Inspection on 20/05/05 for Highroyd

This inspection was carried out on 20th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highroyd 07/11/07

Highroyd 19/12/06

Highroyd 20/10/05

Highroyd 26/11/04

Highroyd 21/05/04

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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 HD5 9DP Lead Inspector Bronwynn Bennett Unannounced 20 May 2005 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. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highroyd Address Highroyd Lane Moldgreen Huddersfield HD5 9DP 01484 535458 01484 535458 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) Mr Stuart Theobald & Mrs Elizabeth Theobald Mrs Kimberley Hirst care home 19 Category(ies) of Over 65 - 19 places registration, with number of places Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 26th November 2004 Brief Description of the Service: Highroyd is registered to provide personal care and accommodation for up to ninteen 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 recieves 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 on-call arrangements are in place. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed during a seven and a half hour period. Thirteen residents were spoken to, as were the whole of the staff team who were on duty that day. The inspector examined written records kept by the home. What the service does well: What has improved since the last inspection? What they could do better: Care records for residents need to be clear so that care staff have an understanding of the care that is to be provided. All Staff need to be made aware of the appropriate support that is to be provided for residents where English is not their first language. The privacy and dignity of residents who share rooms must be maintained at all times. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 6 Greater care must to be taken with the storage of medication. Care must be taken to ensure that hazardous substances are stored safely. The manager must explore any gaps in a member of staff’s employment history. All staff should receive updates for movement and handling training in order to avoid injury to residents and staff. 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. Highroyd CS0000026272.V229553.R01.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 Highroyd CS0000026272.V229553.R01.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) 3 Residents are assessed prior to admission. EVIDENCE: One service user had been admitted as an emergency the day before this unannounced inspection. The file for this individual contained the relevant preadmission assessment and personal details of how the individual would like to be cared for by the staff. Highroyd CS0000026272.V229553.R01.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) 7,8,9,10. Staff support residents personal care needs. The level of support required to meet individual healthcare needs should be documented in individual care records. Every effort should be made to promote the privacy and dignity of residents. EVIDENCE: The care records for four service users were looked at. Individual care needs are identified in these care records but lacked detail in some cases. Care records should contain all the relevant information required so that care staff is sure what action to take and the appropriate care is provided. Where English is not the residents first language, the appropriate support reqiured should be documented in the individuals care records. Risk assessments need to be in place for all risks identified and a discussion took place with the manager about this. Some of the daily records kept were detailed and person-centred giving clear information of how the individual service user had spent their day, however other daily records were vague. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 10 Residents spoken to said that they receive the appropriate level of support from care staff, and there is evidence in personal records that residents are encouraged to be independent. Oral hygiene needs were not detailed for each individual resident and this was discussed with the manager. The district nursing agencies support the home in the prevention and treatment of pressure area care, and continence management. The manager said that the home has links with the community psychiatric nurse team and the community mental health team. All new residents are supported to register with the GP of their choice and have access to specialist medical services. The medication for three residents was looked and all tallied with the medication records kept. Some individual medication kept for pain relief was old stock and this was discussed with the manager. The manager advised that all those who administer medication have completed training in the care of medication. Residents said they have a good relationship with staff. Through observation the inspector noted that staff treated residents respectfully, however one resident commented that they had not been given the opportunity to choose their own clothing that day. A shared room did not have any suitable screening in place and this was brought up with the manager. Greater care needs to be given to the privacy and dignity of residents who share rooms. Highroyd CS0000026272.V229553.R01.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) 12,13,14,15. Residents have good relationships with staff. Activities are provided within the home to the resident’s satisfaction. The home provides a varied diet that caters for individual and cultural needs. EVIDENCE: There was a relaxed atmosphere within the home with staff interacting well with residents. The home has an activities worker who advised of the activity that takes place in the home. Residents spoke about the activities they have taken part in. On the day of this inspection some residents had chosen to watch one of their favourite videos. Residents are supported to maintain contacts with family and friends and residents spoken with confirmed this. There are no restrictions on visiting the home and information relating to the visiting is written in the service user guide. Residents are supported to handle their own finances for as long as they are able to do so, and are provided with the lockable space for this purpose. Residents are entitled to bring personal possessions with them into the home and evidence of this was seen during a tour of the home. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 12 Residents spoken with said they enjoyed the food and are offered a choice of menu. The meal of the day and a choice of menu were clearly displayed and advice was given that drinks and snacks are available to residents at all times. Specialist and cultural dietary needs are currently provided for by the home and this was discussed with the cook on duty. Mealtimes were observed and these were relaxed and unhurried. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18. Residents feel able to voice concerns and are supported to exercise their legal rights. Staff spoken to have a good understanding of adult protection issues. EVIDENCE: Residents spoken to explained that they knew whom to talk to if they had a concern or a complaint. There is a complaints policy in place and a record of any complaints made is kept. Residents are supported to exercise their rights with some residents voting during the last election. The home has the relevant policy in place to respond to any suspicion or evidence of abuse. During a conversation with staff it was clear that they have a good understanding of how to act, and the necessary action that needs to be taken should there be an allegation of abuse. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,24,26. The home was clean and residents live in comfortable surroundings. Sufficient facilities are available for residents personal hygiene needs, but care must be taken to ensure that the individual’s privacy and dignity is maintained at all times. EVIDENCE: The owner of the home advised that there are plans to improve parts of the home, with plans to provide a new kitchen and a conservatory. The home has recently received a visit from the fire safety officer with a recommendation for work that needs to undertaken. The home is bright and airy with the furnishings within the home being domestic in character. There is a lawned area to the side of the property that is suitable for residents. Washing, bathing and toilet facilities are provided to meet the needs of the residents with some bedrooms having en suite facilities. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 15 During a tour of the building it was noted that service users rooms are personalised, complete with suitable furnishings. A shared room did not have a suitable screen in place to promote the privacy and the dignity for those who use it;(See standard 10). The manager advised that doors are fitted with locks that are suitable for resident’s capabilities with one resident who has chosen to have a key. All residents are provided with a lockable space for valuables. The home was noted to be clean, airy and free from offensive odour. The laundry facilities are sited to the lower floor, and were clean and well organised on the day of this inspection. The home has a washer with a sluicing facility. Highroyd CS0000026272.V229553.R01.doc Version 1.30 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 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) 27,28,29. The home has achieved the 50 of care staff achieving NVQ Level 2 award. The home’s recruitment practice must ensure residents are protected. EVIDENCE: A record is kept showing all staff on duty at time. There were sufficient staff on duty during this inspection, and the manager discussed that there will shortly be an increase in the level of staff to meet the needs of the service user’s. The home has 50 of staff at present with the NVQ Level 2 award and four staff are presently undertaking the NVQ Level 3 award. Staff records for three staff were looked at. All records held the relevant police checks and written references but care must be taken to ensure any gaps in employment histories are explored. Highroyd CS0000026272.V229553.R01.doc Version 1.30 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 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) 31,35,36,38. The manager is supportive to residents and staff. The manager and owners must ensure that staff are trained to ensure the safe movement and handling of residents. Greater care needs to be given to the health and safety issues within the home EVIDENCE: The manager was noted to be approachable and have good relationships with both residents and staff. The manager is currently working towards her NVQ Level 4 award and also completing the NVQ Assessors award. The financial records for three residents were looked at, and all money tallied with the written records kept. Secure facilities are provided for resident’s money and any valuables kept. All staff spoken with said they receive regular supervision and evidence of supervision was seen in staff records. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 18 Four staff have undertaken first aid training and another three staff are booked on this course, and the manager advised that all staff ongoing with food hygiene training. All staff are due to be updated in movement and handling training. This needs to be completed as soon as possible as two staff were seen by the inspector, carrying out unsafe movement and handling practice. Hazardous substances are stored in the homes locked cellar, however some of this storage is not safe as it located near the main boiler for the home. All hazardous substances should have an up to date risk assessment completed. The water supply is direct feed and all water is stored at 65 degrees, the manager on a weekly basis completes hot water checks. Testing for electrical items, fire system and the emergency lighting have been recently completed. The fire safety officer visited the home January 2005, and fire safety procedures are displayed. The inspector saw the records kept for accidents and injuries. Highroyd CS0000026272.V229553.R01.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 1 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x 3 3 x 1 Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 20 yes 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. 2. 3. Standard 24 38 38 Regulation 12(4)(a) 13(5) 13(4) Requirement Screening must be provided in shared rooms to ensure privacy and dignity. Movement and handling training needs to be completed to avoid injury to service users and staff All parts of the home so far as is reasonably practicable be free from avoidable risk. Timescale for action With effect from 20/5/05 29/8/05 20/6/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 8 9 29 Good Practice Recommendations All care needs and identified risks for residents should be documented in individual care records. The oral health care needs for each resident should be documented in their plan of care. Greater care must be taken with the safe storage of medication. Medication kept in the home must be up to date. Gaps in staffs employment history should be explored by the manager. Highroyd CS0000026272.V229553.R01.doc Version 1.30 Page 21 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse. HD6 4AB 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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