Inspection on 20/10/05 for Highroyd

This inspection was carried out on 20th October 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

Highroyd 07/11/07

Highroyd 19/12/06

Highroyd 20/05/05

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 West Yorkshire HD5 9DP Lead Inspector Bronwynn Bennett Unannounced Inspection 20th October 2005 09:45 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.V251180.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. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 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.V251180.R01.S.doc Version 5.0 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 May 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.V251180.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out during a five-hour period and was the second inspection conducted during this inspection year. The inspector carried out a tour of the building, and a sample of the records kept by the home was looked at. The inspection was conducted with the manager and the provider of the home and some of the service users and staff were spoken with. What the service does well: 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. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 6 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.V251180.R01.S.doc Version 5.0 Page 7 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): EVIDENCE: These standards were not assessed during this inspection. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 8 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. The staff are working well to meet the needs of the residents. Greater care needs to be taken to ensure the health care needs of the residents is fully met. Generally, the residents are protected by the home’s policy and procedure for medication. EVIDENCE: The residents spoken with said that the staff are helpful and supportive. The staff were seen to be treating the residents with dignity and respect. The care records were looked at for two residents. The individual care needs are identified in the care records but lack sufficient detail. Care needs to be taken to ensure that all the relevant information is available to the care staff. There were risk assessments in place for some identified risks. However care should be taken to ensure that all identified risks are documented in the individual’s care records so that the staff have the information required to work safely with the residents. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 9 The medication for two service users was checked. All the medication could be reconciled with the records kept. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These standards were not assessed during this inspection. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were not assessed during this inspection. There are no recorded concerns, complaints, or adult protection issues recorded since the last inspection. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 12 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): 24. Where the residents share a room their privacy and the dignity is promoted. EVIDENCE: The home was clean and free from odour on the day of this inspection. The requirement from the last inspection regarding suitable screening in the identified bedroom has now been met. Where the residents share a room their privacy and the dignity is promoted. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 13 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): 29,30. The home’s recruitment practice does not sufficiently protect the residents. Generally, the staff are trained and competent to do their jobs. EVIDENCE: The staff records for two staff were looked at. Both records had full employment histories complete with written references. The manager must ensure that the staff are supervised at all times until the relevant police checks are received by the home. The inspector saw evidence of induction training complete by some of the staff in the home. Training in movement and handling was conducted in the home in September 2005 and the manager said that this training will be updated annually. All staff have recently received fire training through individual supervision and all new staff complete fire safety training as part of the induction training. Dementia care and first aid training has been completed by most of the staff team. The care staff have either attained or are working towards NVQ level 2 or 3. The manager is an NVQ assessor and has a qualification in presentation skills. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 14 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): 33,38. The home works well to ensure that the home is run in the residents’ best interests. The health and welfare of the residents is generally promoted and protected. EVIDENCE: The home has an annual quality monitoring development plan. There is a quality monitoring system in place and the views of the residents, there relatives and any other interested parties is sought through residents’ meetings and an annual questionnaire, with the findings published in the home’s statement of purpose. The manager and the registered provider also monitor the quality standards within the home by conducting random spot checks. A sample of maintenance records and certificates was checked and were up to date. The testing of the fire alarm equipment and the checking of the Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 15 emergency lighting is carried out on a weekly basis. The fire safety work as recommended by the fire service is near completion. Prompt action should be taken to finish this work. There has been no fire drill training with the entire staff team since December 2004; this was discussed with the manager and needs to be addressed. The hot water temperatures for bathing and showering are not monitored on a weekly basis and the home does not currently have a system for the routine cleaning of showerheads. The manager should ensure that the hot water temperatures are checked, and all the showerheads are cleaned, on a weekly basis. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 16 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 2 8 2 9 3 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 X 18 X X X X X X 3 X X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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. 5 6 7 Refer to Standard OP7 OP8 OP29 OP38 OP38 OP38 OP38 Good Practice Recommendations There should be sufficient detail of the residents care needs documented in individual care records. The identified risks for the residents should be documented in the individual’s care records. The manager should develop a suitable monitoring system to ensure the residents are fully protected by the home’s recruitment policy and practice. The hot water temperatures for bathing and showering should be tested and recorded on a weekly basis. Routine cleaning of the showerheads should be undertaken with the appropriate records kept. Prompt action should be taken to finish the outstanding fire safety work with the CSCI been notified on its completion. The staff should have fire drill training twice a year. Highroyd DS0000026272.V251180.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office 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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