Inspection on 10/11/05 for Highgrove Care Home

This inspection was carried out on 10th November 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

Highgrove Care Home 27/09/06

Highgrove Care Home 22/06/05

Highgrove Care Home 16/02/05

Highgrove Care Home 17/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Highgrove Care Home Highgrove Care Home West Rd Mexborough Doncaster South Yorkshire S64 9NL Lead Inspector Janet McBride Unannounced Inspection 10th November 2005 10:30a 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 Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 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. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highgrove Care Home Address Highgrove Care Home West Rd Mexborough Doncaster South Yorkshire S64 9NL 01709 578889 01709 578842 paulhulbert@ntworld.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Winnie Care (Highgrove) Ltd Mrs Christine C McDonnell Care Home 78 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (57) of places Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. One named Service User under 65 years old. Highgrove Care Home provides a separate 21 bedded EMI residential unit. The Registered Manager, Christine McDonnell, must undertake and complete further training on Dementia Care conversant with her professional status. Julie Morgan, Care manager, must also undertake and complete further training on Dementia Care. 22nd June 2005 Date of last inspection Brief Description of the Service: Highgrove Care Home provides residential, nursing care and accommodation for older people and is registered for 78 beds, comprised of a nursing and residential unit and a separate 21 bedded residential EMI unit. Highgrove was first registered in July 2002. It is owned by Winnie Care, who has other homes in the area. Highgrove Care Home is located in the town of Mexborough and is in within walking distance to local shops, public houses and other community amenities. All the bedrooms are single, and the home has two specific bedrooms for high dependency nursing service users. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Highgrove Care Home, on the 10th November 2005, commencing at 10:30 and finished at 15:30,this was the homes second Inspection since April 2005. Any standards not covered in this inspection were covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. The manager was on annual leave and one of her deputy’s was in charge at the time, and the company’s operations manager was also available to discuss and issues. During the Inspection we looked at chosen number of documents, sampling of records, and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with residents, and feedback from relatives and visitors on the day. A second visit was made to the home to give feedback to the manager, and discuss any further issues. What the service does well: What has improved since the last inspection? The home has addressed all the requirements made at the last Inspection; new blinds have been fitted in the large lounge to ensure comfort to residents during the hot weather. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 6 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. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 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 Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 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): 346 Residents can visit the home prior to their admission to assess if they want to live there, and new residents are admitted on the basis of a full assessment has been completed, to ensure their needs will be met. EVIDENCE: The home offers a wide range of services, including specialised e.g. dementia care. Service users are assessed for residential EMI and residential and nursing care needs, the home does not offer intermediate care. Those care plans seen on the day provided evidence that residents had been fully assessed prior to their admission, involving other professional involved in their care, once admitted various assessments had been completed and plan of care put in place, which was relevant for each individual. Staff that was interviewed had the skill and experience to deliver this care. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 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): 789 Residents health, personal and social care needs are assessed and set out in a plan of care to ensure that each resident health care needs are fully met, based on their individual need. EVIDENCE: Care plans seen were found to be of a good standard, and, those care plans seen reflects their health needs by including appropriate risk assessments and body maps are used to document either pressure areas or body marks, nutritional assessments are undertaken and involvement of dietician when required and weight checked on a regular basis. Evaluations were done on a regular basis, evidence that some residents have been involved in planning of their care. Some issues raised on the last inspection had been addressed, and found that staff had completed checklists, and documenting if residents don’t wear dentures or hearing aids, and the reason why. Residents have access to health care services, and evidence that residents are referred to other health professionals when required, the EMI unit also have access to a Consultant Psychiatrist and CPN services that visit the Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 10 home on a regular basis. Residents can also access to dental, optician and chiropody services when appropriate. The homes accident book was seen and appropriate documentation had been completed, the manager also completes a monthly accident analysis report, which was also examined. Medication records were discussed with the nurse in charge; the home has a comprehensive policy on the safe receipt, storage, handling and administration of medication, which complies with the requirements of the Medicines Act. Since the last Inspection the home has arranged for the collection of waste medicines. An audit of the records and stock checked on the day raised some issues; Mar sheets that were hand written were not signed by two members of staff, and no reason was documented when medication was omitted, and waste disposal of medicine records must be signed. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 11 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 14 15 Residents confirm they have choice and control over most everyday issues, therefore they find the home satisfies their needs. Social activities are arranged by the home and residents are able to participate if they wish, to enhance their social and recreational needs. EVIDENCE: Social activities are co coordinated across the home, which are advertised so that residents, relatives and visitors are aware what is taking place within the home. The home arranges monthly meeting for residents and minutes are taken, evidence was seen that kitchen staff have attend these meeting to discuss are issues relating to the food within the home. The home produces a monthly newsletter, which is very informative, and they have an information board, which contains loads of useful information for both residents and visitors for example, results of quality audits undertaken, Inspection reports and how to contact external advocates. Residents were able to confirm that activities take place and informed the Inspector of what took place to celebrate Halloween, pie and pea supper followed by games night, entertainers also come into the home and the home usually take some residents to a pantomime at Christmas, but this year are Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 12 trying to organise a company that will come into the home to perform so all residents will have the opportunity to enjoy this. Some residents seen had the capacity to make choices and could give examples, when to get up and go to bed, what to wear, what to eat and if they take part in activities. When staff were interviewed they were asked about those residents who don’t have the capacity to make choices how the deal with this; always encourage residents to make a choice and involve relatives in this process whenever possible, e.g life history, hobbies and likes and dislikes. Lunchtime was indirectly observed; residents were asked about food at the home, they stated they had a choice, including a cooked breakfast. Assistant cook was interviewed and discussed menu’s state that residents always have a choice, food and drinks available 24 hours a day. Residents likes and dislikes are usually recorded, and she attended the last residents meeting to answer any questions about the menus and food within the home. Evidence was seen that nutritional assessments are completed and involvement of dietician if necessary. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 13 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): 18 Residents are protected by the homes policies and procedures, and resident, relatives and visitors are provided with information to enable them to raise any concerns or complaints about the home or their care. EVIDENCE: The home does have an Adult Protection procedure including Whistle Blowing. This was discussed with some of the staff seen on the day; and all staff is aware of the homes abuse policy, and could explain to the Inspector about the policy and whistle blowing. All staff is CRB and POVA checks completed, before commencing employment with the home. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 14 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): All of these standards were assessed at the last Inspection, and met. EVIDENCE: Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 15 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): 28 29 30 Recruitment policies are followed ensuring the safety and protection of residents within the home. Training provides staff with the skills and knowledge to fulfil their roles; this ensures that residents are in safe hands at all times. EVIDENCE: Recruitment policy and practice was examined, three files were checked, and these were new staff at the home. It was evident that the home operates a through recruitment procedure, based on equal opportunities and ensues the protection of service users; e.g.two written reference, gaps in employment checked and satisfactory police check completed, PIN and qualifications of nurses, and one nurse confirmed they continue with their own development and attend courses as required by their registration, all files were well organised and easy to follow. The company is committed to providing staff training to ensure that staff fulfil the aims of the home and meet the changing needs of service users. Training and development files available, random files checked show, all staff has their own training file, and all new staff undertake the TOPSS training induction this was confirmed by staff at the home that they work through this package, and other staff members confirm the training they had completed. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 16 NVQ training was discussed with the operations manager, who provided evidence of which staff had completed NVQ training and those staff working towards this. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 17 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): 31 33 35 38 Resident’s benefit from living in a home where the manager is approachable, ensures that their health and safety is promoted and provides leadership, guidance and direction to staff. EVIDENCE: The homes registered manager was visited at a later date has she was on annual leave when the Inspection took place, she,s fully aware of her responsibilities and provides leadership, guidance and direction to staff and tries to ensure that residents receive consistent quality care. She has completed the Registered Managers Award and will commence on a Dementia course, to fulfil her own development needs. Quality monitoring systems are in place and a number of audits have been completed since the last Inspection, and this evidence was available for the Inspector to examine. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 18 Service users money was discussed with the homes operations manager and records checked, which show that each resident had individual monies with appropriate records and receipts kept. Safe working practice was discussed with members of staff, observation of practice and a number of records checked all of which was satisfactory. Records required by regulation and for the protection of residents were all maintained, those seen on the day were up to date and accurate with the exception of medication records. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 19 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 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 Requirement Medication; 1) Handwritten MAR sheets must have two signatures for verification of medication regime. 2) Staff must record reason medication is omitted. 3) Disposal of medication records must be signed. Timescale for action 01/12/05 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 OP28 Good Practice Recommendations A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. Highgrove Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Care Home DS0000058632.V260991.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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