Inspection on 05/12/05 for Highlands Residential Home

This inspection was carried out on 5th December 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

Highlands Residential Home 13/02/09

Highlands Residential Home 21/02/07

Highlands Residential Home 21/07/05

Highlands Residential Home 11/03/05

Highlands Residential Home 14/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Highlands Residential Home Fitzgerald Road Woodbridge Suffolk IP12 1EN Lead Inspector Jill Clarke Second Inspector Jess Scotford. Unannounced 5th December 2005 10:00 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 Highlands Residential Home DS0000024416.V271367.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. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highlands Residential Home Address Fitzgerald Road Woodbridge Suffolk IP12 1EN 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) 01394 386204 01394 386204 The Abbeyfield Deben Extra Care Society Mrs Lyn Jane Ward Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: Highlands is one of a group of care homes, which is affiliated to the National Abbeyfield Society Group and is responsible to a local management committee, the Abbeyfield Deben Extra Society Limited. Situated in a quite residential area of Woodbridge, within walking distance of the town centre. Woodbridge offers a range of amenities, which include restaurants, garden centres, shops, library, banks, post office, Riverside Theatre and swimming pool. Highlands provides care for 24 older people. The home is an adapted period house, which overlooks the Deben estuary. Lift or stairs can access all areas of the home. Most of the bedrooms and living areas, including a large conservatory, have views over the home’s wellestablished grounds and gardens. There is limited car parking provided at the front of the home. The 24 single bedrooms are located on the first floor and ground floors; all have en-suite wash hand basin and toilet. There are also communal toilets and bathrooms located close to the bedrooms. Communal areas include a large dining room, lounge and conservatory, all of which are decorated and furnished to a good standard. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second, of 2 routine regulatory inspections undertaken between 1 April 2005 and 31 March 2006. The unannounced inspection, was undertaken by 2 inspectors, took place over 5 hours, on a Monday in December. The home was full on the day of inspection. In the absence of the manager who was on annual leave, senior carers, the administrator, carers, catering and domestic staff gave assistance throughout the inspection. A member of the committee was also present for part of the inspection. Time was spent with residents, staff and visitors in order to hear their views on matters concerning the home. Some of the conversations were held in private while others, of a more general nature, were held throughout the inspection. Records viewed included medication, staff recruitment, care plans, training and health and safety. What the service does well: What has improved since the last inspection? Good practice recommendations from the last inspection had both been implemented. Residents are now involved in the review process which takes place on a regular monthly basis. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 6 The home has made a start on introducing pressure sore risk assessment for residents. This is to help staff monitor residents skin, and take action if there is any risk that the skin may become sore, or break down. A new call bell system has recently been introduced which involves staff carrying individual receivers and residents benefit from clearly designed, colour coded handsets with extra large press buttons. 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. Highlands Residential Home DS0000024416.V271367.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 Highlands Residential Home DS0000024416.V271367.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): 2. People moving into the home can expect that a written contract will be provided, which details terms and conditions of occupancy. EVIDENCE: Standards 1,3,4, and 5 were assessed as met, during the first of the two routine regulatory inspections undertaken on the 21.7.05. A sample of two completed contracts were looked at which gave terms of residency, weekly costs and room to be occupied. The contracts had been signed prior to the resident moving in, by themselves or their representative. Two residents confirmed that they were aware of the costs involved before moving into the home. One answered “yes, as I had to make sure that I could afford it” and the other had compared the cost of living at home with the costs of being in Highlands before making the decision to move in. Both confirmed that they had come to look round the home before having their names put on the waiting list and then came to view the bedroom offered once a vacancy arose. Highlands Residential Home DS0000024416.V271367.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): 9. Residents can expect that their medications will be handled and administered in a safe and timely way, although minor shortfalls in recording and storage were identified. EVIDENCE: Standards 7, 8 and 10 were assessed as met during the first of the two routine regulatory inspections undertaken on the 21.7.05. The dispensing pharmacist supplies resident’s medication to the home on a weekly basis, in sealed dossett boxes. The back of the box lists the medications contained within, to enable staff to check that the required number of tablets has been sent. Medication not supplied in dossett boxes is sent monthly. Eye drops, which should be stored in the fridge until opened, were stored in a cupboard. The drugs fridge was empty and unplugged. It was noted that staff had not dated the eye drops (which had a 28 day shelf life once opened) when they were opened. One eye medication container in the drugs trolley was opened, and the dispensing label dated June 2005. Staff identified that the Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 10 named resident no longer required these drops, and that the drops should have been disposed of. Good practice was observed in relation to secure storage of drugs in a clean and well-organised environment. Checks of storage and recording of controlled drugs will be undertaken on a future inspection. The home has systems in place for documenting the number of brought forward figures, for any remaining medications not supplied in dossett boxes. Records are kept of all medication coming into and out of the home. A sample of 3 residents tablets not supplied in dossett boxes was checked against the records, and found to be correct. Each Medication Administration Record (MAR) sheet had a photograph of the resident at the front, and also a record of specimen staff signatures was seen. Records of administration for the past month were examined. There were missing staff signatures on 10 MAR sheets. Two residents were found to have excessive stock of some medication for example, the home had still ordered another 100 painkillers for a resident who had over 2 months supply. The home has medication policies in place, to ensure staff follow a safe system of giving out medication. However, this did not contain guidance for staff, if they gave out medication in error (for example to the wrong resident, or the wrong dose given). Five residents who were asked if staff brought their medication around on time replied “Yes,”. When asked if there had ever been any problems for example the wrong medication being given out, one resident replied “No, staff were very good”, “I wouldn’t take anything unless I knew what I was taking.” Highlands Residential Home DS0000024416.V271367.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): None. See below. EVIDENCE: Standards 12, 13, 14 and 15 were assessed as met during the first of the two routine regulatory inspections undertaken on the 21.7.05. The judgement made in the report (21/7/05), stated ‘People living at the home can expect to be treated with respect and supported to have control over their lives. Meals served are varied, nutritious and well presented’. Discussions with residents during the inspection did not raise any concerns that would require the above standards needing to be re-assessed during this inspection. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 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 the following standard(s): 17. Residents can expect that their legal rights will be protected. Procedures are in place to deal with any complaints, allegations or suspicions of abuse. EVIDENCE: Standards 16 and 18 were assessed as met during the first of the two routine regulatory inspections undertaken on the 21.7.05. Two staff members, spoken with individually, confirmed that residents are encouraged and enabled to vote during elections either by postal vote or in person, both of which the home would facilitate. Three members of staff demonstrated knowledge of the correct procedure to follow in the event of actual or potential abuse. One member of staff had recently attended a Protection of Vulnerable Adult (POVA) training session arranged at the home. Another staff member had been involved in reporting suspected abuse in the past. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 22, 25 and 26. People can expect a homely, clean environment, which is decorated and furnished to a high standard. This gives residents a safe and comfortable home to live in. EVIDENCE: The home’s maintenance plan for 2005 was seen, which covered the servicing of hoists and fire equipment. A resident confirmed that when they moved into the home their bedroom was re-decorated, and they were able to choose a new carpet. Staff spoken with also confirmed that all bedrooms are redecorated when they become vacant. Three bathrooms were looked at – all of which had assisted baths. A resident said that “the green bath was excellent, that you sit in the bath and it fills up, then the staff alter it so the warm water comes right up to your shoulders and you can have a good soak.” They went on to say that staff assisted them to get in the bath, then would leave them with a call bell to ring, so they had some privacy, and could call when they wanted help to get out. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 14 A resident who had an en-suite toilet was asked if they found the water to be of a comfortable heat. The reply was “yes”. Residents confirmed that they felt warm. One resident said that they had not yet needed to turn on all the radiators in their bedroom, as they found it was warm enough. During the visit, residents were seen to be walking freely around the home and were able to use the passenger lift. Staff offered assistance appropriately when needed. Care plans held information on mobility aids used by residents to maintain their independence. Disposable gloves, dispersible bags, liquid soap and paper towels were available around the home. Sample visits were made in the following areas of the home – two bedrooms, the laundry, sluice, three bathrooms and communal rooms all of which were found to be clean and odour free. Residents said that their bedrooms were kept clean and tidy. One resident said that their en-suite toilet and wash hand basin was “cleaned everyday” and the bedroom was given a good dust and vacuum once a week. A group of 5 residents gave their views on the cleanliness of the home all of which were positive. “Spotless” and “very clean” were two comments received. Highlands Residential Home DS0000024416.V271367.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 and 29 Residents can expect that the staff who care for them to have the skills, training and knowledge to support their individual care needs, however there is a chance that shortfalls in recruitment practice could compromise safety. EVIDENCE: Standards 27 and 30 were assessed as met during the first of the two routine regulatory inspections undertaken on the 21.7.05. Although the manager was not available and the staff were unable to locate all the information requested, sufficient evidence was obtained to make a judgement. The rota showed that the home employed 25 carers. Eight of the staff have already achieved an NVQ and information from the last regulation 26 report, verified that 7 more have recently started the qualification. Three members of staff spoken with confirmed that they had completed level 2 NVQ. One was enrolled on level 3 and another was hoping to start. A resident who was asked if they felt that the staff had the skills and knowledge to provide the level of care they required replied, “although I don’t need a lot of help – if I was poorly during the night I would have no hesitation in using the call bell and knowing I will be looked after.” Three recently recruited staff files were looked at. All contained a full CRB clearance, although the date on one was issued 4 days after the member of staff started work, and there was no evidence that a POVA first had been requested. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 16 Two files contained written references obtained before the member of staff started work. The third file, although it now held two written references, one had been obtained two months after start of work. This was fed back to the staff who said that although a verbal reference had been obtained, they had problems getting the previous employer to put it in writing. Notes held in the file showed that the member of staff had offered to chase up the reference after being notified of the problem by the manager. This finding led to discussions with staff present, that the home must be in receipt of two written references before the person starts work. References for one member of staff whose previous job was as a carer had not been requested from the previous workplace but instead from a previous employer 5 years ago and a friend as second reference. For another member of staff who had worked with children, the reference did not appear to be from their previous employer, but a colleague. This led to further discussions with staff with regard to the fact that they should try and obtain professional references from their last employer, and steps should be taken to validate the reason why they left any post, which involves working with vulnerable adults or children. There was no paperwork on file to validate the person’s identity although staff felt sure that the manager had seen/taken copies when completing the staff CRB applications. The home did not have the full employment history for one of the staff. Highlands Residential Home DS0000024416.V271367.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): 35, 36, 37, 38 Residents can expect a well run home, although some shortfalls in record keeping could impact on safety. EVIDENCE: Standards 31, 32 and 33 were assessed as met during the first of the two routine regulatory inspections undertaken on the 21.7.05. Residents’ monies were kept in a locked safe with restricted key access. Records of all residents’ financial transactions were kept, which included receipts where applicable. Two residents’ monies held were checked against records and found to be correct. The administrator confirmed that all residents’ accounts are checked routinely each month. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 18 Three staff members were spoken with in private. Each confirmed that they received regular supervision from a line manager, which was documented. Two senior carers said that they were involved in giving supervision to other staff. None of the staff could confirm that appraisals were taking place. Omissions on some drug records were found, which could lead to doubt about administration of prescribed medication. During the environmental tour servicing stickers were seen on assisted baths. Fire exits were clear. Fire records showed that 23 staff had received 2 hour training in Fire safety (undertaken by an external company). Training included instruction in Evacuation, Fire extinguishers and their use. Regular checks are undertaken by the staff to ensure that the fire alarm system and back up lighting is in good working order. Highlands Residential Home DS0000024416.V271367.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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 X 3 3 X X 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 2 3 Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 (2) Requirement Timescale for action 06/01/06 2 OP9OP37 13 (2) 17 (1) (a) 3 OP29 19 (1) Sch 2 (3) 4 OP29 19 (1) Sch 2 (4) The home must ensure that eye drops are stored correctly, according to the manufactures instructions. The home must have monitoring 06/01/06 systems in place to check and ensure that staff are completing the MAR sheets fully, to evidence that medication has been given. The home must ensure that they 06/01/06 have 2 written references, paperwork to validate identity and POVA First or CRB clearance prior to staff staring employment at the home. Where a member of staff has 06/01/06 worked with vulnerable adults before, steps should be taken, unless it is not reasonably practicable, to confirm the reason why the person left their employment. Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 21 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 OP9 Good Practice Recommendations Medications and medicines, which have a short shelf life, once unopened or dispense from the Pharmacist, should have the date of opening written on the container. This will support staff to be aware, and dispose of any medications/preparations within in the required time period. Monitoring systems should be put in place to ensure that staff do not re-order medication, before checking the current stock levels. Where the home has not requested the medication, but has been sent it, staff should liaise with the GP surgery and dispensing pharmacist to see why they have been sent it. The home should produce guidelines for staff; to state what action they should take if medication is given in error. For example if the wrong dosage is given, or the medication given to the wrong resident. When the home has problems obtaining a written reference, they should clearly document the reasons why, and make judgement if another suitable referee could be contacted/obtained. 2 OP9 3 OP9 4 OP29 Highlands Residential Home DS0000024416.V271367.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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