Inspection on 07/08/06 for Heather Vale

This inspection was carried out on 7th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heather Vale 18/01/06

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 Key Unannounced Inspection 8th August 2006 02:30 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.V298605.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. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 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) Sharon.blackwell@anchor.org 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.V298605.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Plus Three (3) Day Care Places Date of last inspection 18th January 2006 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. The current scale of charges per week at the home are: Self funders £347.00 Self funders higher rate £367.60 Local Authority funded (All Local authority funded are subject to £20.00 top up) Low rate £289.20. Middle rate £311.50 High Rate £328.20 For information regarding the home and availability the registered manager and deputy manager can be contacted on 01246 554760. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced and all of the key national minimum standards were inspected. The inspection took place over a three-hour period and the manager and deputy manager were available throughout the inspection to assist the inspector in providing the required documents. On the day of inspection there was 32 people living at the home on a permanent basis and 1 person staying at the home for respite care. During the inspection 3 residents files were examined, looking at the residents care plans and other relevant information regarding the care and support they received. 3 residents and 2 members of the care team were spoken with and a brief tour of the home was undertaken. Other documentation and records regarding meals, medication, resident’s finances and health and safety practices were examined. What the service does well: What has improved since the last inspection? One of three requirements left at the last inspection 1 has been met which related to medication administration records. The other two requirements have not been fully met but were being addressed by the providers of the home. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 6 Staffing hours have been increased, this includes additional hours for the homes activities co-ordinator, which has allowed for more activities to be undertaken with the residents, and two of the residents spoken with confirmed that activities and outings provided were enjoyed. A new care planning package has been developed and was robust in detail, some of the residents files had been transferred onto the new system and staff spoken with felt that new care plans were more user friendly and provided staff with a more efficient and easier to access recording system. 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.V298605.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 Heather Vale DS0000020009.V298605.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Resident’s needs are assessed prior to moving into the home to ensure their needs can be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Standard 6 is not applicable to this home. EVIDENCE: 3 residents files were examined and all had the relevant pre- admission needs assessments in place undertaken by the home and, for residents who were locality authority funded a care managers assessment was also in place. The homes pre-admission assessment was detailed and assessed resident’s; health care needs- including mobility, history of falls, diet and weight, sight, hearing, continence and medication. Residents social, emotional and cultural needs and preferences and mental state including psychological well-being were also assessed. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 9 Heather Vale DS0000020009.V298605.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Care plans were developed with resident involvement and residents’ health, personal and social care needs appeared to be well met. Resident’s, who were able were responsible for their medication and the homes practices for dealing with medicines indicated that the residents’ welfare was protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: As stated in standards 1-6, new care plan packages had been developed and one resident whose file was examined had recently moved in to the home, and therefore these new care plans had been used. The deputy manager confirmed that all residents care plans would be transferred to the new system over the coming months. The new care plan package was robust in detail and provided staff with detailed information regarding the support the resident needed and stated the resident’s abilities, this demonstrated that a person centred approach was used to ensure that residents needs were met, whilst allowing them to maintain Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 11 their independence and thereby retain as much control over their lives as possible. Of the three residents’ files seen all were detailed and each resident had been assigned a key worker who was responsible for ensuring care plans and risk assessments were updated as required. All care plans were reviewed on a monthly basis. Residents’ were involved in the development of their care plans although not all the files seen had evidence in place to demonstrate this. Evidence was in place within the 3 resident’s files seen that demonstrated that residents health care needs were assessed and the appropriate action taken, this included, nutritional screening on admission including weight and subsequent assessment of nutritional needs, diet and weight. One resident’s file clearly demonstrated that the resident had been underweight on admission and therefore all dietary intake had been recorded along with regular weighing of the resident, a record of the residents food intake had continued until the resident was no longer underweight. This demonstrated that the home strived to promote the health of residents. Residents had access to health care professional including hearing and sight tests, foot care, general practioner and district nurses as required and evidence was in place to demonstrate this. 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. Medication administration records seen had been completed appropriately and no gaps were found. Controlled drugs within the home were recorded, stored and administered appropriately and in line with safe working practice Staff who administered medication had received the appropriate training and evidence was seen regarding this within the staffs’ personal files seen. Staff were observed in their interaction with residents and demonstrated a positive and respectful attitude towards the residents. The residents spoken with confirmed this, and stated that the staff were very thoughtful towards them and always treated them with respect. 2 of the residents spoken with had their own telephones within their private accommodation. This option was available to all residents as all rooms were equipped with a private telephone line. A portable pay phone was also available for residents use and could be used within the lounge or dining area. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 12 Visiting hours at the home were open and residents were able to choose were they entertained their guests, either within their private accommodation or within the communal areas of the home. Of the residents’ personal files seen, the residents preferred term of address/name was recorded. Heather Vale DS0000020009.V298605.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents’ social and recreational needs were met within the home and residents’ were able to main contact with family and friends. Meals at the home were balanced, and catered for nutritional requirements and preference. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Details of the residents preferred social, cultural and recreational needs and choices were documented within the personal records seen. The hours worked by the activities co-ordinator had been increased since the last inspection and a range of activities were provided within and outside of the home. A recent activity had been a boat trip on the canal, which one resident spoken with had attended and stated that she thoroughly enjoyed it. Other activities included: • Saturday night bingo or music and movement- alternating weeks • Trips out once a month – i.e. seaside, theatre • One to one trips out with residents- i.e. shopping trips, local areas • Reminiscence sessions • BBQ’s Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 14 • • • • • • Group activities Quizzes Flower arranging Clothes parties Theme evenings/events Pamper days Residents had access to a hairdresser who visited the home once a week. Some of the residents preferred to visit their own hairdresser and some residents’ hairdressers’ used the facilities at the home. This again demonstrates that residents are encouraged to maintain control over their lives whenever possible. Residents spoken with confirmed that they were able to receive their visitors as they wished and were able to choose if the saw them in private or within the communal areas of the home. All residents at the home were able to vote if they chose to do so. The deputy manager stated that many of the residents had chosen to vote at the polling station and the remainder had voted by post. The menus at the home ran over a four week period and provided choices at all meal times, that appeared varied and of a high nutritional content. Evening meals included a cooked meal or sandwiches where a choice of fillings was available. Residents spoken with were very complimentary regarding the meals and stated they were enjoyable. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 15 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, and residents were confident that their concerns would be listened to and acted upon. The systems in place promote the protection of residents from abuse and neglect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: 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, it is therefore advised that stage 3 of the homes procedure be amended to avoid any confusion or misunderstanding. 3 Complaints had been received by the home in the last twelve months 2 of these had been dealt with appropriately and within the required timescales. 1 complaint was at the time of inspection being dealt with jointly between the home and Derbyshire local authority social services department. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 16 Staff at the home had received training in adult protection both with Derbyshire local authority and in house. Staff spoken with had a good understanding of adult protection issues and the required procedures to follow. The home had procedures and relevant documentation in place for responding to suspicion/ evidence of abuse, which followed Derbyshire’s local authority procedure. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 17 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): 19,26 Residents lived within a well-maintained environment that appeared clean, fresh and pleasant in décor. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A brief tour of the home was undertaken, the grounds of the home were accessible to the residents and outdoor seating was provided. The home was decorated to a good standard and two residents spoken with commented on the bright and cheerful décor and praised the home for its standards of cleanliness. One resident discussed how the staff also ensured her private accommodation was kept clean and stated that it was lovely not to have to do your own washing and ironing, saying it was like living in a hotel. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 18 Residents’ private accommodation that was seen was decorated and maintained to a high standard and contained residents’ personal belongings that expressed residents’ individuality. A maintenance log was kept at the home for ongoing work/repairs, this was seen and demonstrated that the home completes any work required. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Adequate numbers and skill mix of staff are on duty at the home, and staff had received the appropriate training to ensure resident’s needs can be met. The homes recruitment practices require further development. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the last inspection staffing hours have been increased at the home, 26 care staff were employed at the home. The staffing rotas that ran over 2 weeks in July and August were seen and demonstrated that on weekdays 7 staff were on duty in the mornings and 6 in the afternoon and evening, and 2 staff worked waking night duty. At weekends the staffing levels were reduced slightly during the day and showed that 5 or 6 staff were on duty. The staffing levels therefore meet the recommended levels set out by the residential forum. In addition to the care staff team the home also employed 1 activities coordinator who worked 24 hrs a week, 4 kitchen staff who worked over 7 days, 3 laundry staff who worked over 7 days and 4 housekeepers who worked Monday to Friday and 1 handyman. 14 of the care staff had achieved a National Vocational Qualification (NVQ) in care at level 2 or above, this equates to 53 of the staff team, which demonstrates that the home has achieved the national target set of 50 of the care team achieving an NVQ2 or above. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 20 The recruitment practices at the home were examined within two staff files, the required criminal records bureau checks had been undertaken and 2 satisfactory references had been obtained along with personal identification documents. The homes employment application form only requested the last ten years employment history rather than the required full employment history, which must be undertaken to ensure residents safety and welfare, is protected. The training received by staff within the last twelve months included; fire training, back care, food hygiene, infection control, dementia care, protection of vulnerable adults, continence training, first aid, NVQ 2 and 3 and assessors training for NVQ 2 and 3. All training was undertaken on a rolling programme as and when required. 2 staff were spoken with and both stated that they felt the care and support provided to the residents was very good. Both staff felt the support provided by the manager and colleagues was very good and that a wide variety of training was provided which enabled them to support and enhance the care they provided to the residents’. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 The registered manager has the training and experience required to manage and run the home effectively and in the best interest of the residents. Residents’ financial interests are safeguarded and the health and welfare of residents and staff are protected and promoted by the home’s health and safety practices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager has many years of management experience and has been running the home since it opened 17 years ago and has achieved a management qualification. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 22 Staff spoken with were very positive regarding the registered managers skills and competence and felt that the manager was approachable and demonstrated good leadership skills. The quality assurance systems used at Heather Vale were seen and included; newsletters every three months, the editor being one of the residents. Residents and relatives’ satisfaction questionnaires, including the results of these questionnaires and residents meetings held every 6-8 weeks. The activities co-ordinator at the home is also the homes representative on the works council which is run by anchor trust, where on the residents’ behalf she is able to share ideas and views regarding activities, including supporting residents with their own hobbies and interests. This demonstrates that the home strives to seek the views of the residents to ensure their home is run in their best interests. 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. Records of the safe working practices of the home were examined and were in date and satisfactory and included: • Weekly fire tests • Moving and handling risk assessments • Water systems management risk assessments • Building risk assessments • Legionella assessment • Hoist assessments • Potable electrical equipment test • Electrical wiring certificate • Lift service • Gas appliance service • Control of substances hazardous to health (COSHH) assessments Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 23 Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 24 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 3 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 4 X 3 X X 3 Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 25 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 OP29 Regulation 19 Requirement A full employments history must be sought before appointing staff and any gaps in employment must be explored. (Previous timescale 01/02/06) Timescale for action 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP16 Good Practice Recommendations Evidence should be in place to demonstrate resident’s involvement and agreement of their care plans. Timescale for the homes response to complaints should be clearly stated on all stages of the homes complaints procedure. Heather Vale DS0000020009.V298605.R01.S.doc Version 5.2 Page 26 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.V298605.R01.S.doc Version 5.2 Page 27 - 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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