Inspection on 18/03/06 for Highview

This inspection was carried out on 18th March 2006.

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

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

Other inspections for this house

Highview 06/04/09

Highview 14/04/08

Highview 26/07/07

Highview 06/09/06

Highview 10/11/05

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 12:45 18 March 2006 th 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.V281574.R01.S.doc Version 5.1 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.V281574.R01.S.doc Version 5.1 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 (2), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (22), Physical disability (1) Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category DE is for two named individuals under 65 years of age. If either of these people leave the service user category will revert 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 November 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. Highview Residential Ltd owns the home and 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.V281574.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 18 March 2006. During the course of the inspection time was spent talking to the staff on duty and a number of residents. 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. 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. Staff were seen to be responding to residents in a courteous and respectful manner. Not all 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 had taken place with the care planning process. Care plans were noted to contain good detailed information with clear instructions to staff on how best to help and support the person they are caring for. Policies and procedures that are available to support the managers and staff to carry out their duties to the best of their abilities had been reviewed and updated since the last inspection. This is good practice as information regularly changes and new information needs to be included in the policies and procedures used. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were inspected on this occasion. However, a requirement made at the last inspection regarding Standard 3 appears to have been met. EVIDENCE: To ensure if the requirement made at the last inspection that pre-admission assessments are signed and dated had been met a number of pre-admission assessments for those residents recently admitted to the home were examined. These were found to be signed and dated. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 Information is available to assist staff meet residents’ needs in the most appropriate way. Some shortfalls in maintaining appropriate medication procedure could place residents health at risk. EVIDENCE: A number of files of residents living in the home were examined during the inspection and included the files of the three most recently admitted residents. Each file contained a signed and dated pre-admission assessment document and a care plan. Care plans contained good detailed information about the individual with clear instructions on how individuals needs and choices could be met in the most appropriate way by care staff. Evidence was available to indicate that regular reviews of care plans were taking place. Risk assessments were in place for a number of residents and covered such issues as moving and handling, pressure areas, skin care and medication. Examination of the risk assessments indicated that these were not being reviewed on a regular basis, which could compromise the health and well being of a resident. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 10 Wherever possible, residents are supported to achieve ‘personal goals’ and this is documented as part of the care planning process. However, it was noted that these records required dating and signing by the person completing the form and a review date setting. If this is not done it could mean that the resident is restricted from further developing or maintaining their independence. Information contained within the care plans examined indicated that other health care professionals such as district nurses, doctors and community psychiatric nurses are involved in maintaining the health and well being of residents living in the home. One doctor visited the home during the inspection to see a particular resident. The resident was treated in the privacy of his or her own room. 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. A number of Medication Administration Records (MAR) were examined and although the majority were correct a number were found not to contain the signature of the person administering the medication at certain times. Such errors could place residents at risk of the wrong medication being administered at the wrong time. Some MARs were signed with the ‘key’ Q, however the abbreviations at the bottom of the MAR did not contain the letter Q so it was difficult to understand what this abbreviation meant. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 the following standard(s): 13 and 15 Residents are able to maintain contact with family and friends and are offered suitable and appropriate meals with choices being made available. EVIDENCE: Information contained within care plans demonstrated that residents were encouraged and supported to maintain contact with their family and friends and to also participate in community based activities. One lady regularly goes out for a walk with a member of staff, another uses the local community services to go shopping and a gentleman maintains regular contact with the Salvation Army, visiting their place of worship on a regular basis. Residents and a staff member working with people with dementia demonstrated several activities they were undertaking including planting seeds, making greetings cards and one resident was teaching a staff member to play chess. The manager of the home has held a meeting with residents to ensure that their views are known about the meals they would like/not like and about the standard of cooking in the home. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 12 Menus are planned over a four weekly cycle and include alternative choices to the main ‘planned’ menu for the day. Seasonal availability of vegetables and fruits is also taken into account and menus adjusted accordingly. Special diets are catered for with the support of a dietician. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 the following standard(s): 18 The manager had systems in place to protect residents living in the home from abuse. However, further information was needed to be available to staff. EVIDENCE: The home has a policy relating to abuse and the manager had recently reviewed this. However, further work was needed to ensure that information was available to all staff relating to Salford Social Service’s joint agency Adult Protection Procedure. The manager however, has recently demonstrated in the way she managed a particular situation that she is fully aware of the policy and procedure guidelines operated by Salford Social Services. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 the following standard(s): 19, 20 and 26 Regular monitoring of the home is needed to ensure that the resident’s and their visitors have a comfortable, safe and pleasant atmosphere in which to live. EVIDENCE: There are three floors in the home providing accommodation to residents and all are accessible via a passenger lift. Level access is available into the main entrance of the building. There is a potential risk to residents should they leave the grounds of the home at the front entrance adjacent to a busy main road. There is no gate from the steps leading from the grounds. The lack of a gate means that any resident could walk directly onto the pavement of the main road and potentially try to cross the road unescorted. An Immediate Requirements Notice was issued for appropriate action to be taken. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 15 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 small lounges situated on the ground floor, one of which is a designated smoking area. Some areas of the home were in need of redecorating and a full audit of the home should be undertaken and an action plan produced to indicate how and when decorating and maintenance of the property and furnishings is to take place. A copy of the action plan must be provided to the Commission for Social Care Inspection. The home was found to be generally clean and tidy, however, some areas had slightly unpleasant odours. Highview DS0000064499.V281574.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Residents’ needs were met by the manager and staff team on duty. EVIDENCE: On the day of the inspection there appeared to be sufficient staff on duty to meet the needs of the residents in the home. Staff were observed supporting residents in a positive and professional manner and treating them with dignity and respect and residents spoken to said they felt safe living in the home. Staff demonstrated a good knowledge of the needs and wishes of individual residents and were able to give examples of the types of training they had undertaken in the home. One member of the staff team told the inspector that they were ‘amazed’ when they did training relating to supporting people with dementia. This training taught them to approach and support people differently depending on the type of dementia the resident is suffering from. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32, 33, 35 and 38 Further work is needed to ensure that the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: A requirement was made in the last two report’s that that the responsible person must ensure that they or their representative visits the home at least once a month and that they provide the manager and the Commission with a written report of the visit. To date, this requirement has not been met and is therefore reiterated. The manager was not on duty at the time of this inspection and the inspector was unable to assess if a quality assurance monitoring exercise had taken place since the last inspection. A requirement was made in the last report that the results of any quality audit were published and an action plan produced. This requirement has therefore been reiterated in this report. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 18 Again, as the manager was not on duty at the time of this inspection the inspector could not examine residents’ personal finance or records, as they were not accessible. These will be examined during the next inspection. Since the last inspection conducted in November 2005 the manager has reviewed and updated all the policies and procedures used in the home. During a tour of the home a number of fire doors were found to be ‘wedged’ open. This would make them inoperative should the fire alarm be activated and could place both residents and staff at risk. Doors must not be ‘wedged’ open. An Immediate Requirements Notice was issued. Although hot water temperatures were being monitored and recorded on a weekly basis hot water temperatures were found to be in excess of 44°C on the day of the inspection. A note on the record stated that the home was waiting for ‘valves’ to be fitted. Such extremes of hot water temperature could place residents at risk and an Immediate Requirements Notice was issued. The hoist in the ground floor bathroom was found to be in need of servicing/urgent repair. Using a hoist in such a condition could place residents at risk and an Immediate Requirements Notice was issued. The small kitchen area near to the smoking room contained a refrigerator that was broken and needed disposing of. This was a potential hazard to anyone using the kitchen area and an Immediate Requirements Notice was issued. The handle to the ground floor bathroom door needs replacing. The tap in the bathroom on the 1st floor needs repairing/replacing. The floor in the bathroom on the 1st floor needs repairing. Evidence was available to show that the testing of the fire alarm system was being conducted on a weekly basis. An inspection was made of the home on 25.10.05 by the Environmental Health Office who made several requirements of the home to ensure that all health and safety measures were in place. At the time of this inspection all but one of the requirements made by the Environmental Health Officer had been carried out. The kitchen is required to be painted. Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 2 X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 2 X X X X 2 Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 Requirement Risk assessments and goal planning information must, as part of the care planning process, be reviewed, signed and dated when completed. Medication Administration Records must contain the correct information relating to abbreviations used and must be signed at the time medication is administered to the individual. Relevant information must be contained within Policies and Procedures relating to the protection of vulnerable adults that will assists staff should they need to deal with such issues. A full audit of the home must be undertaken and an action plan produced as to when updating of the decorating in the home will be carried out. A copy of this action plan must be provided to the Commission. Appropriate action must be taken to ensure the safety of any resident leaving the grounds of the building via the ungated entry at the front of the building. DS0000064499.V281574.R01.S.doc Timescale for action 26/05/06 2 OP9 13 19/03/06 3 OP18 12 26/05/06 4 OP19 23 26/05/06 5 OP20 23 20/03/06 Highview Version 5.1 Page 21 6 OP26 12 7 OP32 26 8 OP33 24 9 10 11 12 13 14 OP38 OP38 OP38 OP38 OP38 OP38 23 13 13 13 13 13 15 OP38 12 It is required that the home is kept free from unpleasant odours at all times (Previous timescale 07/03/06 not met). The responsible person or their representative 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 (Previous timescale 10/03/06 not met). 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 (Previous timescale 20/03/06 not met). Fire doors must not be ‘wedged’ open at any time. Hot water temperatures must not exceed 44°C where residents have access. All bath hoists must be fully operational and safe to use at all times. The broken refrigerator identified in this report must be appropriately disposed of. The broken handle on the downstairs bathroom door must be replaced. The tap identified as not working in the bathroom on the first floor must be repaired or replaced. The damaged flooring must also be repaired/replaced. It is required that the home carries out all the requirements made by the Environmental Health Office during the visit on 25.10.05 (Previous timescale 01/03/06 not met). 26/05/06 26/05/06 26/05/06 19/03/06 20/03/06 20/03/06 20/03/06 26/05/06 26/05/06 26/05/06 Highview DS0000064499.V281574.R01.S.doc Version 5.1 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. Refer to Standard Good Practice Recommendations Highview DS0000064499.V281574.R01.S.doc Version 5.1 Page 23 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.V281574.R01.S.doc Version 5.1 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. 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!