Inspection on 20/05/05 for Heathercroft

This inspection was carried out on 20th May 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

Heathercroft 24/10/07

Heathercroft 28/09/06

Heathercroft 26/01/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Heathercroft 18 Wolverton Gardens Horley Surrey RH6 7LX Lead Inspector Mrs Pauline Long Unannounced 20/05/05 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Heathercroft Address 18 Wolverton Gardens Horley Surrey RH6 7LX 01737 765800 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) Prospect Housing Association Ltd Ms Anastasia Bell Care Home 5 Category(ies) of LD - Learning Disability (4) registration, with number of places LD(E) - Learning Disability over 65 (1) Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accomodated will be: 33 - 65 years of age and one (1) whom can be over 65 years of age. Date of last inspection 26th Jan 2005 Brief Description of the Service: Heathercroft is a care home providing personal care and accommodation for 5 people with moderate to severe learning disabilities. On the day of the inspection there were four women living at the home all of whom had been there since the home opened six years ago. The home is owned and maintained by Prospect Housing Association. The home is located on the outskirts of Horley. The home has a vehicle to access the shops and other amenities in the town centre. The home was opened in 1997 and is a bungalow providing all ground floor accommodation. All the bedrooms are single although none have en suite facilities. There is a pleasant garden on three sides of the building. There is limited car parking at the property. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried out by two CSCI staff and lasted for two and a half hours. CSCI would like to thank the residents and staff for their hospitality and co-operation during the inspection process. On the day the service had a very quiet, relaxed and homely atmosphere. All four of the residents were at home. Two members of staff were on duty. No immediate requirements were made on the day. During the inspection process, evidence was gathered in the following ways: • • • • • • • Discussions with the staff. Discussions with residents Direct observation of interactions between the residents and staff. Examination of resident’s, staff records. Feedback from the last inspection reports. Feedback from the last monthly visit and report completed by the responsible individual. A tour of the home and garden. The feedback from the residents was limited in view of their communication difficulties. What the service does well: The relaxed, friendly and supportive atmosphere of the home helps the residents to feel that the home is their own. Three residents were resting in the sitting room and one was observed working on a jigsaw puzzle. This support has created lifestyles, in which residents can feel safe and have a quality of life which includes opportunities for residents to take part in local clubs, swimming and horse riding. The home is active in promoting family involvement and contact with the local church and the wider community. It was observed that there are close relationships between the residents and staff. Interaction between staff and resident’s was familiar yet respectful. One resident stated that she enjoyed cooking and eating fish and chips. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Although most of the previously made requirements had been met, the home still has to address some areas which now must be a priority for attention. Failure to comply with these may result in CSCI seeking legal advice, if these continue to remain unmet. • • The Commission for Social Care Inspection have not received an application for a registered manager. An application must be made. The home could improve in some areas of staff training. For example some staff needed training in adult protection and CSCI have made this a requirement. An alternative facility for hand drying in the toilet must be found, in the absence of towels. The home must have relevant documentation in place for staff recruited to work at the home. Staffing levels must reflect the dependency levels of the residents and must be consistent. • • • Requirements have been made in these areas. Please refer to page 25 of this report. 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. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 4, Arrangements are in place to ensure a full needs assessment takes place before any new admission. The home does not provide for intermediate care. EVIDENCE: The home can accommodate five residents. On the day of inspection, one room was vacant. The senior member of staff on duty explained that three prospective residents had been admitted for introductory visits. These visits ranged from an afternoon to overnight and weekend stays. All of the prospective residents decided they that Heathercroft was not suitable for them. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 10 The staff on duty on the day had a good understanding of the resident’s health and personal care needs, these were well met. EVIDENCE: All of the residents had care plans in place which included a comprehensive needs assessment. On the day of inspection residents were observed being enabled to make choices safely. Some risk assessments were in place and had been reviewed. There were records with regard to the activities and care given being kept. All records were stored appropriately and securely. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15,17 The Manager and staff enable the residents to maintain fulfilling lifestyles in and outside the home. The home promotes contact with family, friends and the local community. EVIDENCE: The home’s activity calendar and resident’s care plans, demonstrated activity programs both inside the home and in the community. Discussions with staff, described various sessions such as, make up and music evenings, foot spas, and visits from professional Activities organisers. “ Us in a Bus” comes to the home on a weekly basis. Staff stated that, “the residents enjoy this activity”. According to staff one resident particularly enjoys helping with the cooking. Some of the resident’s have regular visits from their families. One family member comes to the home every second Thursday and spends all of the afternoon there. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 11 On the day of inspection meal times were not observed, however one resident spoken with described how she enjoyed fish and chips and jelly. A member of staff stated that the resident enjoyed having “fish and chips” at home. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19, 20 The staff have a good understanding of the residents support needs. This was evident from the positive interactions and relationships observed and discussed. EVIDENCE: Care plans included clear guidelines on the support each resident required with personal care. Physical and emotional needs of the residents were also detailed in the care plans and daily records, which included visits to the doctor, dietician, dentist and reviews of care. Instructions and guidelines with regard to managing a residents challenging behaviour was quite clearly recorded All of the residents in the home have difficulties communicating. At present the home does not use pictorial means of communication. However the senior member of staff on duty stated that the manager was exploring the possibility of introducing this form of communication in the future. A recommendation was made in this respect. The home had clear medication policies and procedures. None of the residents in home administers their own medication. All of the resident’s medication and record sheets were checked and were found to be in good order and properly completed. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 13 All of the care staff are conversant with the policies and procedures regarding medication. Not all of the care staff had completed medication training. A requirement and a recommendation was made in these areas. Please refer to pages 23 and 24 of this report. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the residents. EVIDENCE: CSCI have received no complaints about the home since the last inspection. There were no records of complaints being made in the home. One referral has been made under the Local Authority Multi Agency procedures for the Protection of Vulnerable adults. Meetings have taken place in respect of this referral and the matter appropriately resolved. Not all of the staff have attended Protection of Vulnerable adults training. However the training records and training plan indicated that staff have been allocated various training dates. A requirement has been made in this respect. Please refer to pages 23 and 24 of this report. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26,27, 28, 30 The standard of the environment within this home is good. All of the areas in the home currently meets the collective and individual needs of the residents, providing an attractive and homely place to live. EVIDENCE: All of the resident’s bedrooms were viewed during this inspection. They were found to be personalised. They looked comfortable, warm, and the quality of the furniture and decoration was very good. There were various soft toys sitting around on the beds. There were photographs of family members and other personal items. The main sitting room and dining room were comfortable. The standard of decoration in the home was satisfactory. The home was clean and no odours were present. The bathrooms and toilet’s were clean and odour free. It was noted that one of the toilets had no hand towels. The staff on duty indicated that a towel dispenser had been bought, but had yet to be fixed to the wall. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 16 A requirement has been made in this area. Please refer to pages 23 and 24 of this report. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32,33,34, 35, 36 The home employs a stable and efficient staff team who provide a good quality of care to the residents. However on the day staffing levels were not adequate. EVIDENCE: The home has clear policies and procedures for staff recruitment. One new member of “Bank staff” has been recruited since the last inspection. There was no evidence of any paperwork relating to this new staff member. The senior member of staff on duty explained that all of the paperwork was still at head office. Other staff files seen on the day demonstrated a thorough recruitment and selection practice. The dependency levels of the residents on the day indicated that the present staffing ratio was inadequate. One member of the staff team had called in sick and had not been replaced. The senior member of staff on duty explained that she was going to try and cover the shift, but was distracted by the arrival of the inspectors. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 18 Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Staff also discussed the training opportunities in the home. The training file contained evidence of the following : • • • • • • Manual handling. Health and Safety. Fire Awareness. Food Hygiene. NVQ Vulnerable Adults There is a supervision programme in the home. There was some evidence of formal one to one supervision meetings. The whole staff team meet as group however this does not happen on a regular basis. Requirements have been made in these areas. Please refer to pages 23 and 24 of this report. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 42, The home has clear Policies and Procedures and the standard of record keeping in the home is good. EVIDENCE: The manager has been in post since October 2004 but was not on duty on the day of inspection. To date CSCI have not received an application in respect of registration. Through discussions with one of the senior staff during the inspection, it was evident that the last year has been a challenging time for them. She stated that communication in the home had improved. A new Deputy manager has been appointed and the staff stated she felt more positive with regard to the future of the home. All the service users have a moderate to severe learning disability and communication difficulties, therefore the inspectors were unable to fully ascertain their views. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 20 The Policies and procedures are easily accessible by the staff and service users if they wish to read them. It was pleasing to note that all of the garden gates were secured. All cleaning equipment was properly stored. All confidential records relating to service users and staff were stored securely. A requirement has been made in respect of the Manager at the home. Please refer to pages 23 and 24 of this report. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heathercroft Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x 3 x 3 x H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 22 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. Standard YA 37 Regulation Part 2 The Care Homes Regulation s & The Care Standards Act 2000 19(1)(b) Requirement The registered provider must ensure that an application for the registration of the manager is submitted to the CSCI. Timescale for action 23/6/2005 2. YA 34 3. YA 20 13(2) 4. YA 23 13(6) 5. YA 33 18 (1)(a) 6. YA 27 13(3) The registered person(s) must ensure that the home has all relevant documentation in place for staff recruited to work at the home. Timescale of 13/09/04 not met The registerd person(s) must ensure that all members of staff are appropriatly trained in all aspects of medication administration. The registered person(s) must ensure that all staff receive Protection of Vulnerable Adults training. The registered person(s) must ensure that staffing levels in the home, reflect the depencency levels and numbers of residents and that the staffing levels are consistent. The registered person(s) must ensure there is an alternative Version 1.30 23/6/2005 23/7/2005 23/7/2005 23/6/2005 Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Page 23 facility for hand drying in the toilet , in the absence of towels. Timescale of 13/09/04 not met 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 All standards YA 20 Good Practice Recommendations The registered person(s) should consider introducing a pictoral form of communication. It is recommended that a local guideline on the ordering of medication is produced to assist staff in implementing this part of the policy in this home. Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Heathercroft H58_s59971_Heathercroft_v230910_200505_stage4.doc Version 1.30 Page 25 - 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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