Inspection on 22/06/05 for Highgrove Care Home

This inspection was carried out on 22nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/11/05

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 22 June 2005 13:50 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 CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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@ntlworld.com Winnie Care (Highgrove Limited) 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) Ms Christine 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 J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named Service User under 65 years old. 2. Highgrove Care Home provides a separate 21 bedded EMI residential unit. 3. The Registered Manager, Christine McDonnell, must undertake and complete further training on Dementia Care conversant with her professional status. Date of last inspection 16-Feb-2005 Brief Description of the Service: Highgrove Care Home was first registered in July 2002.The home is registered for 78 beds, comprised of a nursing and residential unit and a separate 21 bedded residential EMI unit. It is owned by Winnie Care and the registered provider is Mr Paul Warwick who is the managing director for the organisation, the operations Manager Moira Ockenden, and the homes Manager Christine McDonnell. All the bedrooms are single, and the home has two specific bedrooms for high dependency nursing residents. Highgrove Care Home is situated in the town of Mexborough and is in within walking distance to local shops, public houses and other community amenities HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A statutory unannounced Inspection was carried on the 22nd and 28th June 2005.On the first day of Inspection the manager was on sick leave, and in her absence the deputy and operations manager were available for comments and any information required. A second visit to the home to assess those standards that relate to the management and required the input of the homes manager. During the Inspection we looked at a chosen selection of the National Minimum Standards, sampling of records, document reading, partical tour of all three units and direct and indirect observation during the Inspection. Individual and group discussions with residents took place, and feedback from relatives and visitors on the day. Comment cards were also left at the home for service users and relatives; who wish to make comments relating to the home. Any issues or concerns that were raised were discussed with the Deputy Manager at the time of Inspection, and verbal feedback session to the manager on the second visit. 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 carpet in the EMI lounge and comments received from visitors of how nice it looks. Nets or blinds have been purchased for some of the bedrooms to ensure privacy for residents. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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 J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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 CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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) None of these standards were assessed at this Inspection. EVIDENCE: HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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 standard(s) 7 10 Each resident receives health and personal care based on their individual needs, but staff do not always document what care has been given. EVIDENCE: Care plans were not case tracked at this Inspection but were examined and looked for specific information on those residents who require the majority of their care whilst in bed. Three residents were chosen, and they were seen in their bedrooms and care plans were examined. All seen were very comfortable with appropriate bedding and pillows for comfort; some were on specialist beds or special mattresses. Care plans seen were found to be of a good standard, and set out in detail what care was required for each individual resident. Evaluations were done on a regular basis, evidence that some service users have been involved in planning of their care. Some issues were raised and these were about staff not completing checklists, e.g. fluid and turn charts. Staff did not always document why residents don’t wear dentures or hearing aids and some had dirty fingernails, all these issues were discussed with the manager. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 10 During the Inspection staff were observed carry out tasks; talking to residents and staff appeared to be both prompt in attending to their care and attentive to residents. Those residents that could voice their opinions had very positive views on the home, stating staff were good and most of them were always cheerful when carry out their duties. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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 standard(s) 13 Resident maintain contact with family, friends and links to local community whenever possible. EVIDENCE: Visitors were in and out of the home most of the time during the Inspection; they saw residents in either one of the lounge areas or in the resident’s bedroom. It was evident on the day of Inspection that visitors were made welcome to the home and those visitors seen stated that visiting was not restricted and they could visit at any time, also state that they are kept informed of what’s happening within the home via a newsletter which is published every month. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 12 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 Resident, relatives and visitors are provided with information to enable them to raise concerns or complaints about the home and their care, and are encouraged to raise issues or concerns however minor they seem. EVIDENCE: The home has an appropriate complaints procedure, and the complaints documentation is organised to demonstrate clear progression through the complaints process and actions taken. Records examined show no complaints since the last inspection, the home also has a concerns book this is to record any minor issues e.g. laundry going missing. Relatives and residents were aware of the policy, and stated they feel they can go to the manager or staff with any minor concerns or issues. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 13 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 20 24 25 26 The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection. Toilet, washing and bathing facilities are provided to meet the needs of residents and private accommodation is furnished and equipped for comfort and privacy, and meets the assessed needs of the residents. EVIDENCE: Location of the home is near shops and other community facilities; it is a well maintained, safe and accessible for residents. The reception area of the home seems to be a favourite place to sit for some of the residents, one person informed the Inspector they enjoy sitting, here “they can see what happening and who comes in and out of the home.” Tour of communal areas on each of the units found them all to be clean and tidy, the conservatory was very hot, but speaking to residents they did not HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 14 seem to mind, however the home are having blinds fitted to ensures it’s a more comfortable environment. Tour of the lounge area on the EMI unit raised an issue some of the windows had been taken off the restrictors an open to wide, although the Inspector was informed that staff are always present in this area, it is a health and safety risk for residents and must be risk assessed and documented if this practice continues. Random sample of bedrooms on each unit was seen, all the bedrooms had been personalised with service users own items, photos and other memorabilia. Each bedroom looked very comfortable and was furnished to a high standard, houses on a nearby estate overlook some bedrooms and the windows have been fitted with nets to ensure privacy for residents. The home has two specific bedrooms on the nursing unit for high dependency residents these are very large bedrooms for any equipment that may be needed. One issues raised some of the bedroom windows had been taken off the restrictors an open to wide, although the Inspector was informed that bedrooms are usually locked, however this practice must cease and windows were closed to the required opening. The laundry room for the home was examined and found to have the required impermeable flooring and was well organised. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 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 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 28 Staff are trained and have the skills and knowledge to fulfil their roles within the home. On going development of staff was evident by some staff achieving NVQ qualifications. EVIDENCE: Duty rota clearly identifies staff within the home and their role, including ancillary, domestic and kitchen staff, the manager is supernummary with two identified deputy managers. The home has a very stable staff group, which ensures continuity of care by staff who know the residents. Staff had the skills and knowledge to fulfil their roles within the home, and the company offer on going development for staff via NVQ training and fifteen out of the fifty-three care staff has completed their NVQ level 2 and three other staff members are working towards this, the company are trying to ensure that 50 of care staff will be NVQ trained. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 16 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) 31 38 Residents live in a home that is managed by a manager who provides leadership, guidance and direction to staff, however residents are being put at risk by windows being taken off their restrictors. EVIDENCE: The homes registered manager is fully aware of her responsibilities and provides leadership, guidance and direction to staff to ensure that residents receive consistent quality care. She is working towards the Registered Managers Award and on a Dementia course, to fulfil her own development needs. Safe working practice were discussed with members of staff, observation of practice and a number of records checked all of which was satisfactory with the exception of some windows being off the restrictors and opened to wide, this could put residents safety at risk. HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 2 x x x 3 3 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x x x 2 HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)17(1 scheduale 3 Requirement Care Plans,staff must complete all documentation with regard to;checklists when service users are on bedrest. Care plans must provide evidence if aids are required e.g.dentures,hearing aids and glasses or state reason if not used.Staff must ensure service users fingernails are clean. Blinds to be fitted in the conservatory to ensure comfortable environment for service users. Safe working practices; the home must ensure that residents are not being put at risk e.g. windows restrictors being taken off. Timescale for action 31st July 2005 2. OP7 15(1) schedule( 1)(6) 31st July 2005 3. OP20 23(2)(p) 31st August 2005 4. OP38 13(4) (c ) 31st July 2005 HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 19 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. The registered manager achieves NVQ 4 in management by December 2005. 2. OP31 HIGHGROVE CARE HOME J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire 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 J55-J07 S58632 Highgrove V215468 210605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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