Inspection on 07/11/07 for Highroyd

This inspection was carried out on 7th November 2007.

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 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 19/12/06

Highroyd 20/10/05

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 Key Unannounced Inspection 7th November 2007 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.V354381.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.V354381.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 kim2highroyd@hotmail.co.uk 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.V354381.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)) 19th December 2006 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 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 DS0000026272.V354381.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. The visit began at 9.30am and finished at 4.45 pm. During this visit the inspector spoke to people living at Highroyd Care Home, some staff, the manager and the registered provider. The inspector read records of people’s care and records about staff working at the home, looked at how medicines are given and looked at the accommodation available in the home. There were seventeen people living at the home on the day of this visit. Before this visit the Commission for Social Care Inspection sent out questionnaires. Ten questionnaires were received from people living at the home, three from relatives and one from a health care professional. Prior to this visit the manager carried out a self assessment to show how they feel the home is performing and gave the CSCI information that had been requested, for example about any illnesses, accidents and incidents and how the home is managed. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The home continues to provide a warm and homely environment for people to enjoy. People have their needs assessed prior to them moving into the care home. People spoken to during this visit said the staff are “good” and “very nice” and good relationships were observed between staff and people living at the home during this visit. There were some positive comments made in the survey. A relative commented that the staff show warmth and kindness and another said they were satisfied with the care their loved one received. Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 6 The registered provider has worked hard to ensure the staff are competent and have the right skills to care for people. A relative commented in the survey they felt the manager was approachable, and the staff have the right skills and experience needed to care for people. 50 of the staff have achieved NVQ (national vocational qualification) level 2 in care. The staff continue to work hard to ensure the home is run in everyone’s 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.V354381.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.V354381.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No individual moves into the care home without having their care needs assessed. EVIDENCE: The way people are admitted into the care home was discussed with the manager. Assessments carried out by the home and social work assessments were seen in care records. In addition the manager has developed a self assessment questionnaire so that people can record their needs should they choose to do so. Everyone who responded to the survey said they had received sufficient information about the care home before deciding if it was the right place for them to live. Highroyd DS0000026272.V354381.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. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally health, personal and social care needs are set out in the individuals’ plan of care. The home’s medication policy and procedure does not sufficiently protect people living in the home. Generally people are treated with dignity, respect and privacy. EVIDENCE: Everyone responded positively in the survey when asked if the staff listen and act on what they say and if they receive the care and support they need. Many relatives commented that there is good care provided by the staff at the home. The care records for three people were looked at. There was some good information available in these records with individuals and their relatives being involved in the developing care plan. However, more care is needed to ensure Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 10 all the records contain sufficient detail. For example, one record did not have the information that may be required by staff for wound care and dressings. One person was having their diet and fluid intake monitored but the recording for this was not adequate. Where there is monitoring of individual diet and fluids, staff must be given clear instruction of what is a sufficient intake. The required amounts of diet and fluids must be measurable to ensure that staff know when to seek medical advice. This was discussed with the manager who agreed to take action to improve this area of recording. There were up to date nutritional risk assessments and assessments to measure an individual’s risk of developing a pressure sore. However, one individual had a significant weight loss but no action had been taken such as referral to the GP or dietician. However there was some discussion about the accuracy of the current weighing scales used and this was brought to the attention of the registered provider who agreed to purchase suitable sit on scales as soon as possible. The level of detail in a movement and handling care record was good and gave clear information to staff about how to move the person safely. The detail required in individual care records was discussed with the home’s manager. A concern was raised with the manager regarding the care of one individual. Their staff call buzzer was out of reach and inappropriate equipment was being used to keep the individual safe. The CSCI later received information to confirm that these issues had been addressed. The medication and records for three people were checked. There were some errors noted. Not all the medication from the previous month had been carried forward on to the current MAR (medication administration record). There was an error in the recording on a MAR and no explanation available for this, and one medication currently in use was not recorded on the MAR. These issues were discussed with the manager who agreed to take action in the matter. During this visit people were observed being treated in a dignified and respectful manner by the staff at the home. Highroyd DS0000026272.V354381.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally individual cultural, religious, social needs are being met and people are supported to maintain contact with their family and friends. People are able to exercise choice and control over their lives. The home provides people with a varied and nutritious diet. EVIDENCE: Positive comments were received when people were asked in the survey if there are activities arranged in the home that they can take part in. In the survey one relative said they should be more entertainment and this information was passed on to the manager during this visit. On the day of this visit people were observed enjoying the singing and dancing entertainer who regularly visits the home. Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 12 The home has a newsletter that informs people of the planned activities and outings. There is an activity co-ordinator who arranges hairdressing and handicrafts in the home. During this visit some individuals were observed spending time in the company of others or watching the television. Some people go out with family and friends or independently should they choose to do so. Staff support individuals to go out walking, to the local shops and to church. There are no restrictions for visiting the home, and during this visit relatives were observed freely visiting people and being greeted by the staff team. Individuals spoken to during this visit said they enjoyed the food served in the home and there was plenty to eat. The cook was observed during this visit consulting people about their choice of food and the meals served look appetising and well presented. There is a four weekly menu available in the home and specialist diets such as blended meals and diabetic diets are catered for. Highroyd DS0000026272.V354381.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service People living at home and their relatives are confident their complaints will be listened to and acted upon. Individuals are protected from abuse. EVIDENCE: There has been one complaint made to the CSCI about the home. The CSCI are satisfied by the response of the registered provider in this matter. Generally people who responded to the survey said they knew who to speak to if they were not happy, and with the exception of one person everyone knew how to make a complaint. A relative commented in the survey that any concerns are responded to appropriately. The staff spoken to during this visit had a good understanding of adult protection (safeguarding) issues. All staff have received safeguarding training to ensure they know how to respond should there be any allegations of abuse in the home. Highroyd DS0000026272.V354381.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally people live in a safe and well-maintained environment. The home is clean and people have comfortable rooms with their own possessions around them. EVIDENCE: Positive comments were received when people were asked in the survey if the home is fresh and clean. During this visit the home was noted to be fresh and clean. Some bedrooms have been redecorated since the last visit by the CSCI and individual rooms seen during this visit had been personalised by the individual with items such as pictures and other personal effects. The registered provider Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 15 said that chairs in communal areas are being replaced, some replacement carpets were on order for individual rooms and a bathroom is being refurbished. The laundry facilities were generally clean and well organised and equipped with items suitable for hand washing. Highroyd DS0000026272.V354381.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. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally staff are employed in sufficient numbers and receive training to ensure they are competent to do their jobs. Generally people are protected by the home’s recruitment practices. EVIDENCE: Everyone responded positively in the survey when asked if the staff are available when needed, and listen and act to what they say. A relative commented that the staff show warmth and kindness and another said they were satisfied with the care their loved one received. During this visit staff were observed treating people with dignity, kindness and respect. Individuals spoken to during this visit said that the staff are “good” and “very nice”. Three staff records were looked at. Records indicated that the required checks had been carried out however some did not have the date of the police check. This was due to the provider being given misinformation on storing these checks. However, all the information regarding police checks for newly appointed staff must be kept so that the CSCI can verify that the required checks have been carried out and when. Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 17 All newly appointed staff undertake induction training that meets “Skills for Care” induction standards. (Skills for Care is the national training organisation). Nine staff have achieved the NVQ level 2 or in care. The manager said that some staff are working towards this qualification. The home has worked hard to ensure its staff are competent and have the right skills to care for people. Staff have completed adult protection (safeguarding) training, fire, health and safety, food hygiene, infection control and manual handling training. Senior staff have completed medication training to ensure they are competent to administer medicines. Some staff have completed, or currently taking part in specialist training for dementia care. Highroyd DS0000026272.V354381.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): 31,33,35 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run and managed by a person who is fit to be in charge and run in the best interests of people who use the service. The financial interests of people are safeguarded. The health and welfare of everyone is promoted and protected. EVIDENCE: The home’s manager is Ms Kimberely Hirst, she has many years experience of working with older people and is awaiting her certificate for completing the registered managers award. Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 19 The procedure for handling people’s money was discussed and the records and money for two people was checked and correct. The home has a quality monitoring system that seeks the views of people living at Highroyds, their relatives and relevant professionals such as doctors and social workers. In addition there are resident and staff meetings. The registered provider is available in the home most days in the week. The findings of quality monitoring carried out in the home are published and made available to everyone. The information looked at during this visit shows that equipment and services 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. The staff have received fire training and take part in fire drills. Highroyd DS0000026272.V354381.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 3 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 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 07/11/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. All medication in use by the individual must be recorded on their medication administration record Any medication carried forward from the previous month must be carried forward onto the current medication administration record Requirement Highroyd DS0000026272.V354381.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations Where fluid and dietary needs are being monitored staff must be given clear instruction of what is a sufficient intake. The required amount of diet and fluids must be measurable so that staff are aware of when to seek medical advice. Where an individual is receiving wound care from a district nurse, a care plan should be developed so staff are clear of any action they must take in order to maintain the required level of care. The home should purchase suitable sit on weighing scales to ensure there is accurate monitoring of people’s weight. The registered person should ensure prompt, professional advice is sought to ensure any equipment needed by the individual is provided. This ensures that inappropriate items are not used to keep people safe. The registered person should ensure that staff respect the privacy and dignity of people at all times. Each individual should be able to summon help from the staff at all times. All the information regarding police checks for newly appointed staff must be kept so that the CSCI can verify that the required checks have been carried out and when. 2. OP8 3. 4. OP8 OP8 4. 5. OP10 OP29 Highroyd DS0000026272.V354381.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.V354381.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. 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