Inspection on 18/01/06 for Heather Vale

This inspection was carried out on 18th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Heather Vale 07/08/06

Heather Vale 26/08/05

Heather Vale 04/02/05

Heather Vale 25/09/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Heather Vale Heathervale Road Hasland Chesterfield Derbyshire S41 OHZ Lead Inspector Angela Kennedy Unannounced Inspection 18th January 2006 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 Heather Vale DS0000020009.V277519.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. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heather Vale Address Heathervale Road Hasland Chesterfield Derbyshire S41 OHZ (01246) 221569 (01246) 554760 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) Anchor Trust Mrs Anne Brooke Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 26th August 2005 Brief Description of the Service: Heather Vale is a purpose built care home which opened in 1989. The home provides personal care and accommodation for 39 older people in thirty-seven single rooms and one double room, all with en-suite facilities. The home has two communal lounges and four dining rooms and is set in pleasant accessible gardens. Heather Vale is situated on the outskirts of the village of Hasland which has a range of shops, pubs, churches, a public park and access to public transport. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over approximately 3 hours. There were 36 residents accommodated at the home on the day of inspection. The manager and deputy manager were available throughout the inspection. Discussions took place with several residents and staff during the inspection. A number of records were examined during the inspection, including residents’ personal files (as part of the case tracking process which is used to help determine how the home meets the needs of the individual resident). A tour of the building also took place during the inspection. What the service does well: What has improved since the last inspection? No requirements were left at the last inspection Of the recommendations left at the last inspection all have been addressed and demonstrates that the home makes every effort to meet the needs and expectations of the residents, this included: Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 6 Amending the terms and conditions for residents to refer to the commission for social care inspection rather than the national care standards (its former name). Residents preferred name has been recorded within their lifestyle agreement plans. Nutritional and tissue viability assessments are signed by the member of staff completing them. The activities programme for residents is being further developed; this includes plans to increase the weekly working hours of the activities co-ordinator. Staffing levels have been increased at the home, and additional care staff are now available during peak times. 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. Heather Vale DS0000020009.V277519.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 Heather Vale DS0000020009.V277519.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): EVIDENCE: Standards 1 – 5 were not assessed at this inspection. Standard 6 is not applicable to this home. Heather Vale DS0000020009.V277519.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): 7,9,10,11 Care plans were developed with resident involvement and residents’ needs appeared to be well met. EVIDENCE: The storage of medication within the home was found to be satisfactory, both for residents who retain their own medication and for those who do not. All medication brought into the home was recorded, including residents who self – administered their medication. Residents who wished to retain responsibility for the custody and administration of some or all of their medication were able to do so and risk assessment were in place to confirm the appropriateness of this arrangement. In general the medication administration recording sheets were found to be satisfactory, however one resident had gaps on their medication sheet over a two week period where their lunch time medication had not been signed for and no code had been inserted on to the medication administration recording sheet to state why the medication had not been administered. Controlled drugs within the home were recorded, stored and administered appropriately and in line with safe working practice. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 10 Staff who administered medication had received the appropriate training and evidence was seen regarding this within the staffs’ personal files. Residents spoken with confirmed that staff are respectful of their privacy and dignity, observation of staff with the residents supported this. Visiting hours at the home were open; the residents who were spoken with confirmed this. There was a portable pay phone available for residents use within the home; this could be used in the lounge or dining room area. However all residents had a private telephone line within their room and many chose to have their own private telephone. Of the residents’ personal files seen, the residents preferred term of address/name was recorded and residents’ wishes regarding the procedures required in the event of death or dying was also documented. All assessments seen had been regularly updated and included the signatures of the staff that had completed them. Heather Vale DS0000020009.V277519.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): 12,15 Residents social needs and recreational interests were met within the home, and residents were able to exercise choice in the activities undertaken. Residents at the home received a balanced diet that catered for both nutritional requirements and preference. EVIDENCE: Details of the residents preferred social, cultural and recreational needs and choices were documented within the personal records seen. The deputy manager discussed the on- going activities that were planned, this included an intention to increase the hours worked by the activities coordinator employed at the home to enable more one to one activities to be offered to the residents. On the day of inspection a hairdresser was visiting the home, this seemed very popular especially with the female residents and many had appointments booked to have their hair washed and set. One of the residents spoken with said that the hairdresser was very good. Another resident said that she did not use this hairdresser herself, as she visited her own hairdresser whom she had used for many years. This demonstrates that residents are able to maintain contact with the local community and maintain control over their own lives. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 12 A tour of the kitchen took place and was found to be of a very high standard. All food was stored correctly and food preparation areas were clean and well organised. On the day of inspection only one member of the catering team was on duty within the home, as the other three catering staff were attending a food hygiene course. However due to excellent organisation and planning this had not impacted on the standard of service provided. The menus ran over a four week period and provided choices at all meal times that appeared varied and of a high nutritional content. The member of staff spoken with stated that omelettes, jacket potatoes and salads were also available along with the daily choices and that cooked breakfasts were available at weekends for residents. Evening meals offered included a cooked meal or sandwiches where a choice of fillings was available. Residents spoken to confirmed that the meals at the home were of a very high standard and many positive comments were received including one resident who stated that the meals were excellent and couldn’t be any better. Heather Vale DS0000020009.V277519.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): 16,18 There is a complaints procedure in place, which is robust in content. The systems in place promote the protection of residents from abuse and neglect. EVIDENCE: The deputy manager stated that there had been no recent complaints. Residents spoken with seemed confident that any concerns they had would be given prompt attention by the manager. There is a complaints procedure, which appears robust in content; this is displayed within the home and in the service user guide. The complaints procedure of the home has three stages and stages one and two clearly states that complaints will be acknowledged and responded to within the required timescales i.e. maximum of 28 days, however stage three of the complaints procedure suggests that any complaints unresolved at this stage must be made within 28 days, rather than stating the homes required response timescale to the person making the complaint i.e. maximum of 28 days. The home has procedures and relevant documentation in place for responding to suspicion/ evidence of abuse. Of the staff files seen, all were up to date in adult protection training; this demonstrates that the current practice of the home promotes the protection of residents. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 14 The documentation regarding residents’ monies was examined and records were found to be robust in detail. Residents, who wished and were able, kept a limited amount of money within their private accommodation (this was for security purposes and the limit appeared to be substantial) Other monies kept for residents were: Within the home, the balance of this money was checked at least once a week and if possible twice weekly. These records were examined and found to be in order. Each resident had their own individual money transaction sheet for money kept within the home and all transactions were recorded and signed for, these were examined and found to be satisfactory. Within a no interest joint bank account, which held the majority of the residents’ monies. This money was accessible to residents as they wished, and each resident had a monthly individual bank statement. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 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): 26 The home appeared clean, fresh and pleasant in décor. EVIDENCE: A tour of the home was undertaken and on the day of inspection the home appeared clean and free from offensive odours. The décor of the home was pleasant and of a good standard. The kitchen was also inspected and seen to be kept to a commendably high standard throughout. The communal areas were pleasantly decorated and appeared clean and tidy, but maintained a homely environment. Residents’ private accommodation that was seen was decorated and maintained to a good standard, and appeared clean and free from offensive odours. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 16 The laundry facilities were also inspected and found to be satisfactory with adequate facilities that were maintained to a high standard. Residents clothing was washed separately and washing machines had the specific programmes that met the required disinfection requirements. Residents spoken with stated that the home was always clean and tidy and praised the staff for the standards of hygiene maintained within the home. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 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 The recruitment practices in place protect residents; this could be enhanced to demonstrate that satisfactory efforts are being made to ensure residents are protected by a robust recruitment practice. Residents assessed needs are met by a competent staff team. EVIDENCE: Although standard 27 was not assessed thoroughly at this inspection, it was assessed at the previous inspection and although found to be satisfactory, a recommendation was left for the staffing levels to be kept under review as staff had felt that at times they were overstretched, particularly when there were residents in the home with higher care needs. This is an ongoing issue within the home and is being regularly reviewed. Additional care staff were rostered on shift at peak times to ensure that current good standards of care are maintained. Of the staff files examined the homes recruitment practices were generally found to be satisfactory with all the required checks in place, however one recently appointed member of staff had not provided a full employment history and this had not been investigated by the home prior to commencement of employment. Any gaps in employment should be investigated to further ensure that residents are protected by a robust recruitment practice. Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 18 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): EVIDENCE: Standards 31 – 38 were not assessed at this inspection. Heather Vale DS0000020009.V277519.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 3 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 20 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 9 Regulation 13 Requirement Timescale for action 01/02/06 2 16 22 3 29 19 No gaps must be left on medication administration records; reasons for nonadministration of medication must be documented using appropriate codes. Timescale for response to 01/04/06 complaints must be clearly stated on all stages of the homes complaints procedure. A full employments history must 01/02/06 be sought before appointing staff and any gaps in employment must be explored. 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 Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Heather Vale DS0000020009.V277519.R01.S.doc Version 5.1 Page 22 - 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. 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