Inspection on 28/11/05 for Heatherbank

This inspection was carried out on 28th November 2005.

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 11/05/06

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 Unannounced Inspection 28th November 2005 9:30 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 Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 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.V266475.R01.S.doc Version 5.0 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.V266475.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th April 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. Residents utilize the front garden in the summer months. The home offers both long term and respite care. It does not have the facilities to offer intermediate care. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 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. 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. There are, however, a large number of requirements (14), 12 of which remain to be met from the previous inspection, and which require action to be taken within the extended timescales 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 staff to undertake statutory adult protection training. 2 recommendations are also made from this inspection. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. The home’s policy and procedures indicate that the views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. An appropriate complaints policy and procedure is in place. Complaints received have been satisfactorily dealt with and there is no evidence of any unresolved concerns. 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. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 6 The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. What has improved since the last inspection? What they could do better: 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 protected by the home’s medication policy and procedures, their protection also requires the extension of accredited medication training to all care staff. 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. While one of the two Acer baths has been put back into use, the other Acer bath still requires attention; and a servicing agreement for the baths’ maintenance needs to be arranged. 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 home needs to develop its quality assurance processes 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. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 7 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 so as to demonstrate that all relevant policies and procedures have been reviewed, and that staff have read and understood these. 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.V266475.R01.S.doc Version 5.0 Page 8 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.V266475.R01.S.doc Version 5.0 Page 9 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): The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. EVIDENCE: Standards 3 and 4 assessed. Standards 1 and 5 met at the last inspection. There have been three admissions to the home since the last inspection, all of which were emergency meetings. The inspector examined the service users’ files and found that assessments and care plans had been completed. The inspector was concerned to find that one service user, admitted in October, is presenting with symptoms of dementia, which is outside of the home’s registration category. Medical opinion has been sought from the GP and a referral has been made for a psycho-geriatric assessment. The service user, who is self-funding, has, however, settled well and there is no indication of any behavioural problems. From the documented care notes and feedback provided, the home would appear to be managing to meet her needs. The Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 10 inspector met the service user. Though not easy to engage in discussion, she presented as being settled and reasonably well orientated in her surroundings. It was agreed, therefore, that the home applies for a minor variation to their registration that would allow the service user to remain living at the home. The inspector met another service user who has been recently admitted and received positive feedback regarding the home and the care provided by staff. No concerns were expressed. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 11 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): 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 protected by the home’s medication policy and procedures, their protection also requires the extension of accredited medication training to all care staff. The home’s policy and procedures indicate that the views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. EVIDENCE: Standards 7, 8, 9 and 11 assessed. Standard 10 met at the last inspection. The inspector examined a sample of service user care plans which (using the Standex tool) evidence that all aspects of service users’ physical and cognitive Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 12 needs are being appropriately addressed. The inspector noted, however, that three service users’ care plans were not evidenced as having been recently reviewed, though there was indication from the provider that these had been done but not recorded. 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 being appropriately met. Service users’ daily notes and the visitors book evidence that visits from health care professionals are taking place. Service users are encouraged to retain their GP where possible. Community nurses and other health care professionals visit the home when required. One service user is currently being treated for a leg ulcer by a district nurse who visits the home twice a week. The inspector was informed that all but two night shift staff have received medication training. Whilst night care staff are able to seek advice on medication, if and when required, the requirement for accredited training from the last inspection applies to all care staff working in the home and must be fully met. There have been four deaths at the home since the last inspection, one of which occurred in hospital. There is a policy in the home concerning death and the care of the dying. Service users’ wishes are discussed with them and that whenever possible, and this is the person’s wish, residents are cared for in the home during the period leading up to their death, with family being fully involved in this process. Staff may not, however, possess the knowledge and skills to provide for the assessed care needs as service users’ dependency levels increase. The inspector is satisfied that the philosophy of the home in this area is a caring one and that the service user’s emotional and spiritual needs are fully respected. The inspector has discussed with the manager the need for training for staff in the area of bereavement and loss. This would assist in raising awareness of the bereavement process and provide relevant counselling skills. The registered manager has previously advised that she has purchased a training package for providing training in the area of bereavement and loss to staff. Training in this area still needs, however, to be rolled out to staff. A recommendation applies. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed. All standards met at the last inspection. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 14 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): An appropriate complaints policy and procedure is in place. Complaints received have been satisfactorily dealt with and there is no evidence of any unresolved concerns. 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: Standards 16 and 18 assessed. Standard 17 met at the last inspection. 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 have been three complaints logged since the last inspection, all of which have been satisfactorily resolved. . Following a previous requirement the complaints record has been amended to indicate whether the complaint has been satisfactorily resolved. The requirement is, however, only partly met as the record also needs to include wording to indicate whether, if not resolved, the complainant has been informed of his/her right to contact the CSCI. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 15 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. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 16 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): 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. While sufficient bathing and toilet facilities are currently in place, an Acer bath needs to be put back into regular use. Service users’ rooms were observed to be 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. Liquid soap dispensers have now been installed in the home’s toilets. EVIDENCE: Standards 19, 20, 21, 23, 24, 25 and 26 assessed. Standard 22 met at the last inspection. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 17 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 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 years (Standard 19). Re-carpeting of the two respite bedrooms (Rooms 11 and 23) is still required. The registered manager advised that plans are in hand to complete recarpeting of these rooms together with the re-carpeting of the front reception and staff room areas. The inspector also noted the need for re-carpeting of the first floor passageway areas. 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. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 18 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. The problem with the two Acer baths is being addressed. The inspector was informed that a repair has been carried out to one of the Acer baths and that the other is due to have work completed. Following the previous contractor (Acer) having gone out of business a new servicing agreement is currently being negotiated with Arjo. The requirement remains to be fully met. Service users were 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. Those service users who were in their rooms indicated that they were happy with their rooms and no concerns were raised. 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 one room (Room 17) has been redecorated and another room (Room 2) has been refurbished. 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 has now installed liquid soap dispensers all the home’s toilets. The registered manager advised that the home received an inspection from Environmental Health on 25/11/05. The report indicated that cleaning and structural improvements in the kitchen and store room area need to be implemented. This includes the need for new easily cleanable floor covering in the storeroom. A requirement applies. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 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): 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. EVIDENCE: Standard 29 assessed. Standards 27, 28 and 30 met at the last inspection. The home has a recruitment policy and procedures in place (Standard 29). All staff have been issued with the General Social Care Council Code of Conduct. The inspector examined some staff files. One staff file for a recently recruited staff member included a CRB check from a previous employer. An up to date CRB check is required, for which a requirement applies. The registered manager was reminded that portability is not allowed, and that a new CRB and POVA check is required for any new staff member who is being recruited. Other identity and employment checks were in place. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 20 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): 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 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 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 so as to demonstrate that all relevant policies and procedures have been reviewed, and that staff have read and understood these. Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 21 EVIDENCE: Standards 31, 32, 33, 36 and 37 assessed. Standard 38 met at the last inspection. 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. There are, however, a large number of requirements that remain unmet from the previous inspection. Management systems for monitoring performance and ensuring compliance with care standards need to be improved. Two requirements remain to be met from the previous inspection. The requirement for the home to have an effective quality assurance and monitoring system in place has yet to be fully implemented (Standard 33). The manager confirmed that surveys with service users and relatives have been undertaken. These need to be extended to include visiting professionals, voluntary workers and any other stakeholders. The home also needs to 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 the feedback received from the surveys (and other sources) and the extent to which the home’s aims and objectives are being met. A requirement from the previous inspection, for regular, recorded supervision with all care staff has not yet been met. The inspector examined staff supervision notes which evidenced that one-to-one supervision with care staff is taking place. Supervision is not, however, being held on a sufficiently regular basis, with files indicating that some staff had not received supervision within the last few months. This is not acceptable, and the manager was reminded that supervision must be evidenced on at least a 2 monthly basis. The inspector discussed the possibility of the manager delegating some supervision to a senior care worker who is currently studying for an NVQ Level 4 and the Registered Managers Award. The inspector recommends this option as a means Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 22 of enabling more regular supervision, and also recommends that the staff member, if willing to do so, undertake some training in staff supervision and appraisal. A requirement to ensure that a written policy and procedure covering emergency situations is put in place (Standard 37) has been partly met. The wording must, however, include 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 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 Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 23 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 X 3 3 3 2 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 X 2 2 X Heatherbank DS0000007168.V266475.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 14(2)(a) & (b) Timescale for action All service users’ care plans must 31/12/05 be evidenced as having been reviewed on at least a monthly basis. 31/03/06 31/12/05 Requirement 2 3 OP9 OP16 4 OP18 5 OP19 6 OP21 7 OP26 Accredited medication training must be extended to all care staff; to include night staff. 22(2) & The complaints log must state (3) whether the person making the complaint has been informed of his/her right to pursue this further with the CSCI (if the complaint remains unresolved). 18(1)(c) The Registered Manager must 13(6) ensure that all care staff have accessed and completed Suttons Vulnerable Adult and Adult Protection training. 23(1)(a), The Registered Manager must 23(2)(d) ensure that the two respite bedrooms (Rooms 11 and 23) are re-carpeted. 12(1,a) The two Acer baths, on the 23(1,a)(2, ground floor, must be repaired c) and serviced and put back into use. 13(4)(c) The requirements identified in the Environmental Health DS0000007168.V266475.R01.S.doc 18(1)(a) 31/03/06 31/03/06 31/03/06 31/03/06 Heatherbank Version 5.0 Page 25 8 OP29 9 OP30 10 OP33 11 OP33 12 OP34 13 OP36 14 OP37 inspection of 25/11/05 must be fully implemented. This includes the need for new floor covering in the food storeroom. 19(1)(b) CRB (Criminal Records Bureau) (ii), Sch.2 and POVA checks must be in place for all care staff. No portability is allowed. 18(1)(a), The Registered Manager must 18(4) ensure that the wording of the policy and procedure regarding the actions which staff must take, when emergency situations involving a service user arise, includes the need for staff to inform the nearest relative at the earliest opportunity. 24(1)(a) The Registered Manager must & (b) ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals, voluntary workers and any other stakeholders. 24(2) The Registered Manager 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. 25(1)(2,a) The registered manager 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. 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. 12(1)(a), The home must have a policies 18(1)(a) and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was DS0000007168.V266475.R01.S.doc 30/11/05 31/12/05 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Heatherbank Version 5.0 Page 26 last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed. 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 OP19 OP36 Good Practice Recommendations The inspector noted the need for re-carpeting of the first floor passageway areas. 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.V266475.R01.S.doc Version 5.0 Page 27 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.V266475.R01.S.doc Version 5.0 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!