Inspection on 26/02/07 for Heatherdale Residential Home

This inspection was carried out on 26th February 2007.

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 Residential Home 25/02/09

Heatherdale Residential Home 06/12/05

Heatherdale Residential Home 06/05/05

Heatherdale Residential Home 24/11/04

Heatherdale Residential Home 28/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Heatherdale Residential Home South Broomhill Morpeth Northumberland NE65 9RT Lead Inspector Elaine Malloy Key Unannounced Inspection 09:45 26th February to 6th March 2007 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 Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 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 Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heatherdale Residential Home Address South Broomhill Morpeth Northumberland NE65 9RT 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) 01670-760796 01434 636900 Wellburn Care Homes Limited Miss Catherine Margaret Goode Care Home 36 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (21) of places Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Heatherdale is a care home that is located in South Broomhill, within reach of shops and other local amenities. The home provides personal care and support to 36 older people including 12 older people with dementia. It is equipped with a passenger lift. All bedrooms are single and 24 rooms have en-suite facilities. Communal lounge and dining areas are provided. There are baths and showers, and separate toilets. The home has car parking space and accessible attractive gardens. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fees range from £408.00 to £415 for residents who are either privately funded or funded by the Local Authority. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. One inspector visited the home on two days and the visits lasted 10 hours. The home manager completed a questionnaire on information about the service. This was returned to the Commission before the inspection. Key standards were inspected through discussion with management, staff and residents, examining the home’s records and touring the building. Areas that needed improvement from the previous inspection were checked. Surveys were also made available to residents and relatives/visitors to get feedback on the service. Eight surveys were returned from residents and seven from relatives. What the service does well: Residents spoke positively about life in the home. Comments included, “Staff are very good and supportive and have helped me to become more independent”, “Management is always approachable and willing to help”, “The standard of meals is very good”, “The home is always lovely and clean”, “The staff and management have been very helpful at all times”. Relatives who completed surveys said they were satisfied with the overall care provided. Residents have recorded plans that show how they are assisted to meet their care needs. Residents are supported in meeting their health needs. The home’s medication system protects residents. Staff have respect for residents privacy and dignity. Residents maintain contact with family, friends and the local community. The service encourages residents to stay independent and make choices and decisions. A varied menu is offered with choice of meals and residents said they enjoy the food. Any complaints received about the service are taken seriously and acted upon. There are procedures for protecting vulnerable adults and staff are trained in prevention of abuse. Residents live in a clean, comfortable building that is well maintained. There are plans to make improvements to the entrance hall and office space. There is a responsible manager in charge and good staffing levels are provided. Staff receive training relevant to caring for older people including courses that lead to care qualifications. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 6 Resident finances are held safely in the home. There are systems to promote resident and staff health and safety. What has improved since the last inspection? What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 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 Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Every new resident should have his or her needs thoroughly assessed before admission to the home is agreed. EVIDENCE: The records of two residents who had moved into the home in recent months were examined. In both instances assessments were obtained from Care Managers. Discharge information had also been provided for a gentleman who moved to the home from hospital. At the last inspection a requirement was made for the home’s pre-admission assessment of care needs to be completed according to the company’s procedure. This assessment was completed by telephone for a gentleman who previously lived outside of the area. The assessment for the other resident was only partly completed, and not signed or dated. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 9 Residents who completed surveys said they received enough information about the home before moving in. One commented, “We lived locally to Heatherdale and were aware of the favourable reputation the care home had”. One resident told the inspector how she had looked at other homes before choosing Heatherdale. She said it had taken her time to settle and was now very happy and content. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have personalised care plans that show how their care needs will be met. Residents receive support from staff and medical professionals in meeting their health care needs. Residents are protected by the home’s medication system. Resident privacy and dignity is respected. EVIDENCE: A sample of resident care records was examined. The home uses a range of assessments to identify residents care needs and updates these on a three monthly basis. Care plans are documented which show how staff support residents, what the person can do independently, and have choice and Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 11 flexibility built in. The plans had been improved to include resident personal preferences, as stated in the requirement of the last inspection. Care plan evaluations are completed monthly. Systems are in place for management to monitor and audit resident care plans and the frequency of assessments and reviews. Residents use a local doctor’s practice, and a weekly ‘surgery’ is held in the home. The District Nursing Service currently visits twice weekly. There are arrangements for residents to receive home visits from an optician, dentist and podiatrist. Residents with mental health needs have input from psychiatric services and where necessary a specialist Challenging Behaviour Team. All contact with health professionals is recorded. Individual’s health needs are assessed and care planned. Specific and personalised care plans have been developed addressing needs relating to dementia, continence and nutrition. Moving and handling plans were also improved to incorporate pressure relief issues. The majority of residents who completed surveys said they always or usually received the medical support they need. A resident told the inspector that she received prompt medical attention when she took ill a few months ago. She said that staff had looked after her very well during this time. No residents currently administer their own prescribed medication. Staff who have completed relevant training administer medication. Medication records were examined. Clear directions were recorded and administration was appropriately completed. Each resident has a photograph at the front of their chart for identification purposes. No residents at present take Controlled Drugs. Residents spoken with confirmed that staff respect their privacy and dignity. All residents have single bedroom accommodation and are offered keys to their room. Personal care and any medical examination/treatment are carried out in the privacy of the resident’s bedroom. Residents are asked the name they wish to be addressed by and this is recorded. The home currently employs an all female care team. Two resident have chosen to have a telephone in their bedroom. All bedrooms have telephone points. A portable pay telephone is available for resident use to make and receive calls in private. A staff member is allocated to give out the mail and daily newspapers. Mail is given unopened to residents and staff or relatives give support in dealing with correspondence, where needed. The home employs designated laundry staff. Residents clothing is labelled/marked to make sure it can be identified. Each person has his or her own laundry basket and a wash-bag for socks/tights/stockings. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Provision of activities suitable for residents with dementia, and recording of daily activities needs some improvement. Residents are supported to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions in daily living. A varied diet with choice of meals is offered and residents enjoy the food. EVIDENCE: Individual social profiles/assessments are being introduced. The manager said that, where necessary, relatives would be consulted to provide information on the resident’s lifestyle and interests. A monthly schedule of daily activities is forward planned and a copy is put in each resident’s bedroom. This incorporates seasonal events, birthday parties, Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 13 visiting entertainment and outings. The current schedule showed a variety of activities and outings. These included painting, aromatherapy and massage, sing-a-longs, reminiscence, films, St Patrick’s Day celebration, range of Easter crafts, pub lunch, and visits to the Friendly Café and Tuesday Club. Activities duties are allocated to staff each day. Recordings to the social diary did not reflect all activities that had taken place and gaps were evident. The manager recognised that the provision and recording of daily activities needs to be improved. This includes further development of activities appropriate for residents with dementia who have shorter concentration spans. Survey responses about social activities were variable. One resident said there was always activities arranged by the home that they could take part in, whilst another said there never was. Others said there was usually or sometimes activities they could join in. One commented, “Someone to provide things to do most days would be good”. A relative said they felt stimulation for residents with dementia is a weak point. Another relative said, “Someone for entertainment only would be a bonus. Somewhere to sit outdoors if raining but warm”. Residents who spoke to the inspector gave positive comments about group activities and outings. One lady told the inspector that she goes out regularly and that a wonderful party was held on her birthday. Residents make use of local amenities and support the community. Links have been made with a local school. The home has an open visiting policy and residents choose who they wish to see. Visits take place in the resident’s bedroom or lounge/dining areas. The manager said that relatives are routinely invited to resident care reviews and there is good support from some relatives. All relatives/visitors who completed surveys said they are welcomed into the home at any time and can visit their relative/friend in private. Six of the seven relatives said they are kept informed of important issues affecting their relative/friend; and are consulted about their care if their relative/friend is unable to make decisions. One commented that they felt communication with relatives is a weak point. The manager is looking towards improving communication and has organised a ‘Residents, Family and Friends Forum’ at the end of March. The home’s management does not have Appointeeship responsibility for any resident’s financial affairs. Where possible, residents continue to manage their finances, and relatives and solicitors support others. Cash for personal spending can be held in the home’s safe. Before admission new residents and their relatives agree the extent of possessions they will bring into the home to personalise their room. Information on advocacy services is available, and these would be accessed if needed. Autonomy and choice is built into residents care plans. The home has a policy on access to personal records and these are shown and discussed at reviews. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 14 The home has a 3-week cycle of menus that have recently been revised. The menus now include breakfast, snacks and drinks as previously required. Breakfast consists of fruit juices, grapefruit, cereals, toast and preserves, fresh fruit and cooked items daily. Residents are offered a choice of dishes at lunch and evening meal, followed by dessert. A variety of snacks are provided for supper. Residents can choose whether to eat in the dining room or have a tray taken to their bedroom. Special diets, seasonal events and special occasions are catered for. Residents are encouraged to eat independently, with use aids if needed. Staff assist residents at mealtimes by prompting, cutting up food and feeding individuals. The inspector observed lunch being taken on two days. All residents spoken with said they enjoyed the food and confirmed they are given choice of meals. Mealtime and feeding practices were discussed the manager who will be monitoring these. Residents who completed surveys said they always or usually like the meals at the home. Comments included, “Most times I like plain foods”, “The standard of meals is very good”. One relative said, “Quality of the food is a strong point” and another said, “Excellent home-made cooking which my father-in-law enjoys. Good portion sizes”. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place and any complaints received are taken seriously and investigated. The home aims to protect residents from any form of abuse. EVIDENCE: The home’s complaints procedure is discussed on admission and a copy is provided in the Service User Guide. One complaint had been made to the home in the past year. This was appropriately recorded and included action taken. The Commission had not received any complaints about the service in the period since the last inspection. The majority of residents and relatives who completed surveys indicated that they would know who to speak to if they were not happy or wanted to make a complaint. One resident commented, “Management is always approachable and willing to help”. The home has policies and procedures on prevention of abuse, protecting vulnerable adults (POVA), and ‘whistle blowing’ (informing on bad practice). An internal investigation into an allegation had recently taken place. This did not invoke the local POVA procedure and the outcome was that the allegation was Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 16 unfounded. Safeguarding adults was discussed with the manager to make sure she understands her responsibility to report and notify any allegations of abuse to the relevant authorities. All staff receive training on protecting residents from abuse. The manager, deputy and a team leader are undertaking advanced training as previously recommended. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, comfortable and well-maintained accommodation. Control of infection will be improved by creating a sluice room. EVIDENCE: All parts of the building seen were clean and suitably decorated and furnished. Communal areas are attractive and comfortable. There are 36 single bedrooms, 24 of which have en-suite facilities. The resident’s name and room number is on the door and keys are offered. The home has well-maintained gardens with ramped access. In the period since the last inspection a number of improvements had been made to the environment. These included the fitting of a stainless steel kitchen and redecoration of lounges, hall, corridor and main staircase. There is ongoing Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 18 redecoration and replacement of floor-coverings as needed. Consideration was being given to replacing the conservatory roof. There were also plans to remove the glass sliding doors from the front lounge, and create an internal porch and extend the office space. Residents spoken with were happy with the comfort of the accommodation. Each resident who completed a survey said the home is always fresh and clean. Comments included, “Heatherdale is always extremely clean and a credit to the cleaning staff” and “The home is always lovely and clean”. There are procedures on control of infection and staff receive training. The deputy manager is the liaison person for infection control with the North of Tyne Communicable Disease Unit. Disposable gloves and aprons are provided and there is liquid soap and paper hand towels in bedrooms for hand washing. Arrangements are in place to dispose of clinical waste. At the present time the home does not have a sluicing facility separate from the laundry. A ground floor toilet will be converted into a sluice room in the near future. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good staffing levels are provided to meet the needs of the number of residents. The home is committed to residents being cared for by qualified workers. There is a suitable staff recruitment process and taking up second professional references would strengthen this. Staff are provided with a range of training relevant to the needs of the people they care for. EVIDENCE: All care staff are aged over 18 and staff left in charge of the home are over 21 years of age. At the time of the inspection there was 30 residents. Good care staffing levels are provided. Rotas indicated five carers on duty in the mornings and afternoons, four carers in the evenings and night staffing has been increased to three carers. There is an appropriate level of domestic, laundry and catering staff hours. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 20 The majority of residents who completed surveys said they always or usually received the care and support they need. One resident said they feel cared for but not supported. Each said that staff listen and act on what they say, and are always or usually available when they need them. One resident commented, “The staff and management have been very helpful at all times”. A resident told the inspector, “Staff are very good and supportive and have helped me to become more independent”. Four relatives who completed surveys said in their opinion there are always sufficient numbers of staff on duty and three relatives said there was not. All relatives who completed surveys said they were satisfied with the overall care provided. 50 of care staff have achieved National Vocational Qualifications (NVQ) in care at Level 2 or above, and seven staff are currently studying. All staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. A sample of staff recruitment files was examined. These contained appropriate details including photograph and proof of identification, application form and interview assessments. A reference is always taken up from the last employer. However a number of ‘second’ references were character references. As a matter of good practice a second professional reference should be obtained wherever possible. If there is no other choice but to request a character reference this should be sought from a professional who knows the applicant. There is a training schedule in place that is regularly updated. Records of staff training courses and certificates are maintained. In the past year staff have received training in the following areas: induction training for new staff, National Vocational Qualifications, safe working practices, protection of vulnerable adults, and challenging behaviour. Six staff have started a course on understanding dementia, and training on risk assessment, medication, infection control, Mental Capacity Act awareness, challenging behaviour, and podiatry was organised. In-house training is also provided that links to the home’s policies and procedures and care practices. This can include role-playing and has included receiving visitors, moving and handling, use of bath hoist and weighing scales, hand washing and infection control, and feeding residents. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A responsible manager who is supported by the company and a senior team manages the home. There are good systems to monitor the quality of the service. Resident personal finances are safeguarded. The home aims to comply with health and safety requirements. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 22 EVIDENCE: Miss Goode has managed the home for two years and was approved as the Registered Manager in 2005. She has worked in care settings for eight years. She is in the process of studying for NVQ Level 4 in Care and expects to finish the course by July 2007. She will then go on to study for the Registered Manager Award qualification. A proportion of Miss Goode’s working hours is supernumerary to the rota. She is supported within the home by a management team of deputy manager, team leaders and senior carers. An area manager from the company visits the home at least weekly. A number of residents who spoke to the inspector praised the manager. One resident who completed a survey commented, “Heatherdale has a very happy and relaxed atmosphere to it, very welcoming, but is professionally run by manageress Cath Goode. She is kind, has all the residents best interests at heart, a very dedicated young woman indeed, both competent and able”. The home has an accredited quality assurance system and was last audited in November 2006. Additional methods of measuring the quality of the service include surveys, audits, allocation of duties to staff for accountability, the introduction of resident and relatives meetings and detailed monthly ‘conduct of home’ visits/reports carried out by senior managers. An annual quality assurance plan is to be developed that incorporates all the methods used. Resident personal finances were examined. A book is kept with individual pages for resident transactions. These were appropriately recorded and have two signatures for each entry. Receipts are obtained for purchases. Regular checks of balances and cash are conducted. There is a health and safety policy and range of associated procedures. Risk assessments are completed for the environment and safe working practices. Staff are provided with training on fire safety, moving and handling, first aid, food hygiene, and infection control. Risks to residents are assessed including risk of falls. The manager and a team leader are booked to attend risk assessment training. The home has servicing and maintenance agreements in place for facilities and equipment. Records of fire safety checks, tests and instructions to staff were examined. These were being carried out at the required intervals or more often. Tests of fire alarms had lapsed in recent weeks; these were subsequently brought up to date. Accident reporting was suitably recorded including follow up entries. A formal analysis of accidents is being introduced to help identify any patterns. Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement (Outstanding Requirement) Pre-admission assessments by the home must be completed as per Company Procedure. Timescale for action 26/02/07 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 Evidence of providing daily social activities should be recorded. (b) Social activities suitable for residents with dementia should be further developed. The Commission should be informed of a completion date for the provision of a sluice facility. Good practice should be followed when obtaining second/additional references for the recruitment of new staff. An annual quality plan should be developed that incorporates all methods of monitoring the quality of the service. (a) 2. 3. 4. OP26 OP29 OP33 Heatherdale Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Residential Home DS0000000532.V322675.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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