Archived: Highfield Manor

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 Medication audits needed to be reviewed to ensure that creams are not out of date and that staff have clearer guidance to administer medication.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.