Archived: Highfield Manor

Updated 11 December 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was unannounced and took place on 20 and 21 September 2018. The inspection was carried out by one adult social care inspector.

Before our inspection the provider completed a provider information return (PIR). The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We also reviewed the information we held about the service and we looked at the statutory notifications they had sent us. A statutory notification is information about important events, which the provider is required to send to us by law.

Before the inspection visit we contacted the local authority safeguarding and commissioning teams about the service to gather relevant information. We also contacted Healthwatch Rochdale. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We received concerns from the local authority about a lack of activities and stimulation for the residents and the need to improve the environment of the home.

During the inspection we spoke with the registered manager, five staff members, four relatives and two visiting professionals. The people living at the service, that we approached, either declined or were unable to engage with us.

We therefore undertook a Short Observation Framework for Inspection (SOFI) observation. A SOFI is a specific way of observing care to help us understand the experience of people who are not able to talk with us.

During the office visit we looked at records relating to the management of the service. This included policies and procedures, incident and accident records, safeguarding records, complaint records, three staff recruitment, training and supervision records, three care files, team meeting minutes, satisfaction surveys and a range of auditing tools and systems and other documents related to the management of the service.

Updated 11 December 2018

Highfield Manor is a large detached house situated close to the centre of Heywood. The home is registered to provide accommodation and personal care to up to 38 people who live with dementia and/or a physical disability. Communal areas located on the ground floor consisted of three lounges and one dining area. All bedrooms are single and had ensuite facilities. At the time of the inspection there were 30 people living at the home.

This inspection took place on 20 and 21 September 2018 and was unannounced. The service was last inspected on 12 and 13 May 2016 and received an overall rating of good. It also received an additional focused inspection on 31 August 2017 in response to concerns raised about Highfield House (this is the sister home next door to Highfield Manor and belongs to the same organisation). The inspection focused on safety and well led and both received a good rating.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We rated the home as requiring improvement. The system for collecting references during recruitment was not thorough enough. The registered manager agreed to improve how they collect and record references and the interview form has also been improved for future use. Medication was administered as prescribed. Medication audits needed to be reviewed to ensure that creams are not out of date and that staff have clearer guidance to administer medication. The premises needed modernising and updating including the need to make the environment more dementia friendly. There was a lack of activities suitable for people with a diagnosis of dementia.

Staffing levels were good and both safeguarding and whistle blowing policies were in place and staff understood how to report if they had concerns. The premises had effective systems in place to manage fire safety and all required safety certificates were up to date.

People’s health needs were assessed and the care files provided clear guidance on how to meet these needs and there was a system of regular review each month.

Risks to people's health and well-being had been identified and care plans had been put into place to help reduce or eliminate the identified risks and these were reviewed monthly.

An action plan had been put in place to deal with a poor infection control report from the local council. We will ask the council’s infection control team to visit again to check that this has been effective.

Food and drink were well managed and people’s health needs were met.

The service was compliant with the Mental Capacity Act. The registered manager had a reliable system in place to keep any deprivation of liberty up to date and the files were person centred when assessing people’s capacity.

We observed during the inspection that the staff were kind and attentive to people’s needs. The staff reported that there was a good team culture and that they received good support from the registered manager.

People’s religious and cultural needs were being met. The accessible information standard was met. People were routinely assessed to ascertain what their communication preferences or abilities were.

All the staff we spoke to felt supported in their roles and reported that the registered manager was approachable and supportive.

The service is aware of the areas that need to be improved and are working towards achieving this. This process would benefit from a review of the auditing systems to ensure that they are effective.