Inspection on 19/12/06 for Highroyd

This inspection was carried out on 19th December 2006.

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

Highroyd 07/11/07

Highroyd 20/10/05

Highroyd 20/05/05

Highroyd 26/11/04

Highroyd 21/05/04

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Snydale Care Home

Hawkhills

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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 Highroyd Highroyd Lane Moldgreen Huddersfield West Yorkshire HD5 9DP Lead Inspector Bronwynn Bennett Unannounced Inspection 19th December 2006 09:30 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 Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highroyd Address Highroyd Lane Moldgreen Huddersfield West Yorkshire HD5 9DP 01484 535458 01484 423191 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) Mr Stuart Theobald Mrs Elizabeth Theobald Mrs Kimberley Hirst Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can provide accommodation and care for a maximum of two named service users aged over 65 years with Dementia (DE(E)) Can provide accommodation and care for two named service users aged over 65 years with dementia (DE(E)) 20th October 2005 Date of last inspection Brief Description of the Service: Highroyd is registered to provide personal care and accommodation for up to nineteen older people. It is situated in the Moldgreen area of Huddersfield within walking distance of a bus route, local shops and post office. Mr Stuart and Mrs Elizabeth Theobald own the care home. Mrs Kimberley Hirst is the registered manager. The residential accommodation is on two levels. A stair lift is in place. Sixteen bedrooms are for single occupation. The dining room receives good natural light, as does the communal lounge area, which is well used by residents throughout the day. There is a lawned area to the side of the home in the front of the conservatory. Car parking is available. The home is staffed twenty-four hours a day. There are two wakeful night staff and oncall arrangements are in place. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The visit began at 9.30am and finished at 4.30 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager. The inspector read records of people’s care, staff records, looked at how medicines are given and looked at the accommodation available in the home. Prior to this visit the Commission for Social Care Inspection sent ten questionnaires to service users living at Highroyd. Five completed questionnaires were returned. There were eighteen service users living at the home on the day of this visit. Surveys were sent to ten service users’ relatives and eight responses were received. Surveys were also sent to nine social workers, one GP and a health care professional. One response was received. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire was completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: There is a relaxed and homely atmosphere in the home and the service users spoken to during this visit were satisfied with the overall care provided. Service users spoken to during this visit were complimentary about the staff working at the home. In addition, positive comments were made about the staff through the surveys received by the CSCI. (Commission for social care inspection). Service users said they enjoyed the food served at the home. There is a choice of meals and service users are asked for their opinion regarding the standard of food served on a daily basis. There is ongoing training provided for staff working at the home. And this commitment to training has led to 60 of the care staff achieving NVQ (national vocational qualification) level 2 in care. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 6 The staff at Highroyd work hard to ensure the home is run in the service users best interests. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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 Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ needs are assessed prior to admission into the care home. EVIDENCE: There was evidence to show that the needs of service users are assessed prior to admission into the care home and the admission process was discussed with the manager. The Commission for Social Care Inspection received five service user surveys. These individuals said they received enough information about the home before deciding if it was the right place for them. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Greater care is required to ensure all the service users health and personal care needs are recorded in the care records. Greater care is required to ensure the service users are sufficiently protected by the home’s medication policy and procedure. Generally service users are treated with dignity and respect. EVIDENCE: There is a warm and relaxed atmosphere in the home. The service user spoken to during this visit said that the staff are helpful and supportive. The surveys received by the CSCI indicate that the service users receive the care and support they need. Eight relatives and a health care professional that responded to the survey said that they were satisfied with the overall care provided at the home. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 10 During this visit the service users were seen being treated in a dignified and respectful manner by staff. The care records for three service users were looked at. Generally there was some good information available in these records however, greater care is needed to ensure all the records contain sufficient detail. For example, one service user did not have an up to date care plan for diabetes. These concerns were discussed with the manager. There were risk assessments in place. But where the level of risk changes, such changes should be recorded in the relevant risk assessment. The weight of service users is monitored and recorded but not all service users are able to access the weighing scales presently available in the home. It is a recommendation of this report that suitable sit on weighing scales are purchased. The level of detail required in individual care records was discussed with the home’s manager. Some of the care records had been reviewed and there was evidence of individuals being involved in their plan of care. The home’s medication system was audited and the medication for three service users was checked. Not all medication could be fully reconciled with the records kept. One pain relief medication had been administered and not signed for, and some medication had not being carried forward onto the current MAR (Medication Administration Record) sheet. This was discussed with the manager who agreed to take immediate action to rectify the matter. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: The information from the survey showed that two service users said there were “always” activities arranged by the home and three service users said there were “usually” activities arranged. The manager produces a newsletter for the home that informs service users of any planned activities and outings. The choice of activity is displayed in the home. There is an activity co-ordinator who arranges hairdressing and handicrafts for those living at the home. Some of the service users spoken with said they enjoyed sitting in the company of others and watching the television. Religious observance is respected for service users, with religious ministers visiting individual service users on a regular basis. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 12 There are no restrictions on visiting to the home and service users are able to see their visitors in private. Eight relatives who responded to the survey said they were always welcomed into the home by the staff. The information relating to activities and visiting is made available in the service users guide. Service users manage their own finances should they wish to do so. Individual rooms were seen during a tour of the home and service users’ rooms were personalised. Four service users who responded to the survey said they always liked the food served at the home. Individuals spoken with during this visit said the food was good and that there is a choice of food available. The home has a four weekly menu that offers a varied diet and a choice of foods. During this visit both the breakfast and lunchtime was observed and the meals were served in a relaxed and unhurried manner. The food served was well presented and looked appealing. A carer was noted supporting a service user to eat their meal and should be commended for the care and consideration given to the individual concerned. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally service users and their relatives are confident their complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home. The relatives who responded to the survey said they were aware of the home’s complaints procedure. Service users who took part in the survey said that they knew who to speak to if they were not happy and knew how to make a complaint. The staff spoken with during this visit had a good understanding of adult protection issues and the necessary action that must be taken should there be any allegations of abuse. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well-maintained environment that is clean and comfortable. EVIDENCE: During this visit the home was noted to be fresh and clean. Two service users who responded to the survey said the home is “always” fresh and clean, and three said the home is “usually” fresh and clean. The manager said that there are plans to repaint the outside of the home and to redecorate some service users bedrooms. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 15 The conservatory did not have the required fire safety notices fitted over the identified fire doors. This was discussed with the manager who agreed to take immediate action to rectify the matter. The laundry facilities were seen and were clean and well organised. However this area was not suitably equipped for hand washing. Laundry facilities should be equipped with antibacterial hand wash and paper towels. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and receive induction, foundation and ongoing training. Service users are supported and protected by the home’s recruitment policy. EVIDENCE: There are staff employed in sufficient numbers to meet the needs of the service users. Service users spoken to during this visit were complimentary about the staff working at the home. There were comments such as “staff are very good” made during this visit. The service users who responded to the survey said that they receive the care and support they need and that staff are generally available when needed. There were many positive comments received from the relatives survey such as “ care at the home is excellent” and “staff are very caring and sympathetic”. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 17 The information received by the CSCI states that there are 60 of the care staff working in the home that have achieved NVQ (National Vocational Qualification) level 2 or above. Three staff files were looked at. These records contained the information required to ensure service users are protected by the home’s recruitment procedures. Staff have undertaken induction and foundation training. There is ongoing training for staff to ensure they are suitably trained to meet the needs of the service users. The manager said that infection control training is being arranged for all staff early in 2007. During this visit the inspector observed poor movement and handling practice. This was discussed with the manager who agreed to address the matter. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a home run by a manager who is fit to be in charge. The home is generally run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. EVIDENCE: The registered manager is Ms Kimberley Hirst. Positive comments were made during this visit about the manager from both service users and the staff. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 19 The procedure for handling service users money was discussed during this visit. Service users are supported to handle their own finances should they wish to do so and are provided with lockable facilities for this purpose. The home has a quality monitoring system in place that seeks the views of service users and their relatives. The manager carries out discussion on a daily basis with the service users and the staff regarding facilities and services available in the home. In addition there are service user meetings. The findings of quality monitoring carried out in the home are published and made available to service users and any interested parties. This is good practice. The information received by the CSCI shows that the equipment in the home is serviced regularly. The fire records were looked at. There is weekly testing of the home’s fire alarm system and emergency lighting system, and all staff undertakes fire drill training. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 21 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 13.2 Timescale for action The registered person shall make 19/12/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. Requirement 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 OP7 OP8 Good Practice Recommendations There should be sufficient detail of the service users care needs documented in individual care records. The identified risks for the service users should be documented in the individual’s care records. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 22 3. 3. 4. 5. OP8 OP19 OP26 OP30 The home should purchase suitable sit on weighing scales to ensure there is accurate monitoring of service users weight. Prompt action should be taken to fit both fire doors in the conservatory with the appropriate fire safety notices. The laundry facilities should be equipped with suitable hand wash and paper towels. There should be careful monitoring of the movement and handling practice of staff working in the care home. Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Highroyd DS0000026272.V319333.R01.S.doc Version 5.2 Page 24 - 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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