Stapehill Wimborne BH21 7NF Lead Inspector Jo Palmer Unannounced 07 April 2005 10:15 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 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. Highgrove Version 1.10 Page 3 SERVICE INFORMATION Name of service Highgrove Address Stapehill Road, Stapehill, Wimborne, Dorset, BH21 7NF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01202 875614 01202 861296 Samily Care Ltd Mrs Janice Rose CRH 21 Category(ies) of OP - 21 registration, with number of places Highgrove Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 September 2004 Brief Description of the Service: Highgrove is a well established care home which has been operational since 1991; the home changed hands in June 2004 and is now owned by Mr & Mrs Bleach under the company name of Samily Care Ltd. Mrs Janice Rose remains as the registered manager. The home is registered to accommodate a maximum of 21 elderly frail persons. The property is a large Victorian house that has been extended and is set in grounds of approximately three quarters of an acre. There are pleasant gardens laid mainly to lawn with flower boarders and patio area. The home is situated in Stapehill between the towns of Ferndown and Wimborne and is a short walk from the local bus route and post office. The home provides accommodation for service users on ground and first floor levels. The first floor is accessible by a central stairway, and there is no lift. Catering and laundry services are available on site with domestic washing machines and dryers. Highgrove Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 8th April lasted for five hours. Janice Rose, the registered manager was having a day off, Sally Anstee, deputy manager provided the inspector with the necessary records. Mr & Mrs Bleach, owners of Samily Care Ltd, the registered company, arrived for the last hour of the inspection visit. The last inspection of Highgrove raised some concerns about the safety of service users. Highgrove has been inspected once previously in September 2004 since the current owners have been registered. Following this last inspection, Mr & Mrs Bleach sent an action plan detailing how, and by when, requirements would be addressed. The purpose of this inspection was to measure progress in meeting these requirements and developing the service. The inspector spoke with four residents, one care assistant, the deputy manager and Mr & Mrs Bleach, toured the premises and examined relevant records. What the service does well: What has improved since the last inspection? The interior décor of the home and the exterior front driveway have been improved. Records of resident’s financial management are clearer. Highgrove Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highgrove Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Highgrove Version 1.10 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 standard(s) 1 & 3 Prospective residents do not have sufficient or correct information to make an informed choice about whether to move to Highgrove. The assessment process is insufficient and does not enable the home to thoroughly assess a persons needs or establish whether those needs can be met at Highgrove. EVIDENCE: The Statement of Purpose and Service User Guide held in the entrance of the home is out of date and refers to the previous registered person. The Service User Guide does not contain all the information specified in Schedule 1 of the regulations. The deputy manager stated that residents have a copy of an up to date Service User Guide in their rooms; on a tour of the premises this was found not to be the case, Mrs Bleach later confirmed that copies were being up-dated and were in the manager’s office. Residents spoken with stated they had not had a copy of this information. One care file reviewed did not have a pre-admission assessment. Where preadmission assessments were seen, they did not evidence an assessment of the persons emotional, psychological and mental health needs. One person Highgrove Version 1.10 Page 9 referred through care management arrangements did not have a copy of the summary of the care management assessment until the day after admission, the home had not undertaken their own assessment resulting in this person being admitted to the home without any acknowledgement or recognition of their needs. There was no evidence of the resident’s involvement or consultation in the assessment process or their agreement with the outcome. Highgrove Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The systems for resident consultation are poor with little evidence that resident’s views are sought or acted upon. There is no comprehensive or reliable care planning system in place to effectively provide staff with the information they need to satisfactorily meet resident’s needs. Resident’s health needs are met in part through visits to doctors and other health professionals as required. Procedures for managing medication do not meet the guidance of the Royal Pharmaceutical Society, and therefore do not provide protection for residents. The manner in which residents are addressed by staff is generally, but not always respectful. EVIDENCE: Care plans are generic in nature with each resident having the same plan of care for daily routines and personal care. More personalised care plans are added if there is an individual need. One resident with quite complex needs did not have a care plan; there were no assessments of need or of risk. There was no evidence of assessment of mental health needs. Information held on one Highgrove Version 1.10 Page 11 file stated the resident was at risk of wandering and becoming lost, there was no associated care plan and daily records showed this person leaving the home, unattended, several times each week. Care plans are not written in consultation with the resident. Recording of appointments held with health care professionals evidenced that residents are able to see their GP, optician, dentist, chiropodist etc as required, residents spoken with also confirmed this to be the case. One care file however did not contain any form of assessment or care plan in relation to meeting the person’s health needs in relation to diabetes, another held insufficient evidence of pressure relief where it was evident that this person had needs in this area. Examination of records of medication administration found them to be incomplete with some gaps in recording, not indicating whether medication had been given or omitted. Some medicines were held in plastic pots, these were unmarked, therefore unidentifiable in relation to the drug, their purpose or the person for whom they were prescribed. Residents spoken with confirmed that they are treated respectfully. One care file examined explicitly stated the resident’s preferred term of address; this was not respected, staff both verbally and in writing (daily records) referred to the resident by the given name rather than the preferred name. Highgrove Version 1.10 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 standard(s) 12, 13, 14 & 15 The social, cultural, and recreational activities provided by the home or by families meet the expectations of residents. Relatives and visitors are welcome in the home at any time with no restrictions. Residents are able to enjoy self-determined activity as far as their health and general abilities allow. Support from the home in enabling residents to exercise choice was not measurable as written assessments and care plans did not indicate their involvement. A good, wholesome, varied diet is provided offering a choice of menu. EVIDENCE: Daily care records demonstrated the extent to which each resident participates in the home’s programme of activity including sing-a-longs and ‘extend’ exercise classes. Records also demonstrate frequent visits by friends and families and levels of independent activity. Care records do not indicate the residents participation in decision making processes. Menus and records of meals provide identified a choice of two dishes at the midday main meal and two evening meal choices. Residents spoken with confirmed that the provision of meals was good. Highgrove Version 1.10 Page 13 One resident commented that she ‘wants for nothing’, and another said that ‘nothing is too much trouble for staff’. Highgrove Version 1.10 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 standard(s) 16 & 18 Complainants are not directed through a written procedure detailing how their concerns will be addressed, therefore, they cannot be confident that their complaints will be listened to or taken seriously. Procedures for responding to suspicions of abuse are not held in accordance with Department of Health guidance, therefore, any allegations of abuse cannot be managed effectively. EVIDENCE: The Service User Guide, which contains the complaints procedure is out of date and has not been provided to all residents and their representatives. However, a complaints log is held evidencing that residents do feel able to raise their concerns with staff. The record indicated complaints that had been received verbally although no written response to the complainant was available. There have been no complaints since the last inspection. A copy of the local authority multi-agency guidelines, ‘No Secrets’, is available for staff reference detailing action to be taken if any form of abuse is suspected or reported. There is a policy also with procedural guidance written by the manager at Highgrove, which provides contradictory information and does not refer staff to the ‘No Secrets’ policy. Highgrove Version 1.10 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 standard(s) 19, 21, 23, 24,, 25 & 26. Recent investment has improved the appearance of the home creating a better environment for those living there and visiting. Risks posed by exposed radiators and hot water compromise the safety of residents. Residents live in a comfortable, clean environment with their own belongings around them. Facilities for staff to ensure against the spread of infection are not in accordance with recommended best practice. EVIDENCE: There has been ongoing decoration and some refurbishment since the last inspection. The entrance hall, stairways and landings and some of the bedrooms have been decorated. Mr Bleach confirmed that all bedrooms would all be decorated as they become vacant. The front driveway has been re-laid Highgrove Version 1.10 Page 16 providing more parking spaces and a more attractive entrance and better parking. There are sufficient numbers of lavatories and washing facilities. In one ground floor lavatory the toilet paper holder was fixed to the wall in a position that was out of reach of the toilet. Mr Bleach confirmed after the last inspection that hot water temperatures were regulated to a temperature around 43°C. This inspector noted the water temperature in the first floor bathroom to be too hot to place a hand under. Not all radiators are guarded and residents needs in relation to the risks posed by this have not been assessed. Residents spoken with confirmed that their bedrooms suited their needs although one resident on the first floor stated that the stairs were getting difficult to negotiate; there is no lift. There is sufficient communal space although residents tend to prefer the sun lounge and dining area to the rear of the home, the front sitting room area is not used and Mrs Bleach confirmed that it is sometimes used for storage as it was on the day of inspection. Mrs Bleach confirmed that this room might be converted to provide alternative dining room space, the present dining area being cleared to extend the rear lounge. Some bedroom doors have been replaced and include suitable locks. The bedroom doors that have not been replaced have deadlock style locks that would not be accessible from the outside in the event of an emergency. Not all rooms provide lockable storage for residents to secure any valuables or medication. Infection control procedures are in place although there is no provision of satisfactory hand washing facilities for staff. The lid on one sanitary disposal bin was broken, on another the lid was missing. Highgrove Version 1.10 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 There is a stable, consistent staffing group that is sufficient although for residents to be confident that there are sufficient numbers of staff, they should undergo a thorough assessment of their care needs. EVIDENCE: Staff rotas demonstrated the numbers and skill mix of staff on duty; residents spoken with confirmed that there were always sufficient staff available to assist them. Staff recruitment records were not available. Staff training records were not assessed. Resident’s spoken with complimented the staff in the home and the care received, one stating that ‘nothing was too much trouble’ (for staff) and another saying that ‘they will get you anything you need’. Highgrove Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 & 37 Some management practices do not promote and safeguard the health, safety and welfare of residents. Residents are assured of sound management of their financial interests. Records held in relation to assessments and care plans do not safeguard the rights and best interests of residents. EVIDENCE: The registered providers confirmed that they visit the home several times each week to support the manager. Staff spoken to are not actively involved in management decisions in the home. The deputy manager confirmed that she is not involved in the care planning process or resident consultation. Staff spoken with confirmed that they do write daily records relating to residents care but do not contribute to care reviews and do not look at care plans. Highgrove Version 1.10 Page 19 When the manager is absent as on the day of inspection, neither staff or registered providers have access to some of the records in the home, which are locked away in the managers office. Records relating to assessment and care planning require attention. Highgrove Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION x x 2 x x 2 1 1 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 x 2 x x 3 x 1 x Highgrove Version 1.10 Page 21 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 1 Regulation 4&5 Requirement The registered persons must supply a copy of the Service User Guide to each service user; this must contain a summary of the homes Statement of Purpose, complaints procedure and the latest inspection report and must hold up to date informaiton about the current circumstances of homes ownership. (Previous time-scale of 31/12/04 not met) Accommodation must not be provided to persons at the care home until their needs have been assessed; assessments must be comprehensive and provide sufficient detail to enable staff at the home to understand the needs to be met. All service users must have a full and comprehensive assessment on which to base an individualised plan of care that must be followed in order that care needs can be met and risks reduced or eliminated. Service users must be consulted with regard to decsion making prosesses of assessment and care planning. Version 1.10 Timescale for action 30 June 2005 2. 3 14 30 June 2005 3. 7 14 & 15 30 June 2005 Highgrove Page 22 4. 8 13 5. 9 13 6. 16 22 7. 18 13 8. 25 13 9. 25 13 Where service users have specific health needs, these must be assessed by persons qualified to do so and any necessary action detailed in a plan of care; in this instance, relating specifically to diabetic care and pressure relief. Records of medication administration must indicate what medication is used, ommited or returned to the pharmacy and for what reason. Storage of medication must be secure with each medication held in its original, named container. The homes complaints procedure must be available to all service users and their representatives. Any complaint received must be responded to formally in the given time-scale (28 days) detailing the outcome of any investigation and any further action necessary. (Previous time-scale of 31/12/04 not met) The homes procedure for responding to suspicion or evidence of abuse or neglect (including whistle blowing) must be held in accordance with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets. (Previous time-scales not met, requirement repeated for the fifth time) Pipe-work and radiators must be guarded or have guaranteed low surface temperatures. (previous time-scale of 31/12/04 not met) All service users must have an assessment in relation to the risks of accidental scalding posed by unguarded pipe-work and radiators. Failure to comply may result in enforcement action. Version 1.10 30 June 2005 7 April 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 Highgrove Page 23 10. 25 13 11. 38 13 12. 26 13 13. 37 17 14. 29 19 All service users must have an assessment of the risks of accidental scalding posed by hot water temperatures that are above 43 degrees in both baths and wash basins. Hot water temperatures must be regulated by means of working thermostatic valves to a temperature close to 43 degrees centigrade. Failure to comply may result in enforcement action. In the absence of a lift, service users must be assessed with regard to any risks posed in negotiating the stairs in the home and where a risk is identified action must be taken to eliminate this risk. To prevent the spread of infection, staff must be provided with suitable hand washing facilities including anti-bacterial soap and disposable towels. Records required by regulation must be avaialble for inspection; when the manager is not avaialble, access to locked records should be provided for the senior person in charge of the home and for registered providers. Evidence of a new employees identification must be held on file. Two written references must be held in respect of each employee. New staff must only be confirmed in post following completion of a satisfactory Criminal Records Bureau and must be supernumerary until such time as this confirmation is received. (This requirement was made at inspections dated 14/08/02, 15/05/03 and 21/10/03 when home was registered to the previous owner Version 1.10 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 Highgrove Page 24 although managed by the current registered manager. The requirement was repeated at the first inspection of Samily Care Ltd on 21/10/03 and is repeated here as records were not avaialble during this inspection. Failure to comply may result in enforcement action) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 10 21 24 Good Practice Recommendations Service users preferred term of address should be respectfully used by staff. All lavatories must be supplied with accessible toilet tissue in service users reach. Bedroom doors should be fitted with suitable locks that are accessible from the outside in the event of an emergency unless the reasons for not having a lock are detailed in individual plan of care. All service users should be provided with lockable storage space in which to secure their money, medications and valuables unless the reason for not having such storage is detailed in their individual plan of care. The registered persons should make arrangements for management strategies to be inclusive of service users and staff particularly with regard to the consultation process and process of assessment and care planning. 4. 24 5. 32 Highgrove Version 1.10 Page 25 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF 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 Highgrove Version 1.10 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. 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