Inspection on 03/11/05 for Highnam Hall Residential Home

This inspection was carried out on 3rd 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

Highnam Hall Residential Home 08/05/08

Highnam Hall Residential Home 21/06/07

Highnam Hall Residential Home 22/06/06

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Highnam Hall Residential Home Park Avenue Hartlepool TS26 0DZ Lead Inspector Mr Paul Emmerson Unannounced Inspection 10:00 3 November 2005 rd 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 Highnam Hall Residential Home DS0000065270.V263997.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. Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highnam Hall Residential Home Address Park Avenue Hartlepool TS26 0DZ 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) 01429 869019 01429 233715 Mr Matt Matharu Mrs Christine Noble Care Home 45 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (5), Old age, not falling within any other category (45), Physical disability (5) Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Five persons in the category DE above the age of 55 may be accommodated in accordance with the home`s Statement of Purpose Five persons in the category PD above the age of 55 may be accommodated in accordance with the home`s Statement of Purpose. Five persons in the category MD above the age of 55 may be accommodated in accordance with the homes`s Statement of Purpose First inspection under new ownership. Date of last inspection Brief Description of the Service: Highnam Hall is registered to accommodate up to 45 older people, including people with mental health needs. On the day of the inspection there were 17 people living in the home. Highnam Hall is a grade 2 listed building, which retains many of its original features. The home is situated in a quiet road overlooking a popular park and has lawned areas to the side and private car parking to the front. The home has recently been purchased by Mr. Matt Matharu from the previous owners Mr. Russell Hart & Mrs. Olwyn Hart. Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. By law we have to inspect all care homes at least twice a year. This unannounced inspection was carried out in accordance with this obligation. The inspection took place over 6½ hours, on the morning and afternoon of Thursday 3rd November 2005. In line with current CSCI policy on ‘Proportionality’, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion were assessed during the last inspection of the home. The inspector looked around the building and a number of records were examined. 6 service users, 2 visitors, 5 members of staff, the home’s manager and its owner were spoken to. What the service does well: What has improved since the last inspection? The ownership of Highnam Hall changed hands last month. The new owner has begun a substantial programme of repairs and upgrade work to the home. The new manager has begun to review care practices, care planning and staffing arrangements in the home. Highnam Hall Residential Home DS0000065270.V263997.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. Highnam Hall Residential Home DS0000065270.V263997.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 Highnam Hall Residential Home DS0000065270.V263997.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, due to the change in ownership, service users and /or their representatives must be provided with new contracts setting out the terms and conditions of their accommodation and the services offered by the home. Statement of Purpose and Service Users Guide documents must also be reviewed to reflect the new ownership, new management and any new working arrangements. EVIDENCE: NA Highnam Hall Residential Home DS0000065270.V263997.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): 7, 8, 9 & 10. Personal and healthcare needs are adequately met. Care plans have been developed for all service users. Any medicines required are dealt with correctly. EVIDENCE: Although under new ownership and management, there has been continuity of staffing arrangements. Care staff know the needs of the 17 people currently accommodated well. The inspector spent time in the company of the people who live at Highnam Hall and saw that their care needs continue to be met and people remain comfortable in their home. Management and staff are ensuring that service users’ health care needs are met. Where specialist intervention is required it is sought. Records confirm that contact with GPs and other health professionals is maintained. The inspector saw, through the actions and responses of staff, that staff respect service users’ privacy and dignity. Service users spoken to expressed Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 10 their satisfaction with the manner and the general attitude of the people employed at Highnam Hall. A service user spoken to on the day of the inspection said, “It’s alright here, I’m well looked after and the meals are good”. A visitor commented, “I’m highly delighted with the care being provided”. Care plans examined provide detailed information about the needs of the people accommodated. However, from discussions with the new manager, it is understood that care planning arrangements are to be reviewed and revised to adopt standard care plan documents and practices used in other homes owned by Mr. Matharu. The home’s systems relating to medication were checked. Eldon House uses a monitored dosage system. There are adequate policies, procedures and systems currently in place relating to the receipt, recording, storage, handling, administration and disposal of medicines. However, from discussions with the new manager, it is understood that medication arrangements are being reviewed and revised. Highnam Hall Residential Home DS0000065270.V263997.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 of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, as highlighted in the previous inspection report under the previous management, service users lifestyle and experience in the home must match their expectations and preferences, and satisfy their social, recreational interests and needs. To enhance service users’ quality of life, arrangements to consider such issues should be reviewed. It is recommended that an activities coordinator be employed or designated activities hours be rostered. EVIDENCE: NA Highnam Hall Residential Home DS0000065270.V263997.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): 16 & 18. Systems are in place to respond to any complaints. Service users are safeguarded from abuse. However, the home’s policies and procedures in this area require full implementation and some further development. EVIDENCE: Due to the recent change of ownership, systems to ensure service users’ and relatives’ views are obtained are yet to be fully established. Nevertheless, preexisting systems are still in place and any complaints made would be dealt with and responded to appropriately. From discussions with the new manager, it is understood that such arrangements are to be reviewed and implemented as soon as possible. The home has a copy of the local authority’s ‘No Secrets’ guidance on abuse and the protection of vulnerable adults. However, although the home has its own policies and procedures about abuse and whistle blowing, they require further development and should be amended to reflect local protocols, contact arrangements and the initial action to be taken (things to do and things not to do) if an allegation of abuse arises. Highnam Hall Residential Home DS0000065270.V263997.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): None of these outcomes / standards were assessed on this occasion. They were examined during the last inspection of the home. However, substantial upgrade work, for example to bathrooms, showers and decoration generally, is required. For example, as highlighted in previous inspections of the home under the previous management, the design of bathroom and shower facilities must be suitable and accessible for service users. An action plan showing redecoration / building works intended and timescales for completion should be forwarded to CSCI. However, any issues raised by the fire officer require more urgent consideration. The financial implications associated with this should be given ongoing consideration within any business plans for the continued running of the home, which should be shared with the Commission for Social Care Inspection. EVIDENCE: NA Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 14 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): 27, 28, 29 & 30. Sufficient staff are employed. The home has a settled, well qualified staff team. However, the home’s staffing and employment policies and procedures require full implementation. EVIDENCE: On the day of the inspection only 17 service users were accommodated. Staffing levels, in addition to the manager and ancillary staff, are a senior care and 2 carers throughout the day, afternoon and evening with an extra care assistant on a morning (8 am – 12 noon). Shift rotas are being changed from 12 hour shifts to shorter shifts 7 am – 2.30 pm, 2.30 pm – 10 pm. During the night, a senior care assistant and a care assistant work waking night duty. These staffing levels are considered suitable to meet the needs of the people currently accommodated. From speaking to staff there is an understandable degree of uncertainty about the many and necessary changes that are taking place under the new management. However, there is also optimism and a willingness to work to ensure that service users’ needs are met and that Highnam Hall’s long-term future is secured. Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 15 As the building is upgraded and bedrooms are refurbished it is anticipated that occupancy levels will increase. An assurance has been given that staffing levels will be adjusted to meet the needs of the additional people accommodated. When occupancy levels increase additional appointments will be required. Recruitment procedures within the home are considered safe. CRB (Criminal Records Bureau) disclosure checks are to be carried out for all staff. A copy of each person’s birth certificate and other certificates are kept on staff files. Applicants for employment will complete an application form and 2 references will be obtained. A reference from the last employer will be requested, plus another; any gaps in employment will be explored. Each member of staff will receive a contract of employment and a job description. However, for existing staff, it is recommended that the management of the home should conduct a full audit of staff files to ensure that necessary recruitment / employment records and checks required have been obtained. Existing staff are well qualified. All care staff have NVQ (National Vocational Qualification) level 2, many have NVQ level 3 and some people are studying NVQ level 4. However, it is recommended that the management of the home should conduct a full audit of staff files to consider staff training needs, in particular core training such as first aid and fire training, to ensure staff training certificates are up to date. Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 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 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. Highnam Hall is well run. However, the new management’s policies, procedures and working practices need to be fully implemented. EVIDENCE: Although new to her current role, the registered manager of Highnam Hall was previously the registered manager of another local care home owned by Mr. Matharu. The registered manager is well qualified, experienced and has commenced a ‘Registered Manager’s Award’ training course. However, the home’s manager must complete the ‘Registered Manager’s Award’ by the end of September 2007. Despite the recent change in ownership, good levels of communication and team working were observed. Staff spoke of a recent staff meeting, with others Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 17 planned to ensure that everyone is involved and kept informed of any changes in the way the home is to be run. Staff spoken to were commendably honest and frank. Although there is an understandable degree of uncertainty about the many and necessary changes that are taking place under the new management, it is reassuring there is also an optimism and a willingness to work to ensure that Highnam Hall’s long term future, and the care of the people accommodated, is secured. The new management’s policies, procedures and working practices are yet to be fully implemented. Nevertheless, formal quality assurance / health and safety systems must be developed as soon as possible. Further, monthly reports required under Regulation 26 of the Care Homes Regulations 2001 must be provided to CSCI to report on the conduct of the home, including information about occupancy, staffing, upgrade work undertaken and the action being taking to address any shortfalls. Copies of these reports must also be provided to the manager of the home. Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NA (first inspection under new ownership). 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 OP1 Regulation 4&5 Requirement Statement of Purpose and Service Users Guide documents must be reviewed to reflect the new ownership, new management and any new working arrangements. Service users and /or their representatives must be provided with new contracts setting out the terms and conditions of their accommodation and the services offered by the home. The home’s manager must complete the Registered Manager’s Award. Timescale for action 31/03/06 2. OP2 5 31/03/06 3. OP31 9 30/09/07 Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 20 4. OP33 24 & 26 Formal quality assurance / health and safety systems must be developed. Monthly reports required under Regulation 26 of the Care Homes Regulations 2001 must be provided to CSCI to report on the conduct of the home and detailing the action being taking to address any shortfalls. Copies of these reports must also be provided to the manager of the home. 31/12/05 Highnam Hall Residential Home DS0000065270.V263997.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. 2. Refer to Standard OP12 OP18 Good Practice Recommendations An activities coordinator should be employed or designated activities should hours be rostered The home’s policies and procedures about abuse and whistle blowing, should be developed / amended to reflect local protocols, contact arrangements and the initial action to be taken (things to do and things not to do) if an allegation of abuse arises. Substantial upgrade work, for example to bathrooms, showers and decoration generally, is required. An action plan showing redecoration / building works intended and timescales for completion should be forwarded to CSCI. Any issues raised by the fire officer require more urgent consideration. The financial implications associated with this should be given ongoing consideration within any business plans for the continued running of the home, which should be shared with the Commission for Social Care Inspection. The management of the home should conduct a full audit of staff files to ensure that any necessary recruitment / employment records and checks required have been obtained. Staff training needs, in particular core training such as first aid and fire training, should also be considered to ensure staff training certificates are up to date. 3. OP19 4. OP28,OP29 & OP30 Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Highnam Hall Residential Home DS0000065270.V263997.R01.S.doc Version 5.0 Page 23 - 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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