Inspection on 10/11/05 for Highview

This inspection was carried out on 10th November 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

Highview 06/04/09

Highview 14/04/08

Highview 26/07/07

Highview 06/09/06

Highview 18/03/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Highview 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 9HD Lead Inspector Adele Berriman Unannounced Inspection 10th November 2005 10:00 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 Highview DS0000064499.V263795.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. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highview Address 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 9HD 0161 792 2610 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) Highview Residential Limited Mrs Linda Yari Care Home 35 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (23), Physical disability (1) Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category DE is for one named individual under 65 years of age. If this person leaves the service user category will to OP. The dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted, where appropriate, to ensure continued compliance with the Residential Forum Guidance in Care Homes for Older People. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The manager must undertake awareness training in Adult Protection Awareness by the end of October 2005. One named service user under the age of 65 (PD) is accommodated for a period of 3 months from 1 September 2005. When this person leaves the home the category will revert back to service users over the age of 65 years of age (OP). 10th January 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Highview is a residential home providing care, support and accommodation for up to thirty-five residents, twenty-five people who require personal care only and ten people with dementia requiring personal care. The home is owned by Highview Residential Ltd who took ownership of the home since the previous inspection. The registered manager of the home is Ms Linda Yari. The home occupies an elevated position off Great Clowes Street in Salford. Access is to the rear of the building via a level access route which leads to the main entrance/reception area. Parking is available to the rear of the building. The front of the building provides an enclosed patio seating area for residents. Accommodation is provided on three floors which are all serviced by a passenger lift. There are 32 single bedrooms, 6 with en-suite facilities and 3 double bedrooms. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 10th November 2005. During the course of the inspection time was spent talking to a number of residents, the home manager and staff. Examination of records, care plans, medication records and policies and procedures relating to the home took place. A tour of some areas of the interior of the building was also carried out. The home continues to provide long stay accommodation. Throughout the inspection the inspector observed a pleasant and comfortable atmosphere around the home with lots of conversation taking place between residents and residents and staff. Not all the standards were assessed during this inspection. It is strongly recommended that this report be read along with the previous report. What the service does well: What has improved since the last inspection? Further development has taken place with the care planning process. The additional information helps provide staff with details of the person they are caring for. The home had been decorated in several areas and the manager explained that further decoration was planned for the near future. Both kitchens attached to the ground floor lounges had been refurbished. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 6 Staff administering the medication had signed medication Administration Records appropriately and photographs of residents were present on the medication file to identify individuals. Improvements had been made in the recording of accidents that occurred in the home. The manager of the home had gained information about different cultural and religious needs at the time of death in order to inform the staff team of certain residents needs and wishes. The home had sought information about a local advocacy service and this information was clearly displayed in the foyer of the home. An external water leak outside the front entrance had been repaired. The manager had made arrangements for the extractor fan, from the kitchen to be non operational at times of the day when it may cause disturbance to the people who’s bedrooms are situated above the kitchen. What they could do better: Several assessments that formed part of the admittance and care planning process were found unsigned and undated. It is essential that all documents relating to the assessment of need are signed and dated to ensure that all records are devised and reviewed, and stored in an appropriate manner. Staff need to ensure that any documentation received from the dispensing chemist contains the appropriate information. The wrong information on these documents may result in a resident not receiving their appropriate medication. A regular audit of the décor, furniture and fixtures in the home is required to ensure that any outstanding repairs are carried out. Regular maintenance is essential to ensure that all furniture and fixtures are safe and operational and do not cause a risk to anyone. The home needs to ensure that a regular review of the service being delivered is carried out on a regular basis. This is essential to ensure that any ideas, comments or concerns can be raised and dealt with. Staff and residents confirmed that the responsible individual visited the home on a regular basis. A report is needed to be written of the outcome of one of these visits on a monthly basis. This report is needed to inform the manager and the Commission of any findings/outcomes of the visit Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 7 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. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 8 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 Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 9 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): 3, 4 The home had an appropriate admittance procedure that informed residents and their families of what services the home could offer. EVIDENCE: Prior to anyone’s admittance into the home the manager of the service visits the individual and carries out an assessment of their needs to ensure that the home is equipped to meet the individuals needs and wishes. Several preadmission assessments were viewed by the inspector and some did not contain the signature of the assessor or the date of assessment. Since the previous inspection the home had varied its registration to enable ten people with dementia to live at the home. Prior to anyone being admitted under this category all staff had received training in dementia care. There was documentary evidence that healthcare services were involved in supporting residents specific needs that the home were unable to meet, for example community psychiatric services. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 10 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 Minor additions to information and ensuring that all documents are signed and dated will give staff the appropriate information and guidance to ensure residents’ needs are met within the home. EVIDENCE: A requirement was made during the last inspection that care plans needed to specify individuals’ particular care needs. Several care plans were examined during the inspection and the content of the plans had improved in detail informing staff of individuals’ specific needs. Following a requirement made during the last inspection additional information has been added to individual care plans relating to individual residents personal wishes and plans for at the time of death. Discussion took place with the manager regarding further developing the care plans to include how specific tasks needed to be carried out to support staff in delivering a consistent service. Care plans contained detailed information regarding peoples needs in relation to daily living needs which were set out under specific tasks headings, for example, communication, socialising, dressing and undressing, walking, Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 11 bedtime and sleep, eating and drinking, washing, bathing and a biography of the individuals life. There was written evidence that individuals needs relating to emotional wellbeing, leisure and recreation needs and preferences had been considered. Staff recorded what daily events had taken place for each resident. Monitoring charts commissioned by health professionals, for example, community psychiatric nurses and continence advisory nurses, were being completed. There was further evidence recorded that residents had regular access to other primary health care professionals including their GP and district nurse service, who were seen to visit during the inspection. Risk assessments were present on individual care plans. The majority of these assessments had been signed and dated by the assessor. However, not all risk assessments contained a review date. The home had a policy for the receipt, recording, storage, disposal and handling of medication. A local pharmacist supplied medication. The storage facility for medication was examined and found to be clean and tidy. Several MAR sheets (Medication Administration Records) were examined and found to be appropriately completed by the staff team. However, some of the MAR sheets that are produced by the pharmacist contained the wrong information. An example of this was that one MAR sheet for a resident had Highview printed on it instead of the resident’s name. Such errors could place residents at risk of the wrong medication being administered. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 12 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): 12, 14 Residents are offered choices in their day-to-day lives by the staff team. The flexibility of the activities on offer at the home contributed to the care that residents received. EVIDENCE: The inspector spoke to six residents during the inspection. Residents confirmed that they were able to get up and go to bed at a time of their choice. One resident commented that you ‘just need to ask if you need anything and the manager will sort it out’. All residents spoken to spoke positively about the care and support they received from the staff team. An activities programme was displayed in the entrance hall area of the home. Activities on offer throughout the week included feet and hand care, hairdressing, keep fit, arts and crafts, music and dancing, film morning, group discussion, quiz night, playing instruments, TV church service (Songs of Praise) and reminiscence. The activities programme was in both written and pictorial formats. At the time of the inspection care staff were carrying out activities, however, the manager said that it was planned that the home would recruit an activities co-ordinator in the near future. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 13 Arrangements for outside entertainers to occasionally visit were made by the home manager and a representative from a local church visited five times a year to offer communion. A requirement was made during the last inspection that information needed to be displayed and accessible to all regarding local advocacy services. During this inspection it was noted that information was clearly displayed in the entrance hall of the home. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 14 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): 16 Residents were confident in the homes system for dealing with complaints and were comfortable that they would be listened to. EVIDENCE: The home had a clear complaints procedure and details of the procedure were available in the entrance area of the home. All residents spoken to said that if they had a concern or a complaint they would approach the manager. One lady said that she’d ‘go to Linda (the manager) if there was anything wrong as she was sure that she would sort it out.’ Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 15 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): 19, 21, 22, 25, 26 Regular review of décor and furniture in the home is essential to ensure a comfortable environment for residents and their visitors. EVIDENCE: All three floors of the accommodation are accessible via a passenger lift and the front entrance of the building provides level access. There is a large communal lounge area on the ground floor of the accommodation leading to an enclosed outside patio area. There are also two smaller lounges situated on the ground floor, one of which is a designated smoking area. Situated off both these lounges are small kitchen areas. A requirement was made during the previous inspection that these kitchens be refurbished. Both these kitchen areas had been refurbished with new cabinets. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 16 Several areas of the home had recently been redecorated and the manager explained that other areas of the home were being decorated in the near future. Several toilet seats were in need of replacement and the hot tap in the bathroom on the 2nd floor needed securing/replacing. Two communal toilets situated on the ground floor were not in use on the day of the inspection. Staff explained that this was due to a blockage problem. Discussion took place with the manager to ensure that the toilets were made operational as soon as possible. Several days after this inspection took place the manager telephoned the Commission to confirm that both toilets had been made operational. Several bedrooms were inspected during the inspection. A full audit of bedroom furniture is required to ensure that all bedrooms are furnished appropriately. This requirement is reiterated from the previous inspection report. The manager stated that there was planned refurbishment of some bedrooms. Several radiators in the home did not have guards fitted. A risk assessment was in place that identified the risks of unprotected radiators. The manager stated that guards for the radiators were planned to be fitted in near future. A requirement was made in the last inspection report that residents were given the opportunity to decide on what bed linen they require on their bed. The manager stated that she was continuing to explore the options available for mattress protectors. This requirement is reiterated in this report. There is a large extractor fan outside the kitchen and situated under several people’s bedrooms, at times this fan was noisy and could disturb people in their rooms. A requirement was made during the last inspection that consideration be given to reducing the noise. The manager stated that since this requirement was made an agreement has been made that the fan is turned off between the hours of 4.00pm and 8.00am to minimise any disturbance to residents. The home was clean and tidy, however, some areas of the home were slightly odorous. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 17 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): 27, 29, 30 Resident’s needs were met by the manager and staff team on duty. Residents were comfortable and confident about the service delivered. EVIDENCE: On the day of the inspection the manager of the home was on duty and there was a sufficient number of staff on duty to meet the needs of the residents. Staff were observed supporting residents in a positive, professional manner. Residents commented to the inspector that the staff were friendly and supportive. The staffing rotas demonstrated adequate staffing levels throughout the day and night to meet the needs of the residents. The home had a policy on the recruitment of staff and the manager demonstrated a good awareness of recruitment legislation and good practice. Records in the home demonstrated that on going training for staff was available. Since the previous inspection some staff have received training in fire training, adult protection training and some staff had finalised their training in dementia care. Basic food hygiene training was planned to take place two weeks after this inspection. Staff continue to study for their NVQ Level 2 & 3. All training that staff undertake is recorded in a training log. Not all entries to Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 18 the training log were signed and dated. It is also strongly recommended that each member of staff has an individual record of training and development. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 19 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): 31, 32, 33, 38 Written policies and procedures at the home did not fully reflect the service delivered. EVIDENCE: The registered manager of the home has been in post for several years. During the inspection, she demonstrated a thorough awareness of individual residents needs and was seen to support and advise staff in their day-to-day role. A requirement was made in the last report that the responsible person must ensure that they visit the home at least once a month and that they provide the manager and the Commission with a written report of the visit. This requirement had not been met and therefore is reiterated in this report. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 20 No recent quality assurance monitoring exercise had taken place, however, the manager stated that a quality audit was to take place within the next month and that this audit involved distributing questionnaires about the service provided. A requirement was made in the last report that the results of any quality audit were published and an action plan produced. This requirement is reiterated in this report. Some policies and procedures relating to the health, safety and welfare of all had been updated. However, some policies and procedures were in need of further development and updating. The requirement from the last report that a full audit of policies and procedures relating to health, safety and wellbeing takes place to ensure that all the documents required in this standard are reviewed, developed and implemented is reiterated in this report. An inspection was made of the home on 25.10.05 by the Environmental Health Officer who made several requirements of the home to ensure that all health and safety measures were in place. The manager stated that all except one of these requirements had been completed, the final one being the painting of the kitchen area and that was scheduled to be completed a week after this inspection took place. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 21 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 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 2 3 X 2 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X X X 2 Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement All pre admission assessments are required to be signed and dated by the person carrying out the assessment. Care plans must identify specific care needs and include what actions are required to meet the individual needs of the resident. The home is required to liaise with the dispensing pharmacy to ensure that Medication Administration Records contain the correct information. A full audit of toilet seats is required and where needed, the must be replaced. A full audit of bedroom furniture is required to ensure that all bedrooms are furnished appropriately. It is required that residents are given the opportunity to decide on what bed linen they require on their bed. It is required that the home is kept odour free at all times. Timescale for action 20/03/06 2 OP7 15 20/03/06 3 OP9 13 05/03/06 4 5 OP21 OP24 23 23 05/03/06 15/03/06 6 OP24 12 20/03/06 7 OP26 12 07/03/06 Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 23 8 OP32 26 9 OP33 24 10 OP38 12 11 OP38 12 The responsible person must ensure that they visit the home at least once a month and that they provide the manager and the Commission with a report of the visit. The manager is required to carry out a quality assurance audit and publish the results and subsequent action plan, a copy of which is required to be forwarded to the Commission. It is required that a full audit of policies and procedures takes place to ensure that all documents required in this standard are reviewed, updated and implemented. It is required that the home carries out all the requirements made by the Environmental Health Officer during the visit on 25.10.05. 10/03/06 20/03/06 20/03/06 01/03/06 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 OP30 Good Practice Recommendations It is strongly recommended that each member of staff have an individual record of training and development kept on file. Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Highview DS0000064499.V263795.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!