CARE HOMES FOR OLDER PEOPLE
Heatherbank 7-9 Cavendish Road Sutton Surrey SM2 5EY
Lead Inspector Peter Stanley Announced Inspection 6 April 2005 09:30 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 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 Version 1.00 Page 3 SERVICE INFORMATION
Name of service Heatherbank Address 7-9 Cavendish Road, Sutton, Surrey, SM2 5EY Telephone number Fax number Email 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 and Mrs Hazel Hawkins Hazel Hawkins Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Conditions of registration Date of last inspection none 9 December 2004 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. Heatherbank Version 1.00 Page 4 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection of the home which took about six hours. The home’s registered providers, Mr and Mrs Hawkins, were both present. The inspector inspected the premises and spoke to a number of service users, and to staff on duty. Care records and other documentation were examined. As a result of this inspection 14 requirements and 1 recommendation are made. This includes 5 requirements that remain unmet from the last inspection. What the service does well:
Heatherbank has a pleasant, homely atmosphere. Service users present as settled and well cared for. Positive views were expressed about the home, the staff, and the care received. Comprehensive information about the home and the services offered (included in the Statement of Purpose and Service User Guide) is available, and potential service users (and their relatives) are encouraged to visit the home, enabling an informed choice regarding the suitability of the home to be made. The home has appropriate assessments and care plans in place. Service users’ care and support needs have been properly assessed, and the range of health, care and social needs presented are being appropriately met. The home has a settled staff group, with little staff turnover, and has the numbers and skill mix of staff sufficient to meet service users’ needs. The home currently has 7 care staff who have NVQ Level 2 or equivalent. This is in line with the current target of 50 of care staff with NVQ Level 2. Service users were observed to be treated with respect by staff and to have their privacy and dignity respected. Comments from service users were generally positive, with indication that staff are kind and helpful in meeting their care needs. Service users were observed to receive a wholesome, appealing and nutritious diet in pleasant surroundings, with service users indicating that they liked the food. The dietary needs of service users are noted and catered for. Comments from service users indicated that they are encouraged to maintain contact with their friends and relatives, and to receive visitors in the privacy of their own rooms. Links with the local community are encouraged, with visits to the home from a local volunteer group. Service users are able to go out with relatives and friends, though no outings are organised by the home.
Heatherbank Version 1.00 Page 5 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. A policies and procedures checklist needs to be developed. Health and safety checks, including fire safety, are all in place and the home is maintained to a good standard. What has improved since the last inspection? What they could do better:
While service users are being provided with a range of opportunities for recreational and social activity, which accords with their social, cultural and religious needs, the inspector feels that some service users present as understimulated and would benefit from more active engagement in day-to-day activities. The inspector recommends that consideration is given to extending the use of volunteers to visit and befriend service users, and encourage them to participate in social and recreational activities.
Heatherbank Version 1.00 Page 6 Service users are protected from abuse and are living in a safe environment. Comments from service users did not indicate any protection concerns. There is, however, an outstanding requirement for all the home’s staff to be familiarised with the local multi-agency adult protection procedures and to access LB Sutton’s vulnerable adult training. The home’s proprietors, Mr and Mrs Hawkins, informed the inspector that they have abandoned any idea of renovating the garden area at the rear of the property due to budgetary constraints. It is 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. The home needs to develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. A requirement from the previous inspection, for regular, recorded supervision with all care staff has not yet been met. One-to-one supervision with care staff is now taking place, but this is not yet taking place on a regular twomonthly basis. Accredited medication training needs to be extended to all members of the care staff. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Heatherbank Version 1.00 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 Standards Statutory Requirements Identified During the Inspection Heatherbank Version 1.00 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 standard(s) 1,3,4, and5. The necessary information and opportunity to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home to be made. The home is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: Prospective service users are invited to visit the home prior to admission, the majority of whom are referred by social services. The home has some privately funded service users. The home has a comprehensive Statement of Purpose, and Service User Guide, a copy of which is issued to each service user. There have been 3 new admissions for long-stay care in the last 12 months, and 12 short-stay admissions for respite care. The inspector examined a number of service user files and found assessments and care plans to be in place. The Standex system of pre-assessment and care planning is used by the home. The home also provides respite care for short stays, but is not able to provide intermediate care.
Heatherbank Version 1.00 Page 9 The inspector spoke to a number of service users who expressed positive views about the home and the care provided. 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. 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 given the opportunity to fully assess the suitability of the home. Heatherbank Version 1.00 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 standard(s) 7, 8, 9, and10. Service users’ health, personal and social care needs are being appropriately met and reviewed. The home has appropriate policy and procedures in place for administering medication, but needs to ensure that all staff have received training in this area. Service users are treated with respect and have their privacy respected. EVIDENCE: The inspector examined a sample of service user care plans which (using the Standex tool) evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. There was evidence from review notes that service users’ care needs are being regularly reviewed with amendments being made to the service user plans where needs have changed. The inspector spoke to a number of service users who expressed their satisfaction with the help provided by care staff, and felt that their care needs are being well met. Health care needs were evidenced to be appropriately met. Service users’ daily notes and the visitors book evidenced 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
Heatherbank Version 1.00 Page 11 when required. An issue arising from a recent complaint, of ensuring privacy for these visits, has been addressed (see standard 10). The home’s providers are ensuring that visiting health care professionals are reminded of the need for privacy to be respected, with a notice to this effect having been prominently displayed in the reception area. During the last 12 months 5 service users have been taken to Accident and Emergency following falls or other health concerns. There were no service users with pressure sores at the time of inspection. The home has a medication policy in place (Standard 9). The inspector examined medication records which were in order. 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 is provided by the supplying pharmacist, a list of staff trained to administer medication being maintained. This training needs to be updated for recently recruited staff members, for which a requirement is made. This inspector addressed an issue arising from a complaint on the previous inspection. This related to the treatment of a service user in an area of the home which did not afford privacy (Standard 10). The manager has placed a notice in the reception area advising all visiting health care professionals to ensure that service users are treated in the privacy of their own rooms, and staff have been reminded of the need to ensure privacy for these visits. The inspector observed service users being treated with respect and kindness by staff. Staff were observed to knock on residents’ doors before entering their rooms. All service users have a lockable space in their bedrooms for storing personal possessions and valuables. Views expressed by service users to the inspector indicated that staff were generally caring and respectful of their privacy. Personal care is given in service users own rooms. There is one double room which has a dividing screen for use when required. Both service users have confirmed that they are happy with this arrangement. The registered manager has acted on a recommendation from the last inspection (Standard 11) and has purchased a training package for providing training in the area of bereavement and loss to staff. Training in this area is to be rolled out to staff. This standard will be fully assessed on the next inspection. Heatherbank Version 1.00 Page 12 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 standard(s) 12, 13, 14 and 15 Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. However more could be done to encourage their participation in day-today activities. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. They are also 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. Meals are wholesome, appealing and the diet is nutritious. The meals are served in pleasant surroundings, and at times convenient to the residents. EVIDENCE: The inspector expressed concern on the previous inspection that some service users presented as under-stimulated and bored. The inspector spoke to a number of service users who did not express any critical views on this occasion regarding the range of activities offered. The manager indicated that staff try, where possible, to engage service users, and help facilitate their participation in games and activities. The inspector’s impression was that some service users presented as under-stimulated and that more could be done to encourage their participation in day-to-day activities. The use of volunteers to visit and befriend service users, and engage in activities, could be extended in this regard. This is a recommendation.
Heatherbank Version 1.00 Page 13 The registered manager indicated that activities offered include twice-weekly visits from a volunteer to engage residents in activities and occasional visits from a group of volunteers called ‘Non such Orbit’ who provide entertainment including singsongs and bingo sessions. Other activities offered include craft therapy evenings, reminiscence sessions, exercise sessions, and quizzes. A DVD player has recently been purchased with a selection of DVDs for showing to residents. A number of games, books and videos are also available. 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 expressed some positive views to the inspector regarding their ability to exercise choice in their daily routines (Standard 14). Staff at the home were generally seen to be enabling in their attitudes whilst providing the necessary care and support in a way that meets individual needs. 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. Standard 15 was evidenced to have been met. The inspector examined menus provided over a two-week period. These evidenced a varied choice of food with fresh vegetables and fruit being included in the diet. Service users expressed satisfaction with the food offered and the meals served at lunchtime were observed to be both nutritious and appetising. Service 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 Version 1.00 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 standard(s) 16, 17 and 18. Residents, their relatives and friends can be confident that their complaints will be taken seriously and acted upon as an appropriate complaints policy and procedure is in place. Service users’ legal rights are protected. Service users are protected from abuse and are to be living in a safe environment as the home has appropriate adult protection policies and procedures in place. 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, and 4 complaints within the last 12 months. Complaints received have been satisfactorily dealt with and there is no evidence of any unresolved concerns. Following a previous requirement the complaints record has been amended to indicate whether the complaint has been satisfactorily resolved. The requirement has, however, been 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. The manager 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). There have not been any adult protection concerns raised. Service users spoken to expressed the view that they felt they were living in a safe environment and that their welfare and rights are respected. No protection concerns were expressed.
Heatherbank Version 1.00 Page 15 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). There is an outstanding requirement for all staff to attend LB Sutton’s Vulnerable Adult and Adult Protection training. The manager stated that this has not, as yet, been met, but that staff members are being nominated to go on Sutton’s training over the next few months. In addition, the manager stated that an accredited trainer who is familiar with Sutton’s Vulnerable Adult training, will be arranging to visit the home to provide training for all care staff. Heatherbank Version 1.00 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 standard(s) 19, 21, 22 and 26. The home provides a safe, well-maintained environment with service users having access to safe and comfortable facilities. The home is experiencing a problem with the servicing its two adapted Acer baths which is currently restricting its ability to provide sufficient safe bathing facilities for service users. Service users have sufficient aids and adaptations to ensure safety. Generally the home is clean, and pleasant. EVIDENCE: Heatherbank Version 1.00 Page 17 The home is accessible and complies with requirements from the fire service and environmental health department. 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). A requirement from the last inspection has been partly met with the redecoration of the two respite bedrooms (Rooms 11 and 23). Re-carpeting is, however, still required. Torn carpeting in the passageway opposite Room 8 has been replaced, thus removing a risk to service users. The home’s proprietors, Mr and Mrs Hawkins, informed the inspector that they have abandoned any idea of renovating the garden area at the rear of the property due to budgetary constraints. It is 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. No consultation has, as yet, been undertaken with the residents. 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). There is, however, a problem of leakage with one of the two Acer baths which is not currently in use. The inspector was informed that there has been a problem with rectifying this due to the servicing contractor no longer being in business. The inspector understands that the proprietors are seeking to get the bath serviced, and the problem rectified, through another contractor, together with servicing of the other Acer bath. A requirement is made in this regard for repair/servicing of the two Acer baths. A requirement in respect of Standard 22 has been partly met. A risk assessment of the home has been carried out by an occupational therapist, but this has not, as yet, been evidenced with a report. A copy of this must be forwarded to the CSCI and any recommendations will be addressed at the next inspection. The OT assessment was felt by the inspector to be advisable in order to minimise any risks within the home, and to ensure the provision of a sufficient range of equipment and adaptations appropriate to meeting the needs of physically frail and disabled service users. Service users were observed to be mobilising using specialist aids such as zimmer frames. 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 inspector noticed that there was no liquid soap dispenser in two downstairs toilets, one of which was adjacent to Room 16. A requirement for the installation of dispensers applies. Heatherbank Version 1.00 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, and 30. The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety.The home’s recruitment policy and procedures are in place. Two concerns were identified in regard to recruitment checks being completed satisfactorily, which impinge on the safety and protection of service users being ensured. 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. There are always three carers 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 two ancillary staff and a part-time agency cleaner. The home currently has 7 care staff who have NVQ Level 2 or equivalent. This meets the target of at least 50 of care staff with NVQ2 by 2005 (Standard 28). 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
Heatherbank Version 1.00 Page 19 to date CRB check is required, for which a requirement applies. Another file did not evidence a copy of the applicant’s birth certificate. It is a requirement that a copy of the birth certificate is provided as part of the documentation listed in Schedule 2 of the regulations, relating to all persons who work in the home. There is a staff training and development programme in place (Standard 30). Some staff have been employed through Pathways which 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. A requirement to ensure that a written policy and procedure covering emergency situations is put in place, 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. Heatherbank Version 1.00 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36, 37 and 38. The home needs to further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. One-to-one supervision sessions are now being held with staff, but these must be held more regularly, on at least a two-monthly basis as this could affect the staffs ability to consistently meet all a residents’ needs. Records required for regulation were generally in place and well maintained. the health, safety and welfare of service users and staff is being promoted and protected. EVIDENCE: The registered manager has previously attended an Investment In People seminar. The requirement from the previous inspection relating to the need for the home to have an effective quality assurance and monitoring system in
Heatherbank Version 1.00 Page 21 place has yet to be fully implemented (Standard 33). The manager confirmed that surveys with service users and relatives are being undertaken. These need to be extended to include visiting professionals, voluntary workers and any other stakeholders. A requirement applies. It is essential that the home is able 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, detailing the survey feedback and the extent to which the home’s aims and objectives are being met, to be put in place. A requirement applies. The home needs to demonstrate its financial viability (Standard 34). Following a requirement from the previous inspection, a Business Plan has been put in place. No accounts for the financial year 2004/2005 were available to view at the time of inspection. The home needs to demonstrate its financial viability and obtain an up-to-date set of accounts for the year ending 2005. A requirement applies. A requirement from the previous inspection, for regular, recorded supervision with all care staff has not yet been met. The Registered Manager confirmed that one-to-one supervision with care staff is now taking place, but that this is not yet taking place on a regular two-monthly basis. The inspector examined supervision notes. These indicated that a proper format for recording supervision is in place, and that care staff are now being supervised. Supervision is not, however, being held on a sufficiently regular basis (to be held at least 2 monthly) and the requirement for regular supervision remains. 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. The inspector is making it a requirement for the registered manager to develop a policies and procedures checklist. 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. The inspector was satisfied that the health, safety and welfare of service users and staff are being appropriately protected (Standard 38). 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, gas safety, fire safety, hoist maintenance and the testing of call systems, together with certificates for Legionella and environmental health. Heatherbank Version 1.00 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 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 2 x 2 2 x x x 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 Standard No 16 17 18 Score 2 3 2 x x 2 2 x 2 2 3 Heatherbank Version 1.00 Page 23 yes Are there any outstanding requirements from the last inspection? 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. 2. Standard OP9 OP16 Regulation 18(1)(a) 22(2) & (3) Requirement Accredited medication training must be provided for all care staff. The complaints log must state 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). The Registered Manager must ensure that all care staff have accessed and completed Suttons Vulnerable Adult and Adult Protection training. The Registered Manager must ensure that the two respite bedrooms (Rooms 11 and 23) are re-carpeted. The two Acer baths, on the ground floor, must be repaired and serviced and put back into use. Liquid soap dispensers must be installed in all toilets within the home. CRB (Criminal Records Bureau) checks must be in place for all care staff. No portability allowed. The Registered Manager must ensure that a copy of the birth
Version 1.00 Timescale for action 1 October 2005 Extended to 1 June 2005 3. OP18 18(1)(c) 13(6) Extended to 1 October 2005 Extended to July 2005 1 July 2005 4. OP19 23(1)(a), 23(2)(d) 12(1)(a), 23(1)(a), 23(2)(c) 12(1)(a), 13(3) & (4)(c) 19(1)(b) (ii), Sch.2, No.7 19(1)(b) (ii), Sch.2 5. OP21 6. 7. OP26 OP29 1 July 2005 1 July 2005 8. OP29 1 May 2005
Page 24 Heatherbank 9. OP30 18(1)(a), 18(4) 10. OP33 24(1)(a) & (b) 11. OP33 24(2) 12. OP34 25(1), (2)(a), 25(3)(a), (b) & (c) 18(2) 13. OP36 14. OP37 12(1)(a), 18(1)(a) certificate is made available for all persons who work in the home. (as per Schedule 2). The Registered Manager must 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. The Registered Manager must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals, voluntary workers and any other stakeholders. 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. The registered manager must submit a set of accounts for the year 2004/05 to the CSCI, in order to demonstrate the home’s financial viability. 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. 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 read and understood each policy developed and reviewed.
Version 1.00 Extended to 1 May 2005 1 October 2005 1 March 2006 1 September 2005 Extended to 1 September 2005. 1 September 2005 Heatherbank Page 25 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. Refer to Standard OP12 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. Heatherbank Version 1.00 Page 26 Commission for Social Care Inspection 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
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