Care Home: Highfield House

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• St Vincents
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What the care home does well The home is well managed, with the manager having introduced robust systems for overseeing the day-to-day running of the home. Records are generally well maintained and up to date and residents are being involved in the development of their care plans and given the opportunity to comment on the performance of the service. Activities are arranged and overseen by the co-ordinators, who have also been involved in supporting the residents to produce person centred social activities plans/statements. The environment is well decorated and maintained and domestic staff are available to ensure the home remains clean throughout. Information lifted from the residents` surveys supporting this view, with all three parties acknowledging that the environment is `fresh and clean`. The home`s staff recruitment and selection process is thoroughly operated and ensures that all prospective employees are appropriately vetted before commencing their duties. Staff are also provided with good levels of access to training, with the company employing a training manager. The registered manager was observed on our (the Commission`s) arrival at the home to be involved in assisting a carer to complete a training and development assessment. What has improved since the last inspection? The lounge has been redecorated and new furniture purchased and supplied. New carpet has been fitted along the first floor landing and two bedrooms, visited during the fieldwork visit, had also been fitted with new carpets. A member of the estates team was observed installing a new vanity unit within a clients` bedroom. What the care home could do better: The manager and responsible person identified through the AQAA that they feel the following improvements could be made to the service: `Access to computer and greater life style support through access to the greater community and education. Locks on doors for all rooms in the building as appropriate`. During the fieldwork visist the manager confirmed that the latter issue was in hand and that locks had been sourced by the estates manager, although no plan for their installation had yet been identified. The service is correct to identify this as an area for improvement, as the locks that are currently in place are largely of the `Yale` style and their for not suitable for people with dexterity or cognitive impairments. CARE HOMES FOR OLDER PEOPLE Highfield House 4 Highfield Road Shanklin Isle Of Wight PO37 6PP Lead Inspector Mark Sims Unannounced Inspection 10:30 28 February 2008 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 Highfield House DS0000012497.V359360.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. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield House Address 4 Highfield Road Shanklin Isle Of Wight PO37 6PP 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) 01983 862195 01983 866364 teresa.ihl@btconnect.com Island Healthcare Ltd Ms Teresa Shirley Cornelius Care Home 23 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (6) Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one person aged 60 - 65 years of age for respite care. 20th July 2006 Date of last inspection Brief Description of the Service: Highfield House Residential Home is located towards the mid-point of Highfield Road Shanklin, a quiet residential street situated off Victoria Road. The property is a large Victorian house that has been extended and adapted to provide residential accommodation for 23 people under three registration categories, OP - Older Person, DE(E) Dementia (elderly) and PD(E) Physical Disability (elderly). A passenger lift provides easy access to both floors, although for those ambulant enough the stairs are reasonably wide and of a manageable gradient. The premises is well maintained and provides adequate communal facilities for the service users, including a large lounge and separate dining room able to comfortably seat all residents. The gardens are substantial and ramped access has been provided for ease and convenience. Off road parking is provided but spaces are often difficult to come by and occasionally difficult to negotiate. The current scale of charges is from £425 to £500 with additional charges for chiropody, toiletries, hairdressing and newspapers. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the agency was conducted over six hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met staff and management. The inspection process involved pre fieldwork activity, gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/manager. The response to the Commissions surveys was reasonable, with three service users and two relatives returning surveys. The information provided via the service user surveys indicates that people are generally happy wth the service provided at the home. What the service does well: The home is well managed, with the manager having introduced robust systems for overseeing the day-to-day running of the home. Records are generally well maintained and up to date and residents are being involved in the development of their care plans and given the opportunity to comment on the performance of the service. Activities are arranged and overseen by the co-ordinators, who have also been involved in supporting the residents to produce person centred social activities plans/statements. The environment is well decorated and maintained and domestic staff are available to ensure the home remains clean throughout. Information lifted from the residents’ surveys supporting this view, with all three parties acknowledging that the environment is ‘fresh and clean’. The home’s staff recruitment and selection process is thoroughly operated and ensures that all prospective employees are appropriately vetted before commencing their duties. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 6 Staff are also provided with good levels of access to training, with the company employing a training manager. The registered manager was observed on our (the Commission’s) arrival at the home to be involved in assisting a carer to complete a training and development assessment. 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. Highfield House DS0000012497.V359360.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 Highfield House DS0000012497.V359360.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents can expect to receive a visit from a member of the management team and to undergo an assessment, prior to receiving an offer of accommodation at the home. The home does not provide and intermediate care facility. EVIDENCE: The AQAA states that: ‘thorough pre-assessment of needs undertaken by the manager prior to admission to ensure we can meet need. This includes a question regarding what the clients perception of the care service will be and is follow up after 6 weeks by the Group Liaison Manager’. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 9 The care planning records of four people were reviewed during the fieldwork visit, each plan was found to contain a pre-admission assessment carried out prior to the persons’ date of admission. The AQAA also indicates that people are provided with copies of the ‘service users guide’ and ‘statement of purpose documents, which are intended to help or assist them in making the choice of whether or not to accept the offer of accommodation. The AQAA states that the service has ‘clarified the fees section of the service users guide to make our fee structure more transparent’. The surveys returned, by both the residents’ and their representatives tell us (the commission) that they received adequate information about the home, prior to making a decision about moving in. In conversation with the manager it was established that people are welcome to visit the home prior to deciding if the home will meet their or their next-ofkins needs and that people can either visit by appointment or unannounced. The dataset, which is a record that forms part of the AQAA documentation, indicates that the management team have access to policies and procedures around the handling of emergency admissions, although the date of implementation is not documented. The AQAA states that the service has improved its admission procedure over the last twelve months by introducing: ‘Meet and Greet is a new service provided by our Group Liaison Manager who has overarching resonsibility for developing our Quality Assurance (QA) structure. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are provided with individually drafted care plans, which reflect both their health and social care needs. People are being appropriately supported to accessing health and social services and their medications are handled and stored safely. EVIDENCE: Four care plans were reviewed during the fieldwork visit, with each plan found to be well maintained and structured. The AQAA indicates that: ‘Person Centred Plans’, have been introduced, however, on reading through people’s plans it was noted that implementation may have commenced but the move across to a fully ‘person centred’ care planning system has not yet been completed. Each plan did however, contain pre-printed care plans, which encourage staff to tick boxes when indicating a persons’ needs, i.e. ticking needs assistance with personal care, which then list the actions required to complete the task. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 11 These plans were found to be a little impersonal and tended to generalise how people require their care delivered, although as pointed out by the management the introduction of the ‘person centred plans’ will improve this situation by focusing on the person and their preferences, aspirations. Risk assessment documents and a number of assessment and/or monitoring tools were also available, including falls assessment and nutritional screening tools. Information taken from the service user and relative surveys establishes that people are generally satisfied with the care provided at Highfield. The two service user surveys providing evidence of people’s belief that they are appropriately supported when accessing health and social care services, both parties ticking ‘always’ in response to the question: ‘do you receive the medical support you need’. Health records, which form part of the care plans, provide documented evidence of the residents’ involvement with health care services, general practitioners, consultants, community nurses, opticians and chiropodists. One care plan contained copies of correspondents between the person and their health care provider, whilst copies of professional assessments were also seen during the visit. The AQAA makes clear that: ‘escorted access, enabled to optician and all other health professionals as required. Such requirements are diarised and transport arranged by the Registered Manager’. During discussion it was explained that the home has a car, provided by the company, and that this is used to take people to appointments, if clients are admitted to hospital the company has created an admissions sheet, which is used to share information with the admitting ward, this information relating to the persons care needs, medications and medical history. The AQAA also indicates that an: ‘End of Life Pathway is used in the care of clients who are dying and a policy and procedure is available to all staff, as is a new training programme’. The home’s medication system was reviewed during the fieldwork visit, with the storage of all medications found to be safe and appropriate. The home’s ‘medication administration records’ (mar sheets) were reasonably well maintained, although one incorrect entry/ommission was discovered. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 12 The AQAA and dataset, which forms part of the AQAA documentation, states that: ‘medication policies and training are provided’, the latter confirmed whilst reviewing the home’s training records. Residents are able to manage their own medications, with lockable facilities provided in each clients bedroom and an assessment process completed according to the AQAA, although none of the residents reviewed during the fieldwork visit self-medicated. All bedrooms provide single occupancy accommodation, which provides privacy during meetings or consultations, although should the person not wish to use their bedroom to entertain a visitor one of the home’s two offices can be freed up for use. Bedroom and communal facilities were noted to be fitted with locks, however, as identified via the AQAA, these were not always of a type that suit the needs of the residents and therefore plans are in place to replace all existing locks with more suitable alternatives. Information taken from the residents surveys indicate that people feel they are treated with dignity and respect by the staff and that the staff listen and reacted appropriately to their requests. During the fieldwork visit the staffs interactions with both residents and their relatives or visitors were observed and noted to be friendly, polite and respectful. One client was seen being escort or supported to access the home’s downstairs toileting facilties, the staff member checking descreetly that the facility was unoccupied and that the person was not disturbed until they had completed their visit, checking carefully on several occasions that the person was alright, this including knocking/tapping the door to alert the person that they were about to enter the room. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that residents receive appropriate support when choosing or participating in social events and enable them to maintain contact with friends and family, via visits to the home or trips out into the wider community. The food served at the home is well cooked, well presented and nutritionally balanced. EVIDENCE: The AQAA indicates that the service employs an activities co-ordinator, who during the fieldwork visit was seen arranging and/or delivering entertainments to the residents. This largely focused around armchair activities, which could be entered into by all parties sitting within the lounge. However, records produced by the activities co-ordinators establish that a range or variety of entertainments are provided and include both internal and external events, as well as visiting entertainers. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 14 The manager stated that the service has access to a vehicle, provided by the company and that this is used to both transport people to and from appointments’ and to facilitate visits or outings, which has been the case on visits undertaken to sister home’s of the service. The ‘person centred plans’, as mentioned above, are still in the early stages of being introduced into the home. However, where plans have been completed and/or drafted, they typically focus on the person’s wishes in respect of their social activities and stimulation. One draft plan discussed with the manager involved a person’s aspiration or desire to go swimming, which the carer had both documented and given consideration to. The manager explaining that the carer has already volunteered their services to escort the client to a local swimming pool, which has facilities for people with mobility concerns, and that she is also happy to support the client and the carer acting as driver and second carer. The residents’ surveys support the view that the service provides people with access to appropriate levels of entertainment, however, one of the three relative surveys suggested that a greater spread or variety of activities might be needed if they are to meet everyone’s needs, a view not shared by the other two respondents who indicated that the service helps people to lead the life they wish. The home’s visiting arrangements are detailed within the ‘service user guide’ and ‘statement of purpose’ documentation, which the manager states she provides to all prospective residents’ or their representatives, copies of these documents were available within the home’s reception hall. During our visit a number of visitors were noted arriving at the home and being welcomed by the staff prior to meeting up with their next-of-kin. As mentioned above the service provides single occupancy accommodation, which allows visits to be conducted in private, however, should the person not wish to use their bedroom for entertaining the opportunity exists to use one of the home’s two offices. The AQAA also makes clear that people are supported to maintain contact with their families and friends by the staff who: ‘regularly take clients to their own homes for visits with families and friends, some families members visit daily and are able to have lunch with their loved ones if required’. The relative surveys indicate that people are supported by the home in maintaining contact with their next-of-kin, all three people ticking ‘always’ in Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 15 response to the question: ‘does the care home help your friend or relative to keep in touch with you’. The AQAA indicates that: people are provided with the opportunity to comment on the service delivered via ‘residents meetings’, for which there are minutes and audits via the home’s quality assurance system, which includes questionnaires. The introduction by the service of the ‘person centred plans’ makes it much easier to evidence that people are being involved in the identification and drafting of their own plans, based on their needs and wishes, although the use of assessment tools, such as the self-medication and key holder assessment, provide evidence of people’s involvement in the care planning process prior to the ‘person centred plans’ being considered. During the visit people were noted to be involved in both group activities, under the guidance of the activities co-ordinator, or self-directed activities, reading, watching television, etc. One client seen during the tour of the premise and spoken with briefly, was in their bedroom and stated that they preferred to remain apart from the remainder of the clients, as they liked their own company and were able to do what they liked when they wished. The residents’ surveys indicate that people feel generally that they receive both the ‘care and support they require’ and that staff are available to help them when required and listen to their requests and respond appropriately’. The surveys also indicate that the meals provided at the home are popular with people ticking ‘always’ in response to the question: ‘do you like the meals at the home’. The main meal of the day was observed during the fieldwork visit and was noted to be a very social occasion with group of residents’ chatting and talking as they ate and staff available to support people with their meals, as required. The dining area within the home is a large and comfortable room, which provides adequate seating for all of the people accommodated at the home, although some people did choose to dine in their rooms. The meals were well presented and the home’s chosen method of serving, with staff serving meals directly to people, provides the clients’ with the opportunity to have large, small or medium size portions. The menus operate on a four weekly rotational basis and contain a choice of main meals or alternatives for people should they prefer. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user and their relatives are aware of the home’s complaints process and confident that any concerns will be appropriately addressed and managed, whilst protecting them from harm and/or abuse. EVIDENCE: The AQAA indicates that people are made aware of the home’s complaints procedure: ‘complaints procedure is provided within the ‘statement of purpose’ and ‘service users guide’, which are displayed within the reception area of the home’. The dataset establishes that details of the home’s complaints process are made available to staff via the company’s policies and procedures, although no date for implementation or review of this process exist. The dataset also indicates that only one complaint has been received by the service in the last twelve months and that this complaint was investigated and responded to within 28 days. The residents’ and the relative surveys indicate that people are generally aware of whom to and how to make complaints, although as stated on one survey ‘the need to complaint has not arisen’. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 17 During the fieldwork visit the arrangements for logging complaints was reviewed with the manager and found to support the fact that only one complaint has been received by the service this year and that has been resolved. The company also require their managers to indicate the number of complaints they receive each month as part of the company’s quality auditing programme, so that trends can be followed / identified, feedback in the form of graphic presentations are sent to the home to highlight their performance. The AQAA makes clear that: safeguarding adults training is mandatory in house annually’, a statement confirmed during the fieldwork visit when reviewing the staff training records/matrix. The AQAA also indicates that the company’s ‘safeguarding adults procedure has been reviewed and new documentation made available’, a member of the company’s board also sits on the ‘Islands safeguarding review panel’. The dataset establishes that ten safeguarding referrals have been made by the service over the last twelve months, our records evidence that these have been reported to both us and the Local Authority and that these reports have all been appropriately made. Our records also indicate that these issues have been satisfactorily resolved. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and well-maintained environment for the residents that are also clean and hygienic throughout. EVIDENCE: A tour of the premise was undertaken with the manager and the environment found to be clean, tidy and well maintained throughout. The manager identified that new carpets had been fitted along the home’s corridors, which confirmed information provided via the AQAA and a member of the home’s maintenance team was observed fitting a new vanity unit in one of the bedrooms. Plans to replace the home’s existing bedroom door locks was also discussed during the fieldwork visit, as the current locks are not suitable for all clients, Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 19 this issue has also been identified within the AQAA, as an area where the service can be improved. The home employs domestic staff; who were observed during the visit undertaking their duties. A plan is in place to ensure that in rooms where clients are known to suffer with incontinence problems their carpets are regularly shampooed and cleaned and during the visit no odours were noticed. Information taken from the residents’ surveys indicates that people feel the home is: ‘clean and fresh’ throughout. The AQAA indicates that staff receive access to training on the management and control of infections and that policies and procedures are available, although again no dates for implementation or review are provided. Communal toilets and bathrooms were noted to contain liquid soaps, paper towels and bins for the disposal of waste. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs staff in sufficient numbers and with the appropriate skills and experience to meet the clients’ needs. Staff training and development opportunities are good and the recruitment and selection process robust and well operated. EVIDENCE: The AQAA establishes that the company employs a training and development manager and that her role is to: ‘organise and promote training - both internally and externally. The Training Manager timetables relevant training for all staff and advises managers monthly about the staff who have training needs outstanding and progress of qualifications’. During the fieldwork visit the manager provided us with sight of the training matrix, which evidenced that staff have complete six monthly fire awareness sessions, moving and handling training, annual infection control, Protection of Vulnerable Adults, three yearly food hygiene updates, three yearly first aid training, palliative care and medication training. It was also noticed that a board within the staff office was used to advertise forthcoming training events, which at the time of the fieldwork visit included ‘dementia awareness and Mental Capacity Act’ training. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 21 Each staff member is provided with their own training and development portfolio, two of these folders were seen during the fieldwork visit and provide evidence of the training completed by staff, include induction and e-skills UK training programmes. Information taken from the dataset and confirmed with the manager, indicates` that currently the home employs eighteen care staff. Eleven of the eighteen care staff has completed a National Vocational Qualification (NVQ) at level 2 or above and this provides the home with a rate of 61 of its care staff possessing an NVQ at level 2 or above. The dataset also indicates that four other people are completing their NVQ, which would increase the percentage of staff holding an NVQ level 2 or equivalent to 83 . Information contained within the dataset establishes that a recruitment and selection strategy/procedure exists to support the management staff when employing new staff. It also indicates that all of the people who worked in the home over the last twelve months had undergone satisfactory pre-employment checks. On reviewing the files of four newly recruited staff all of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references. The files also contained completed application forms, health declarations, photographs of the employee, interview summaries, personal information and information used to support the CRB application process. Information taken from the surveys indicates that people are satisfied that the staff possess both the skills and knowledge to meet their needs and that they are appropriately looked after. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and provides a safe and pleasant environment where the residents and their relatives can comment upon and influence the service provided. EVIDENCE: The AQAA states that: ‘ the manager holds an NVQ at Level 4 and a Certificate in Health and Social Services Management from Portsmouth University. The manager has 18 years experience of working in residential homes, 8 years at management level and has a special interest in dementia care. The manager works closely with the ‘Corporate Management Team’ in developing the ethos and general business plan for the home. She has overall, Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 23 day-to-day, operational responsibility for the running of the home and management of all staff and ancillary services. Administrative support is provided from the Head Office Team who oversees finance and strategic planning. The company’s ‘Training Manager’ provides additional support, in the development of comprehensive training packages for staff and the ‘Group Liaison Manager’ has responsibility for quality assurance’. The service’s approach to quality assurance is good, with a number of surveys or questionnaires available to the manager and the ‘Group Liaison Manager’, who co-ordinate’s all evaluation of the service’s performance. The AQAA states that: ‘QA procedures require the manager to review significant performance indicators monthly these identify areas of good practice and also areas where performance could be improved, action plans are developed as and when necessary to assist in efforts to constantly improve practice’. Details of the monthly performance indicator reviews, as mentioned above, are translated into graphic depiction and copies of these were noticed on display within the home. The ‘Group Liaison Manager’ also undertakes visits to the home in accordance with Regulation 26 of the Care Homes Regulations and copies of the reports produced as a consequence of these visits were available for review. Residents meetings also occur regularly, with minutes from these meetings also available for review. Previous inspectors have recorded that the company does not become involved in the management of people’s monies or finances. Offering instead the residents the opportunity to join an invoicing scheme, whereby the service pays for any item required by the resident and then itemising their purchases on a monthly invoice, which is the provided for payment, receipts for items purchased are made available. At this visit the manager was asked if any changes or alterations had occurred with this process, the manager confirmed they had not. The AQAA and Dataset information establishes that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. The AQAA also indicates that: ‘ A Director is an IOSH qualified Health and (H&S) Safety Technician and keeps up to date with current practice by Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 24 attending regular external training’, and that in addition to his ‘responsibility for H&S he holds a Portable Appliance Testing qualification and is reviewing the Fire Safety Risk Assessment Policy’. Health and safety training is being made available to staff, with the training matrix and plan providing evidence of the courses attended and to be attended by staff, including: health and safety, infection control and moving and handling, etc. The tour of the premise identified no immediate health and safety issues, and the environmental risk assessments do consider both potential areas of harm and how these can be managed, as highlighted by the service’s decision to improve the ramped access at the front of the home. Generally the service users and their relatives are satisfied with the service being provided at the home and raised no concerns in relation to either Health or Safety issues. Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South East Region The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Highfield House DS0000012497.V359360.R01.S.doc Version 5.2 Page 28 - 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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