Inspection on 11/05/06 for Heatherbank

This inspection was carried out on 11th May 2006.

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

Heatherbank 11/05/07

Heatherbank 28/11/05

Heatherbank 06/04/05

Heatherbank 09/12/04

Heatherbank 30/07/04

Similar services:

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Heatherbank 7-9 Cavendish Road Sutton Surrey SM2 5EY Lead Inspector Peter Stanley Key Unannounced Inspection 11th May 2006 9:30am 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 Heatherbank DS0000007168.V291860.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. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heatherbank Address 7-9 Cavendish Road Sutton Surrey SM2 5EY 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) 020 8642 2930 020 8770 7278 Mr Adrian Hawkins Mrs Hazel Hawkins Mrs Hazel Hawkins Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Heatherbank is a registered care home for 23 older people. It is situated near Sutton Town Centre and is owned by Mr and Mrs Hawkins. Accommodation for users is available on the ground and first floors. There are 21 single and 2 double rooms. Two of the single rooms and one of the double rooms have en suite facilities. Some of the bedrooms are below ten square metres others are much larger. Communal areas include a lounge with an adjoining dining room. There is also a kitchen and an adjoining room which smokers use. A stair lift is provided. There is a garden area to the rear, but this is not easily accessible for service users. The home offers both long term and respite care. It does not have the facilities to offer intermediate care. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took about six hours. The home’s registered manager and provider, Mrs Hawkins, assisted with the inspection. The inspector inspected the premises and spoke to a large number of service users, and to staff members on duty. Questionnaires were received from two service users. Care records and other documentation were examined. Many positive comments were received from service users regarding the home and the care provided by staff, and service users presented as settled in their environment. Staff members on duty also expressed positive views about the home and the support they receive. As a result of the inspection, 15 requirements have been made, 7 of which remain to be met from the previous inspection, and which require action to be taken within the extended time-scales that have been set. Of particular concern is the need for all care staff to be provided with regular, one-to-one supervision, and for all staff to undertake statutory adult protection training. 3 recommendations are also made from this inspection. What the service does well: The home is able to demonstrate that it is assessing the needs of service users admitted to the home. The home is able to demonstrate that the range of needs presented by service users is being appropriately met. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. The health care needs of service users are being fully met. Service users feel that that they are being treated with respect and that their right to privacy is being maintained. Service users are assisted to maintain contact with family and friends, and links with the local community are encouraged. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 6 Service users are able to exercise some choice and control in their day-to-day routines, and to receive appropriate support from staff in helping to facilitate this. Service users receive a wholesome, appealing and nutritious diet in pleasant surroundings, and at times convenient to them. Service users and their relatives/friends are able to raise any concerns they may have, and to know that these will be taken seriously and addressed. Service users’ legal rights are being protected. Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users have access to safe and comfortable communal facilities. Service users presented as settled and satisfied with their environment. Sufficient aids and adaptations are in place to safely meet the needs of service users. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. Generally, service users can be assured that staff are sufficiently trained and competent to do their jobs. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Generally, the inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. Service users’ financial interests are being safeguarded. What has improved since the last inspection? Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 7 Service users are being protected by the home’s medication policy and procedures. Accredited medication training has been extended to all but one of the care staff. With the repair and servicing of two Acer baths, sufficient bathing and toilet facilities are now in place for the home’s service users. All requirements identified in the Environmental Health inspection have been implemented; this includes new floor covering in the food storeroom. Three service users’ rooms have been redecorated. What they could do better: While service users are being provided with all the information they require to enable an informed choice as to where they would like to live, both the Statement of Purpose and Service Users Guide must be reviewed and updated. While service users are having their health, personal and social care needs set out in an individual plan of care, the home must ensure that these are reviewed on a monthly basis. While service users are being provided with a range of opportunities for recreational and social activity, more could be done to meet their interests and needs, and to promote their participation in day-to-day activities. While the home’s policies and procedures are helping to ensure that service users are safeguarded from abuse, their protection also requires that statutory training in adult protection be provided for all care staff. The home presents as clean, pleasant and hygienic. Staff training in infection control is, however, required, if standards are to be maintained. Whilst the home has appropriate recruitment policy and procedures in place, the protection of service users has been potentially compromised by the failure to obtain an up-to-date CRB (Criminal Records Bureau) check for one recently recruited staff member. While, generally, the home is being managed in the best interests of the home’s service users, there is a need for the management systems to be improved so as to monitor performance and ensure compliance with the care standards. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 8 The home needs to develop its quality assurance processes, and compile a Development Plan, so as to demonstrate that the home is meeting its aims and objectives and that it is being run in the best interests of the service users. The financial viability of the home needs to be demonstrated with the submission of an up-to-date set of audited accounts. The home is failing to provide regular supervision for staff. This is detrimental to the support and development of staff, and is potentially compromising the protection and safety of service users. Records required for regulation were generally in place and well maintained. A policies and procedures checklist is, however, required. 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. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 9 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 Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 10 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): 1 to 5 While service users are being provided with all the information they require to enable an informed choice as to where they would like to live, both the Statement of Purpose and Service Users Guide must be reviewed and updated. The home is able to demonstrate that it is assessing the needs of service users admitted to the home. The home is able to demonstrate that the range of needs presented by service users is being appropriately met. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. EVIDENCE: Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 11 The home has a comprehensive Statement of Purpose, and Service User Guide, a copy of which is issued to each service user. These documents need to be reviewed. While the majority of service users are referred by social services, the home has some privately funded service users. Prior to admission, prospective service users are invited to visit the home and to meet service users and staff. The service user and his/her relatives are fully involved in the process leading up to an admission, and are given the opportunity to fully assess the suitability of the home. The home does not provide intermediate care. There have been 4 new admissions for long-stay care in the last 12 months, and 1 admission since the last inspection. The Standex system of preassessment and care planning is used by the home. The home also provides respite care for short stays, and has had occasional admissions. The inspector has examined the service users’ files for these, including the recent admission, and found that assessments and care plans have been completed, and care plans reviewed. The inspector noted, however, that the care plan, for the recent admission, had not been evidenced as being reviewed since 21/3/06; a requirement applies (standard 7). A three-way contract, involving the home, social services and the service user, has been drawn up. Following a concern from the previous inspection, regarding the admission of a service user who presented symptoms of dementia, this has subsequently been confirmed. Medical opinion has been sought from the GP and a referral made for a psycho-geriatric assessment. Though not easy to engage in discussion, the service user presents as being settled and reasonably well orientated in her surroundings. Following discussion with the inspector, the registered manager was advised to apply for a minor variation, as dementia lies outside of the home’s registration category. A requirement applies. The inspector spoke to a large number of service users during the inspection, and received feedback from two questionnaires. Favourable views were expressed, with service users feeling that care staff are supportive, and that their individual care needs are being appropriately met. Assessments and care plans looked at by the inspector indicated that the home has the capacity to meet the assessed needs of service users presenting varying degrees of cognitive and physical dependency. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 12 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 to 10 While service users are having their health, personal and social care needs set out in an individual plan of care, the home must ensure that these are reviewed on a monthly basis. The health care needs of service users are being fully met. Service users are being protected by the home’s medication policy and procedures. Accredited medication training has been extended to all care staff. Service users feel that that they are being treated with respect and that their right to privacy is being maintained. EVIDENCE: The inspector examined a sample of service user care plans, including a recent admission. These use the Standex tool, and evidence that all aspects of service users’ physical and cognitive needs are being appropriately addressed. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 13 The inspector has previously noted that service users’ care plans are not being reviewed on a regular monthly basis. On this inspection, it was noted that two service users’ care plans had not been evidenced as having been recently reviewed, the last review having been recorded on 21/3/06. A requirement applies for all service users’ care plans to be evidenced as having been reviewed on at least a monthly basis. The health care needs of service users are evidenced as being appropriately met. Service users’ care plans and daily notes evidence that visits from health care professionals are taking place, and that health care needs and medical advice are being recorded. The inspector was advised that service users are encouraged to retain their GP where possible, otherwise a GP is allocated following application to the local FPC (Family Practitioner Committee). Community nurses and other health care professionals visit the home when required. One service user currently has a skin condition that has resulted in sores. She is presently receiving visits from a district nurse, and advice regarding her ongoing care is included in her care plan. The home has a medication policy in place (Standard 9). The home uses the Monitored Discharge system for administering medication. No controlled drugs are being used. All medications are kept in a locked cabinet in the staff area adjacent to the lounge. One service user currently self-medicates in accordance with her wishes, a lockable space being provided in the service user’s bedroom. All medicines are prescribed on an individual basis. Accredited medication training has now been extended to all but one night staff member; this must take place. A list of staff trained to administer medication is being maintained. The inspector spoke to a large number of service users. This indicated that service users’ privacy is being respected, with staff being perceived as caring and respectful. Service users are able to see visitors in their own rooms if they wish. The inspector observed service users being treated with respect and kindness by staff. All service users have a lockable space in their bedrooms for storing personal possessions and valuables. Personal care is given in service users own rooms. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 14 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): 11 to 15 While service users are being provided with a range of opportunities for recreational and social activity, more could be done to meet their interests and needs, and to promote their participation in day-to-day activities. Service users are assisted to maintain contact with family and friends, and links with the local community are encouraged. Service users are able to exercise some choice and control in their day-to-day routines, and to receive appropriate support from staff in helping to facilitate this. Service users receive a wholesome, appealing and nutritious diet in pleasant surroundings, and at times convenient to them. EVIDENCE: Activities offered have included weekly visits from a volunteer to engage residents in activities, and occasional visits from a group of volunteers called ‘Non such Orbit’ who provide occasional entertainment including singsongs and bingo sessions. Other activities offered include craft therapy evenings, reminiscence sessions, exercise sessions, and quizzes. A DVD player has been Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 15 purchased with a selection of DVDs for showing to residents. A number of games, books and videos are also available. The inspector expressed concern on a previous inspection that some service users presented as under-stimulated and bored. The inspector spoke to a number of service users sitting in the lounge. While service users seemed generally satisfied, there was little evidence of any attempt by staff to engage service users or involve them in a game or activity. It was observed that some service users presented as passive and under-stimulated. Two questionnaires completed by service users indicated that sometimes activities are arranged, this being apparent from the organised activities that are offered. These include weekly music and movement sessions that service users said they enjoyed. The manager has indicated that staff try, where possible, to engage service users, and help facilitate their participation in games and activities. No facilitation in this way was, however, observed during the inspection. It is felt that more could be done to encourage the participation of service users in day-to-day activities, both by staff and by the use of volunteers. The use of volunteers to visit and befriend service users, and engage them in activities, could be extended in this regard. This has been mentioned in a previous report and is again made a recommendation. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. Service users are encouraged to receive visits from relatives and friends, and to go for outings with them wherever possible. Comments from service users indicated that visitors are made welcome at the home and that maintaining contact with friends and relatives is encouraged wherever possible. There is access to a day centre in the community. and some service users are registered with Dial-a –Ride. Volunteers assist in taking residents out if they wish. Clergy from all denominations attend on a regular basis and hold services at the home. Service users spoken to during the visit expressed their general satisfaction with the way the home is being run, and indicated that they are able to exercise a fair measure of personal autonomy and choice. Staff were perceived to be enabling in their attitudes whilst providing the necessary care and support in a way that meets individual preferences and needs. The inspector examined menus provided over a four-week period, and observed food being prepared for lunch. The menus, and an inspection of the kitchen and food storage areas, evidenced a varied choice of food with fresh vegetables and fruit being made regularly available. Spaghetti bolognaise was on offer, together with an alternative main course, on the day of inspection. Service users expressed satisfaction with the food offered and the meals served at lunchtime were found to be both nutritious and appetising. Service Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 16 users are able to choose their meals the day before with a record of their choice being kept. The dining room presented as a pleasant area in which to have meals. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 17 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 to 18 Service users and their relatives/friends are able to raise any concerns they may have, and to know that these will be taken seriously and addressed. Service users’ legal rights are being protected. While the home’s policies and procedures are helping to ensure that service users are safeguarded from abuse, their protection also requires that statutory training in adult protection be provided for all care staff. EVIDENCE: The home has an appropriate complaints policy and procedure in place, a summary of which is included in the Service User Guide (Standard 16). A copy of the complaints policy is kept in the entrance hall, together with a complaints record sheet. There has been one complaint logged since the last inspection, the details of which were discussed with the inspector, and which was found to have been satisfactorily resolved. . Following a previous requirement the complaints record has been amended to indicate whether the complaint has been satisfactorily resolved. The right of the complainant to contact the CSCI is included in the home’s complaints procedure. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 18 The manager has confirmed that all service users are registered on the electoral role and are able to vote in elections either in person or by post (Standard 17). No adult protection concerns were identified during the inspection. The home has an adult protection procedure. This outlines the home’s procedures in regard to any suspicion or allegation of abuse. The home also has a copy of the London Borough of Sutton adult protection policy and procedures (Standard 18). The manager stated that that an accredited trainer who is familiar with Sutton’s Vulnerable Adult training, has visited the home to provide adult abuse training for all care staff. There is, however, an outstanding requirement for all staff to attend LB Sutton’s Vulnerable Adult and Adult Protection training. The registered manager was informed that this must be met as a priority. The inspector spoke to a large number of service users. Feedback indicated that service users feel safe and secure within the home, and that staff are trusted and liked. No concerns were expressed. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 19 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 to 26 Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users have access to safe and comfortable communal facilities. Service users presented as settled and satisfied with their environment. With the repair and servicing of two Acer baths, sufficient bathing and toilet facilities are now in place for the home’s service users. Sufficient aids and adaptations are in place to safely meet the needs of service users. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The home presents as clean, pleasant and hygienic. Staff training in infection control is, however, required, if standards are to be maintained. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 20 EVIDENCE: The inspector inspected the premises and found the home to be in a generally good state of decoration and repair, and to provide a safe and comfortable environment. Service users have pleasantly laid out communal spaces in which to sit. The inspector spoke to a large number of service users. Positive views were expressed regarding the home and their environment, with residents indicating that they were happy with their rooms and with the communal facilities provided. The home is basically well maintained, with an ongoing programme of external decoration to the front and back of the home having taken place over the last two to three years (Standard 19). Re-carpeting of the two respite bedrooms (Rooms 11 and 23) has not as yet taken place- the inspector agreed to the removal of this requirement as neither of these bedrooms are currently in use. However, the manager was advised that should either of these rooms be bought back into use, then they should be re-carpeted prior to any new occupants moving in. The inspector was informed that plans for re-carpeting of the first floor passageway areas have not, as yet, been done, but are scheduled to take place. Communal areas in the home are adequately furnished and equipped, providing comfort and privacy for the home’s service users. Furnishings and lighting are domestic in style. Service users who spoke to the inspector indicated that they are satisfied with their surroundings and did not express any reservations. The inspector was advised that the laundry area now has a new washing machine and tumble drier. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 21 The home has sufficient bathroom and toilet facilities, which includes two Acer baths, one walk-in and one fixed bath. Toilets have raised seats (Standard 21). An Arjo bath seat has now been installed in all of the home’s bathrooms. A servicing problem with the two Acer baths has been addressed and these are now back in regular use. Following a previous requirement, liquid soap dispensers have been installed in all of the home’s toilets. The home presents as safe, with sufficient aids and adaptations in place. It was risk assessed by an occupational therapist, in November 2004, and found to provide a sufficient range of equipment and adaptations appropriate to meeting the needs of the home’s physically frail and disabled service users. Service users expressed satisfaction with their rooms, these having been observed to be safe and comfortable, and personalised to meet individual preferences and identities. Most service users have chosen to personalise their rooms with photos, pictures and personal mementoes. All rooms have appropriate door locks, which can be opened from the outside if necessary. Door guards (to enable self-closing) have been fitted to all bedroom doors where it is the wish of the service user wish to keep their door open. All rooms have a lockable space. Since the last inspection, Rooms 2 and 10 have been redecorated, Room 17 having also been previously redecorated. There is a pleasant, but not easily accessible, garden at the rear of the property. The home’s proprietors, Mr and Mrs Hawkins, have previously advised that, due to budgetary constraints, there are no current plans to renovate and upgrade the garden area. It is, however, to be hoped that this may be achievable in the longer term as the garden area could potentially be bought into more active use for the benefit of service users. Generally, the premises presented as clean, hygienic and free from any offensive odours (Standard 26). A smoke extractor has been installed in the area between the living room and the hallway where service users are able to smoke if they wish. The home received an inspection from Environmental Health on 25/11/05. The report indicated that cleaning and structural improvements in the kitchen and storeroom area needed to be implemented. This included the need for new easily cleanable floor covering in the storeroom. The requirements identified in the Environmental Health report have now been implemented. For standards of hygiene to be maintained, there is a need for all staff to receive on-site training in infection control. A requirement applies. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 22 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 to 30 The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. Whilst the home has appropriate recruitment policy and procedures in place, the protection of service users has been potentially compromised by the failure to obtain an up-to-date CRB (Criminal Records Bureau) check for one recently recruited staff member. Generally, service users can be assured that staff are sufficiently trained and competent to do their jobs. EVIDENCE: The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. The inspector examined staff rotas. With a significant decrease in the number of service users to 14, there are currently two carers (rather than three, as previously) on duty in the home during the day and two at night. The Registered Manager, who is a trained nurse, and her husband, who is a chef, also work within the home. They are supernumerary and their hours are detailed on the duty rota in response to a previous requirement. There are currently thirteen care staff and two ancillary staff, a cook and a cleaner. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 23 The home currently has three care staff who have NVQ Level 3 and three staff with NVQ Level 2 or equivalent. Two other staff are studying for their NVQ2. This meets the target of at least 50 of care staff with NVQ2 by 2005 (Standard 28). Since the last inspection, no new staff have been recruited. One staff member, previously employed as an agency worker, is now employed on a permanent basis. Whilst having a recent CRB check from the agency with whom the staff member was previously employed, portability is not allowed, and a new CRB is required by the home now that she is being directly employed by the home. The registered manager was advised to obtain a POVA First check and apply for a CRB. All other employment checks were satisfactory. A requirement applies. There is a staff training and development programme in place (Standard 30). Some staff have been employed through Pathways that is affiliated to Mencap. A Certificate in Care Practice has been developed for these staff. A TOPPS induction programme is used for all new staff. There is ongoing training in health and safety, first aid, medication, manual handling and fire prevention. The inspector was advised that most staff have done training in dementia. The inspector spoke individually to two staff members on duty. Both expressed their satisfaction with the support received, and felt that their training and development needs were being addressed. The inspector identified a need for on-site training in infection control. This is required for all staff. The manager advised the inspector that a previous attempt by the home to train staff through the use of ‘distance learning’ had not proved particularly effective; a requirement applies. A requirement to ensure that a written policy and procedure covering emergency situations is put in place has been now been met. The wording now includes reference to the need to inform the service user’s nearest relative or representative at the earliest opportunity when an emergency arises. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 24 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 to 38 While, generally, the home is being managed in the best interests of the home’s service users, there is a need for the management systems to be improved so as to monitor performance and ensure compliance with the care standards. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. The home needs to develop its quality assurance processes, and compile a Development Plan, so as to demonstrate that the home is meeting its aims and objectives and that it is being run in the best interests of the service users. The financial viability of the home needs to be demonstrated with the submission of an up-to-date set of audited accounts. Service users’ financial interests are being safeguarded. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 25 The home is failing to provide regular supervision for staff. This is detrimental to the support and development of staff, and is potentially compromising the protection and safety of service users. Records required for regulation were generally in place and well maintained. A policies and procedures checklist is, however, required. Generally, the inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. EVIDENCE: Mrs Hawkins is a trained nurse. Both she and Mr Hawkins have many years experience in working with this client group, and have undertaken the Registered Managers Award. The inspector observed service users being treated with respect by the manager and staff. Service users spoken to by the inspector expressed their satisfaction with the home and the quality of care provided. The Registered Providers frequently work within the home and are perceived by staff and service users to be open and supportive in their approach. Two requirements remain to be met from the previous inspection. The need for the home to have an effective quality assurance and monitoring system in place has yet to be fully implemented (Standard 33). While surveys with service users and relatives have been undertaken, these must be extended so as to include a questionnaire for visiting professionals, voluntary workers and any other stakeholders. The home must also demonstrate that it has effective systems in place for service users, their relatives and friends, visiting professionals and others to feed back their views about the home and the services provided, and for an annual development plan to be put in place. This must detail all the feedback received from the surveys (and other sources) and the extent to which the home’s aims and objectives are being met. The inspector was advised that the home has yet to receive a set of audited accounts for 2004/05 or 2005/06, the last available accounts dating from 2003/04. The registered providers are reminded that, that in accordance with Regulation 25(1) and 25(2)(a), the registered person is required to demonstrate the financial viability of the home and to provide an up-to-date set of accounts. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 26 The manager confirmed that service users are encouraged to retain as much control over their lives as they are able. Where service users are unable to manage their finances power of attorney rests with a family member, or a solicitor. The home’s proprietors do not wish to be involved in managing any finances, but, with the expressed wish of one service user, act as an appointee, with a record being kept of all receipts and outgoings. A requirement from the previous inspection, for regular, recorded supervision with all care staff has yet to be fully met. The inspector examined a sample of supervision notes from staff files. This evidenced that one-to-one supervision with care staff is taking place, but not on a sufficiently regular basis. Two files indicated that two staff not received supervision since July 2005, while two others did not evidence sufficiently regular supervision, being held twice in 9 months in one case, and none since 13 January 2006 for another staff member. The manager was again reminded that supervision must be held with staff on at least a two-monthly basis, and that the current level and frequency of supervision is not acceptable. The inspector has previously discussed the possibility of the manager delegating some supervision to a senior care worker. However, this option has not, so far, been adopted. The registered providers must take steps to ensure that regular oneto-one supervision is provided, and evidenced, for all staff, otherwise enforcement measures are likely to follow. All records required for regulation are in place and well maintained. Records inspected included staff and service users’ files, medication, complaints, and health and safety records. A requirement to ensure that a written policy and procedure covering emergency situations is put in place (Standard 37) has now been met. The wording now includes reference to ‘the need to inform the service user’s nearest relative or representative at the earliest opportunity when an emergency arises’. A requirement for the registered manager to develop a policies and procedures checklist still, however, remains to be met. This should list all of the home’s policies and procedures, indicating when each policy and procedure was last reviewed. A copy of the checklist should be included in each staff file, to evidence that staff have read and understood each policy developed and reviewed. Generally, the health and safety of service users has been evidenced to have been well-protected in this home. Some concerns were, however, identified. Fire safety training for staff needs to be arranged, and the home’s health and safety risk assessments (last completed in 2004) need to be reviewed and Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 27 updated. There is also a need for staff training in infection control, and in the use of the home’s hoist. Requirements apply. The inspector examined certificates relating to health and safety. Up to date servicing certificates were in place for electrical wiring and installation, portable electrical appliances, fire safety, hoist maintenance and the testing of call systems, together with certificates for Legionella and environmental health. Servicing of the gas supply was, however, overdue, last having been completed on 14/3/05; a requirement applies. The home’s fire alarms were evidenced to be receiving regular weekly checks, and there were regular recorded checks for hot water and fridge/freezers. Monthly checks were recorded for the home’s emergency call systems and emergency lighting. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 28 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 2 3 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 3 2 2 2 Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 29 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 OP1 Regulation 6(a) & (b) Requirement The Statement of Purpose and Service Users Guide must be reviewed and updated. The registered providers must apply for a minor variation in respect of a service user who, since admission, has been diagnosed as having dementia. Timescale for action 30/09/06 2 OP3 14(1) & (2) 31/05/06 3 OP7 15(2)(b) All service users’ care plans must 30/09/06 be evidenced as having been reviewed on at least a monthly basis. Previous time-scale not met. The registered providers must 30/09/06 ensure that all care staff have accessed and completed Suttons Vulnerable Adult and Adult Protection training. Previous time-scale not met. The registered providers must obtain an up-to-date CRB for a care worker recruited from an agency. No portability is allowed. Accredited on-site training in infection control must be DS0000007168.V291860.R01.S.doc 4 OP18 18(1)(c) 13(6) 5 OP29 19(1)(b) (ii), Sch.2 13(4)(c), 13(6), 30/06/06 6 OP26 31/10/06 Heatherbank Version 5.1 Page 30 7 OP30 8 OP33 18(1)(a) & (c) 13(4)(c), 13(6), 18(1)(a) & (c) 24(1)(a) & (b) provided for all staff. All care staff must undertake training in the use of the home’s hoist. The registered providers must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals, voluntary workers and any other stakeholders. Previous time-scale not met. The registered providers must ensure that an annual QA Development Plan is produced. This should include feedback from the surveys and assess the extent to which the home’s aims and objectives are being met. Previous time-scale not met. 31/10/06 30/09/06 9 OP33 24(2) 30/09/06 10 OP34 25(1)(2,a) The registered providers must 25(3a,b,c) submit a set of accounts for the year 2004/05 to the CSCI, in order to demonstrate the home’s financial viability. Previous time-scale not met. 18(2) The registered manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Previous time-scale not met. The home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have DS0000007168.V291860.R01.S.doc 31/10/06 11 OP36 31/10/06 12 OP37 12(1)(a), 18(1)(a) 31/10/06 Heatherbank Version 5.1 Page 31 read and understood each policy developed and reviewed. Previous time-scale not met. 13 OP38 13(4)(a) & (c) 23(4)(a), (c) & (d) 13(4)(a) & (c) The registered providers must ensure that up-to-date servicing of the Home’s gas supply is arranged and evidenced. The registered providers must ensure that updated fire safety training is provided for all staff. The registered providers must ensure that the home’s Health and Safety Risk Assessments are reviewed and updated 30/06/06 14 15 OP38 OP38 30/09/06 31/10/06 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 3 Refer to Standard OP12 OP19 OP36 Good Practice Recommendations Consideration should be given to extending the use of volunteers to visit and befriend service users, and to engage in recreational activities. Re-carpeting of the first floor passageway areas is recommended. The inspector recommends that the manager consider delegating some supervision to a senior care worker who, if willing to do so, undertakes some formal training in staff supervision and appraisal. Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Heatherbank DS0000007168.V291860.R01.S.doc Version 5.1 Page 33 - 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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