Inspection on 09/01/06 for Heatherdale Healthcare Ltd

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heatherdale Healthcare Ltd 10/12/08

Heatherdale Healthcare Ltd 19/01/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Heatherdale Healthcare Ltd 204 Hempstead Road Hempstead Gillingham Kent ME7 3QG Lead Inspector Sue McGrath Announced Inspection 9th January 2006 10:00 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 Heatherdale Healthcare Ltd DS0000065988.V266177.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. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Heatherdale Healthcare Ltd Address 204 Hempstead Road Hempstead Gillingham Kent ME7 3QG 01634 260075 01634 361123 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) Mr Arthur Thomas Wills Margaret Ann Burgess Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/06/05 Brief Description of the Service: Heatherdale Healthcare Limited was previously known as Heatherdale Nursing Home and occupies detached premises, with accommodation for residents on two floors. The premises are registered as a care home with nursing for 37 service users. The Home has a shaft lift and other mobility aids that enable it to accommodate wheelchair users. There is allocated car parking to the front of the building and a pleasant garden to the rear. The Home is situated in a residential area, with local shops, public transport and other community facilities within the vicinity. The Manager employed at the Home has worked in the role of matron for a number of years: the proprietor, Mr Wills is very much involved in the Home and works closely with the Matron in overseeing the daily running of the Home. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection under the terms of the Care Standards Act 2000 and was carried out by one inspector who was in the home from 10.00 to 15.30 on the 9th January 2006. During the inspection the Manager was in attendance. Documentation and records were read, including care plans. A tour of the premises was undertaken and a considerable amount of time was spent talking with residents and some staff. The general impression from the residents and families and visitors spoken to on the day was that the residents were well cared for and lived in a safe and comfortable environment. On the day of the inspection the atmosphere was relaxed and comfortable. What the service does well: What has improved since the last inspection? What they could do better: The toilets in the bathrooms require new toilet seats and to be kept clean and hygienic. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 6 Training needs to be completed and not just planned. The ratio of NVQ qualified care staff is low (25 ). The homes Statement of Purpose would benefit from some minor adjustments. The administration of medication could be improved, as it does not fully meet with the guidelines from the Royal Pharmaceutical Society of Great Britain. Staff supervision needs to better planned, structured and implemented. 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. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,4, 5 and 6 Residents are provided with a statement of terms and condition of residency and benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. EVIDENCE: The organisation’s new Statement of Purpose was viewed and was found not to comply fully with Schedule 1 of the Care Home Regulations 2001.Discussion took place with the manager at a later date and she was advised to consult with the Schedule 1 of the Care Home Regulations 2001 and add the necessary information to the document in place. Residents are provided with a statement of terms and conditions, which has the facility for the manager and the resident or their representative to sign. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 9 Heatherdale’s admission procedure involves the prospective resident, their relatives and other relevant health and social care professionals. Senior staff undertakes a full an assessment and information is sought from the resident, their relatives and other professionals. This enables the home to identify needs and ensure they can meet those needs prior to admission. Prospective resident and/or relatives are encouraged to visit the home prior to admission. Heatherdale offers services for residents with nursing needs. Residents spoken with said they felt well cared for and that there needs were well met. Evidence was seen that good clinical guidelines were in place to ensure specialist medical care was delivered appropriately. Intermediate care was not offered at Heatherdale. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 11 Residents’ health needs are met with residents having full access to all professional health care services as required. Service users are mainly protected by the home’s policies and procedures for dealing with medicines but some minor errors were highlighted. The home has handled the issue of illness and ageing sensitively. EVIDENCE: Standards 7-10 were assessed at the last inspection Medication was again assessed and a few minor errors were still found. It is good practise to have photographs and allergies recorded on the MAR sheets, these were not available. Some had written instructions were found on the Mar sheets these should be avoided where possible. Some gaps were found in with the signatures on the Mar sheets. The main cause of errors seems to be that the home continues to run two systems, Mar and bottles. It is advised that where possible one system should be used for all medications. Some eye drops were out of date and some medications had not been signed in. This made it Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 11 difficult to carry out an audit on the boxed medications. The manager is advised to carry out monthly audits on the medications and record the outcomes. The home has written policies and procedures in place to ensure that illness and the death of a client is treated sensitively. The manager stated that families are involved at all times throughout this process. This information is recorded on the resident’s personal notes. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 and 15 Residents’ social and recreational interest and needs are well provided for with a wide range of activities organised. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents benefit from the appetising meals and balanced diet offered by the home and those residents requiring specialist diets are well catered for. EVIDENCE: Several residents spoken to stated they were happy with the lifestyle offered and ‘were as happy as could be expected’. Most confirmed the food was good and that there was sufficient amounts offered. One relative stated that she was always kept informed of any changes in her relative’s condition or of any accidents. The visitor also confirmed that she could visit at any reasonable time and that staff were always welcoming to her whenever she called. The activities co-ordinator discussed at length what type of activities she encouraged the residents to complete. Several residents complimented the home and the activities co-ordinator ‘on doing a good job and of making the days more interesting’. Examples were seen of some of the handicraft work completed. Entertainment that came into the home every six weeks included Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 13 sing-a long sessions, a violinist, an adult recorder group and a choir. Residents were looking forward to watching a group of belly dancers that were coming into the home to entertain them soon. The residents spoken to praised the amount of activities and events very highly. One resident had recently taken charge of a new electric wheelchair, which she stated ‘had helped my independence greatly’. The kitchen was viewed and found to be cleaner and tidier than at the previous inspection. New staff had been employed and a cleaning schedule introduced. The manager stated that it was her intention to have the flooring replaced sometime this year. Staff confirmed that specialist diets could be catered for and that pureed food was presented in a manner that was attractive and appealing in order to maintain appetite and nutrition. All of the residents spoken to said that the food was very nice and that a choice was given. Residents also confirmed that drinks were always available. Some of the residents managed their own financial affairs with help from their families. One resident explained how she was enabled to bring in some personal items from her home and how this had helped her to settle in. Heatherdale Healthcare Ltd DS0000065988.V266177.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): 16,17,18 The home has a robust complaints system and service users and relatives feel their views are listened to and acted upon. The home has adult protection policies and procedures in place to ensure that residents are protected from abuse. EVIDENCE: Relatives spoken with confirmed they were confident any complaints they had would be listened to and dealt with appropriately. A copy of the home’s complaint procedures was seen and included details of how to complain, timescales for response and information about referring any complaints to the commission. Residents spoken to also confirmed they were aware of the complaints procedure. The requirement that all staff be trained in Adult Abuse had been partially met; the home had recently had a relatively high turnover of staff. All new staff would be completing this training in the very near future. This will remain a requirement until all staff have been trained. The manager confirmed that residents had access to postal voting, but only a few took up this opportunity. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 15 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): 22, 25 and 26 Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. EVIDENCE: Standards 19,20,21,23 and 24 were met at the last inspection. The home was well maintained and decorated and residents said the home was very comfortable to live in. The home provided grab rails and other aids in the corridors, bathrooms, toilets and communal rooms where necessary and according to need. The home generally has problem with the storage of hoists and these were found in the bathrooms. Staff stated that they were always removed from the bathrooms prior to use. All rooms had access to the call system. The lights in the hallways had now been fitted with attractive and suitable covers. The amount of lighting was discussed with the manager and she stated Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 16 that there were plans in place to improved the amount of light offered, particularly in the lounge area. The toilets in the bathrooms were dirty and had not been cleaned for sometime. The seats were badly marked and one was not fixed to the pan. When discussed with staff they stated that these were rarely used. However these toilets must be kept in a hygienic and safe working state. The laundry used the new ‘Otex system’ Which ensured hygienic cleaning of clothing etc. Sluicing facilities, both thermal and chemical, were used. . The home also has two sluice disinfectors to dispose of waste and a macerator is also used. There were policies and procedures in place for the control of clinical waste. Staff training is planned for infection control. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 17 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): The residents benefit from being cared for by staff who have a good understanding of their needs. EVIDENCE: Figures given by the manager evidenced that the home was adequately staff for 31 residents. It will be expected that if the occupancy goes up to amount the home is registered for, 37, extra staff will be employed. Recent staff changes have meant that the home does not currently met the target of 50 of care staff trained to NVQ level 2 or above. However this was also the case at the last inspection in June 05. Some staff were currently completing their awards. The home has 25 of staff qualified to this level. The manager is actively seeking funding for staff to complete their NVQ’s. This will be a requirement. The manager confirmed that a TOPSS induction programme was in place and that new staff were using the programme. The manager stated that a new recruitment and selection policy was being drawn up and this will be assessed at the next inspection. The current procedure used was discussed and met with all the requirements of this standard. The manager was given details of the General Social Care Guidelines and these were to be made available for all staff. The home had is own guidelines and code of conduct which staff had been involved with drawing up. This Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 18 involvement had helped staff to own the policy and it had improved some working practises. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The residents benefit from living in a home where the manager is competent, enthusiastic and experienced with the care of older people and has a clear vision for the home. Staff continue not to be appropriately supervised. Residents are protected by sound financial procedures. Current arrangements were sufficient to protect the health, safety and welfare of residents and staff. EVIDENCE: The manager was open, honest and helpful throughout the inspection and had the necessary qualification and experience to manage the home. There were clear lines of accountability within the home and with the owner. Residents and visitors spoken with confirmed that al staff were approachable and communication well with them. The manager does organise some basic quality assurance amongst the residents but is advised to widen this process to include all other interested Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 20 parties. These results should be published and a copy made available to the CSCI. Although the owner has some basic business plans in mind these need to be formalised and an annual development plan be developed as stated in Standard 33. Notices were seen of the inspection in the foyer. Insurance cover was in place against loss or damage to the assets of the business, as was public liability assurance. Business plans and financial plans need to be developed to ensure full compliance with regulations (Standard 34). The home does hold some personal monies on behalf of some of the residents and these are kept in a secure facility. Accurate records were maintained. Two accounts were selected at random and found to balance. All written records were well maintained. Staff supervision remains an issue. At the last inspection a requirement was made that all staff receive supervision at least six times a year. Although the manager stated that the system had been started, not all staff had had regular supervision. Discussion took place around different methods of supervision and the qualification of those offering supervision. The requirement will remain in place. The home does not use volunteers. Records required by regulation, including Health and Safety, were seen to be secure, mainly up to date and in good order and maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. The accident book was inspected. No major accidents had occurred. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 1 3 3 Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13.2 Requirement Timescale for action 20/02/06 2 OP18 13(6) 3 OP30 18(1) The Registered Person shall ensure that there is a policy and that staff adhere to the procedures for the receipt, recording, storage,handling administration and disposal of medicines. Regular audits to be carried out and recorded. This requirement is carried over from the previous report. Action plan required. The Registered Person shall 20/02/06 ensure that all staff are trainied in Adult Abuse procedures. This requirement is carried over from the previous report. Action plan required. 20/02/06 The Registered Person shall ensure there is a staff training and development programme which meets the National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of the residents and that the training is carried out. This requirement is carried DS0000065988.V266177.R01.S.doc Version 5.0 Heatherdale Healthcare Ltd Page 23 over from the previous report. Action plan required. 4 OP36 18 The Registered Person shall ensure that all staff receive formal supervision at least six times a year. This requirement is carried over from the previous report. Action plan required. The Registered Person shall ensure that a minimum ratio 50 of care staff have achieved NVQ level 2 or equivalent. Action plan required. Action plan required. The Registered Person shall ensure that the toilets in the bathrooms are safe, clean and in good working order. 20/02/06 5 OP28 18(1)(a) 20/02/06 6 OP21 23(2) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP33 OP34 Good Practice Recommendations It is recommended that the current quality assessment be developed to fully meet this standard. It is recommended that a business and financial plan is developed and be open to inspection and reviewed annually. Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Heatherdale Healthcare Ltd DS0000065988.V266177.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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