Inspection on 15/06/05 for Highstone Mews Care Home

This inspection was carried out on 15th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highstone Mews Care Home 02/02/09

Highstone Mews Care Home 22/02/07

Highstone Mews Care Home 29/11/05

Highstone Mews Care Home 05/01/05

Highstone Mews Care Home 06/07/04

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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 Highstone Mews Care Home Highstone Road Worsborough Common Barnsley S70 4DX Lead Inspector Steve Vessey Unannounced 15 June 2005 10:10am 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. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Highstone Mews Care Home Address Highstone Road Worsbrough Common Barnsley S70 4DX 01226 733966 01226 779427 None Four Seasons Healthcare 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) Debra Ann Owen N Care Home with Nursing 60 Category(ies) of 1. OP Old age - 30 registration, with number 2. DE(E) Dementia - over 65 - 30 of places 3. MD(E) Mental Disorder -over 65 - 30 Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 5 January 2005 Brief Description of the Service: Highstone Mews is a registered care home for 60 older people. The home is divided into two units which comprise of a 30 bed unit providing residential care and a 30 bed unit providing dementia/mental disorder nursing care. The home was purpose built. Both units share the same facilities for kitchen, laundry and administrative support. The home is situated in the residential area of Worsbrough Common on the outskirts of Barnsley, close to the M1 motorway and local bus routes and shops. All 60 places are accommodated in single en-suite rooms. Residents rooms are located on the ground and first floors and the home is equipped with handrails, other adaptations and a lift to assist people in moving around the home. Similarly, aids for residents are provided in bathrooms and toilets. The home had a range of communal areas. An enclosed garden and car park are provided. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours from 10:10 to 17:10 The process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with, the manager, staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to eleven staff, five residents and relatives in detail. What the service does well: What has improved since the last inspection? There is an ongoing plan of refurbishment and redecoration, since the last inspection lounge carpets had been replaced and some of the communal areas had been redecorated, crockery and bed linen had been replaced. Security has been improved by the replacement of the wooden garden fence with a metal mesh fence and the home had benefited from external repainting. There has been some improvement in the reviewing and updating of care records and these are stored securely. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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) 2 and 3, standard 6 was not applicable at the home. Residents did not have a written contract. All residents had not had their needs assessed before admission to the home. EVIDENCE: The manager stated that the company has not yet issued Residents with a written contract. Three out of five care plans contained an assessment undertaken by the home before admission. Some of the assessments in place were not fully completed; therefore staff did not give staff full information about the needs of the residents. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 and 9. Residents had a detailed up to date care plan including the actions needed by staff to meet their needs, however these could be improved by the addition of more information relating to the management of identified risks. Resident’s health care needs were met. Medication was well managed and securely stored. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Five care plans checked included detailed information as to the actions required from staff to meet the needs of the individual residents and were reviewed regularly by staff. Care plans had been signed by residents, their relatives or the manager if the resident does not have any relatives. Some information had been recorded on the wrong dates. Risk assessments were in place for, development of pressure areas, moving and handling, falls and nutrition. Individual risk assessments were also included in the care plans but were not all fully completed. Residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved, relatives confirmed that residents were well cared for. Records were kept of medication being received into and leaving the home. There were medication administration records for residents, which were in the main completed appropriately. Staff administering medication on Kingston Unit confirmed that they had received training from other staff at the home and had recently completed a course on the safe administration of medication. Qualified nurses administer medication on Dillington Unit. All medication, including controlled drugs were stored appropriately and securely, maintaining the health safety and welfare of residents. Staff observed administering medication were sensitive to the needs of the residents, maintaining their dignity and followed safe and hygienic practices. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 and 15 Residents are given choice in many aspects of their lives and a variety of activities are provided. Relatives are encouraged to visit and be involved in resident care. Residents receive a choice of food, which is of good quality and can choose where they eat. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 12 EVIDENCE: Residents and staff stated that residents could choose when they get up and go to bed and could spend time in their room when they want to, maintaining their choice and independence. Two activities co-ordinators provide a variety of activities for residents; records are kept to show the activities and entertainment, which have taken place, providing stimulation for residents. Relatives stated that they thought more outings could be offered to residents, the manager stated that recent outings have included a trip to Huddersfield by train and that transport is available for more outings to be arranged during the summer. An activities committee has been set up comprising of the manager, other staff and relatives to plan outings to take place and discuss more constructive activities for residents. A hairdresser was at the home on the day of the inspection. Relatives were observed visiting throughout the day and were observed participating in some aspects of resident care, enhancing the quality of life for all concerned. Residents and relatives stated that visits can take place at any reasonable time and that they are always welcomed into the home by staff, comments included “my relatives can visit me in my room”. Residents said, “the food is alright” and “we can choose what we want to eat”. Residents eat in pleasant small dining areas, staff observed assisted residents to eat and drink in an appropriate and sensitive way, sitting and interacting with residents in the dining room or in their own rooms, maintaining their dignity. The manager stated that new crockery had been purchased. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 and 18 Residents and relatives were aware how to complain and thought that their complaints would be listened to and dealt with. Staff were aware of the policies and procedures in place to protect residents from abuse and had received training. EVIDENCE: A copy of the complaints procedure was displayed in the foyer. Relatives stated that they had been given information about complaints prior to the resident’s admission to the home. Some residents stated that they would tell staff if they were not happy, but also stated that they had nothing to complain about. Policies and procedures relating to recognising and reporting of abuse including whistleblowing were in place. All staff had attended protection of vulnerable adult training. A copy of the local authority adult protection policies and procedures were available and accessible to staff. Residents and relatives spoken to stated that they felt they felt that the home was safe. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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, 24 and 26 The home was in the main well maintained, however the ongoing maintenance plan needs to be implemented to further improve the living environment for residents. Residents were happy and comfortable in their rooms. The home was in the main clean, pleasant and hygienic, however in one of the dining rooms the walls were stained and the carpet was showing signs of age. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 15 EVIDENCE: In the main the home was well decorated and well maintained. Residents stated that they were happy and comfortable in their rooms and that they were always kept clean. Residents and relatives stated that all areas of the home were kept clean, however the ground floor dining room on Kingston Unit had stained walls. The manager stated that all the lounge carpets had been replaced, a new shower had been fitted and a new bath had been delivered and is to be fitted on Dillingotn Unit in the near future. The manager stated that new bed linen had been purchased. The bathroom on the first floor of Dillington unit had damaged paintwork, the manager stated that the redecoration of the bathroom was included as part of the ongoing redecoration programme. Some communal areas had been redecorated, and plans are in place to decorate the corridors and replace some bedroom carpets and furniture, improving the living environments for residents. The carpet in the dining rooms on Kingston Unit were stained, the manager stated that they were to be replaced with wood flooring. Residents stated that in the main they were happy with the standard of the laundry service. Policies and procedures were in place for control of infection, some staff had received training and staff reported that they had sufficient provision of protective clothing. The gardens were pleasant and at times residents were walking outside, the manager stated that wooden fencing had been replaced with a metal mash fence to improve security. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.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 and 30 An assessment of the current staffing levels is needed to ensure residents needs are met. More than fifty percent of care staff are NVQ level 2 qualified. A robust recruitment procedure was in place, protecting residents. Induction training meets TOPSS standards. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: The manager was on duty on the morning of the inspection. On Kingston Unit there was the Unit Manager, two Senior Care staff and two care staff. On Dillington Unit there was two nurses and four care staff. In addition to this five domestic staff, a laundry assistant, a cook, a kitchen assistant, two activities co-ordinators, an administrator and the handyman were working around the home. Residents and relatives stated that there was sufficient staff on duty to meet the needs of the residents. Staff stated that at the present time due to a recent increase in dependency on both units more staff would be useful to meet all the needs of residents. Staff stated that the personal care needs of residents were being met to a good standard but they felt that they did not have sufficient time at present to spend time with residents on an individual basis. Training records showed that 18 care staff employed at the home had completed the level 2 NVQ in care, the manager stated that this was 55 of the care staff team. Five staff files contained appropriate recruitment information including two references and CRB disclosures. The manager confirmed that all staff employed have a CRB disclosure and there is a procedure in place to assist the manager in making a recruitment decision if a positive CRB disclosure is received back for a potential employee. Staff stated that they had received induction training and that there were good opportunities for training. The company had developed an induction booklet to meet the TOPSS standards, which the Unit Manager for Kingston Unit stated was used with all new staff. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 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 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, 33 and 38 The manager is experienced, qualified and competent to run the home. There is a quality monitoring system in place. Residents and relatives feel that the home is safe, however there were some minor gaps in health and safety records. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 19 EVIDENCE: The manager has completed her level 4 NVQ management qualification. Staff stated that a representative from the company visits at least once a month. Copies of the reports of these visits were available at the home and are forwarded to the Commission for Social Care Inspection. Relatives stated that they are asked if everything is all right when they visit. The manager stated that a relatives meetings used to be held but due to poor attendance this had been replaced with an activities committee, this has improved attendance and has given relatives an opportunity to give more focussed input into the running of the home. Records were in place stating fire equipment had been checked, regular fire drills take place and that staff had received fire training. Staff confirmed that they had received fire and moving and handling training, promoting resident safety. Recommendations following a recent visit by the fire officer had been completed. A report following a recent visit from the environmental health officer stated that the home complied with legislation. The manager stated that the gas appliances had been serviced and the electrical testing had been carried, however the landlords gas certificates was not available. The handyman stated that water temperatures were checked, but not always on a monthly basis, hot water temperatures checked were around 43 degrees centigrade. Accident records were fully completed and the manager regularly carries out an audit of accidents. Information relating to accidents was recorded in residents care plans. Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 2 Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 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 2 Regulation 5 Requirement Each resident must have a contract/statement of terms and conditions, containing all the information highlighted in standard 2 of the National Minimum Standards and Regulation 5 of the Care Home Regulations 2001, amended in July 2003. (Previous timescale of 01/04/05 not met). All residents must have a full needs assessment. Information relating to the management of identified risks must be included in residents care plans. The bathroom on Dillington Unit must be redecorated. The flooring in the dining room on Kingston Unit must be cleaned or replaced. The walls in the dining room on Kingston Unit must be cleaned. An assessment of the current staffing levels must be carried out to ensure adequate numbers of staff are available, to meet the needs of residents. Evidence that gas appliances have been serviced by a competent person, must be J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Timescale for action 01/08/05 2. 3. 3 7 14 15 15/09/05 15/08/05 4. 5. 6. 7. 19 19 26 27 23 23 16 18 15/09/05 15/09/05 15/07/05 15/07/05 8. 38 23 15/07/05 Highstone Mews Care Home Version 1.30 Page 22 forwarded to the Commission for Social Care Inspection Office. 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 Good Practice Recommendations Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Highstone Mews Care Home J51 S6484 Highstone Mews V230043 15.06.05 UI Stage 4.doc Version 1.30 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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