CARE HOMES FOR OLDER PEOPLE
Heatherdale Residential Home South Broomhill Morpeth Northumberland NE65 9RT Lead Inspector
Deborah Haugh Announced Inspection 6th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Heatherdale Residential Home DS0000000532.V257671.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 Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 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 01670-760796 Wellburn Care Homes Limited Miss Catherine Margaret Goode Care Home 36 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (24) of places Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: Heatherdale is registered to provide residential care for 36 older people, 12 of who may have dementia. The home cannot provide nursing care. The home has 27 bedrooms with ensuites. Access in the home is level and a lift takes residents to and from both floors. The gardens are well maintained and residents who wish to can have access to them. Heatherdale is located within easy reach of local shops and amenities. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection took place on 6/12/05 from 9.30 until 2.45pm. The Registered Manager, Cath Goode was on duty during the visit. There were 33 service users at the time of the visit. Staffing levels were checked. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Prior to the inspection questionnaires were provided to service users and relatives. Five questionnaires were completed by service users and they also shared their views during the inspection. Time was also spent observing the contact between the service users and staff. No Relative/Visitor questionnaires were completed. But views were sought from visitors during the day. Three Care Plans were examined. Arrangements for the administration and management of medication were checked. Fire safety arrangements, recruitment, training, catering, protection and quality assurance were also examined. What the service does well:
All of the service users spoken with said they liked living at Heatherdale, felt safe, liked the food and felt that staff treated them well. Comments included; - ‘I am enjoying my stay and find it clean and warm, caring and very well managed.’ - ‘Due to the high standards and support I received I settled in at Heatherdale very quickly. I am safe, happy and extremely well cared for in a home which is organised and extremely well managed.’ - ‘The food is lovely, I’ve put on weight.’ - ‘I chose this home because it is immaculate, no smells, you’ll find no problems here.’ - ‘The staff are very kind, I can close my door and be by myself if I want.’ Relatives and visitor comments were very positive and included; - ‘We are very happy with Heatherdale and the staff there.’ - ‘It’s lovely here, mum is looked after, and it’s clean.’ - ‘It’s the little things, a tray set for visitors, the dinner tables are set lovely.’ Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 6 The manager and her team are committed to improving the service provided to people. Staffing levels are appropriate to meet the needs of the service users. A wide range of activities are available at Heatherdale which include group, individual, in- house and out in the community. 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. Heatherdale Residential Home DS0000000532.V257671.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 Residential Home DS0000000532.V257671.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): 3 Service users needs are not consistently assessed before they are admitted to the home. EVIDENCE: Pre-admission assessment documents by the home must be completed as per Company Procedure. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 9 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): 7,8 & 9 Care plans are in place and staff have the information to meet service users needs but personal preferences and financial needs must be identified where appropriate. The health needs of residents are met and multi disciplinary working is taking place. The systems for the administration of medication protect service users. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 10 EVIDENCE: Three care plans were examined and found to be in good detail. The documentation regarding the care of residents is positive. Personal preferences are now being recorded for such tasks as personal care and this must continue as well as for individual social care plans based on interests and hobbies. Care plans are evaluated monthly and reviewed. There is evidence of other professionals being involved. Risk assessments are in place and reviews are held 6 monthly. The requirements regarding the arrangements for the management of medication have been addressed. Staff have also completed 12 weeks on the safe handling of medicines. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 11 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 & 15 Service users are able to maintain relationships which are important to them. Service users receive nutritious meals but the detail on the menus does not reflect the practice of the home. EVIDENCE: Service users are provided with a wide range of activities and occupation inside and outside of the home. Good records are maintained, particularly photographs. Some activities are personal and include reading, washing dishes, dusting and folding napkins. Other activities are more structured and include groups such as Keep Fit with Dave, Angel Feet, Board and floor games. Service users have the opportunity to go out to clubs for Bingo, Church Events and the Friendly café. Trips to pubs, places of interests, parties and entertainers are organised. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 12 Visitors felt they could visit when they wished and were made welcome. Service users are supported to keep contact with people outside of the home. An audit was undertaken of the 3-week menus for the home. The menus have at least 2 courses at lunch and teatime. The menus are nutritious and service users said they enjoyed their meals. The inspector shared lunch with service users. The lunchtime meal choice was roast chicken, Yorkshire pudding, stuffing, carrot, potatoes and gravy or bacon casserole. The pudding was a choice of fruit or apple sponge and custard. Types of in-between meal snacks, fruit and drinks are not recorded on the menus despite a wide choice available at any time. Service users can have anything for breakfast but this detail is not recorded on the menus. The cook demonstrated a good knowledge of dietary needs and fortifying food. Alternatives were available for diabetics, which were not too different from the ordinary menu. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 13 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): 18 Systems are in place to protect service users from abuse. EVIDENCE: Policies and procedures are in place which refer to good practice referring concerns to CSCI, and quality assurance arrangements monitor performance. Whistle blowing procedures and awareness training to staff are in place. Senior staff would benefit from Protection of Vulnerable Adults training in relation to procedures as potential alerters. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 14 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): 19, 21 & 26 Service users live in a home which is suitable for their needs. Improvements have been made to improve the quality of life for service users. EVIDENCE: Wellburn Care Homes Ltd has continued to improve the premises. A tour of the home was completed and the home was clean, well maintained and decorated. Residents and visitors said that the home is always clean. The garden is well tended and an attractive place to spend time in good weather. The home won two local Parish competitions for the garden. The location and layout of the home are suitable for the residents. There is sufficient communal space for 36 service users. The home has a conservatory (used as a dining room), three lounges, a dining room and a pleasant entrance area.
Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 15 The home has adequate numbers of bathrooms and WC’s for the service users living in the home. Twenty-seven bedrooms are en-suite. The bedroom vanity units have been updated and new lights and mirrors put in place. The bedrooms are personal and very cosy. A new walk in shower has been installed. The laundry is clean and good attention to hygiene. The kitchen is showing further effects of wear and tear. Cupboards are broken, paint is chipped and some of the sealants around the sink are compromised. The manager agreed to provide a pedal bin for kitchen waste rather than a flip top for better hygiene. The plan was to refurbish in Spring 2005 but this has not occurred. A new refurbishment date must be provided to CSCI. Two recommendations which were made to improve infection control have been addressed. Paper towels and liquid soap for bedroom sinks where personal care are now provided and plastic covered pull cords are in place in bathrooms and toilets for ease of cleaning. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 16 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): 27-30 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. Service users are protected from potential harm as robust recruitment systems are in place. Service users are cared for by staff that are trained and competent. EVIDENCE: The home maintains the level of staffing in accordance with previous agreements with the local authority and this reflects the size and layout of the building and the needs of the residents currently living in the home. The current levels of staffing are a minimum of 5 care staff on duty during the morning, 4 care staff on duty during the afternoon and early evening and 2 waking night staff. The registered manager is allocated 16 hours off the rota. The home has its own laundry assistant. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 17 The home has 56 of care staff with NVQ Level 2, which is commendable. Two staff are about to commence NVQ Level 3 and one of the seniors is undertaking NVQ Level 4. New staff are provided with a comprehensive Induction programme and policy handbook. The General Social Care Council Code of Conduct is included in February 2005 version. Staff are provided with mandatory training such as First Aid, Food Handling, Moving and Handling and Fire Safety. Senior staff should receive Protection of Vulnerable Adults training in relation to procedures as potential alerters. Staff have completed 12 weeks training in Safe Handling of Medicines. In January 2006 staff will attend a 12-week course on Dementia. In October 2005 senior staff completed Insulin training. Staff recruitment records were checked including Criminal Records Bureau records (CRB’s), Protection of Vulnerable Adults (POVA) checks, references, proof of identity and applications. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 18 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): 31,33,35 & 38 The home is well managed so service users wishes and needs are met. The Registered Manager is updating her training for the benefit of the home. Quality assurance systems are in place, which ensure that the service provided to service users is monitored and improved. Robust arrangements are in place to protect service users from financial abuse. Health and safety checks are monitored which protects service users. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 19 EVIDENCE: The Registered Manager is completing the Registered Manager’s Qualification in management. Wellburn Care Homes Ltd has Quality Assurance systems in place. They have ISO9001/ Health mark Certification and work to the principles of Investors in People Award. Quality Management Reviews are periodically held. Internal and external audits are made which include Regulation 26 monthly visits and reports by the Company’s representative. The home is continually looking to improve the service provided to service users. Service users personal finances that are looked after by the home were checked. Amounts were correct, appropriate records maintained and there are external and internal audits in place. Care plans must be in place for those service users whose finances are looked after by the home. The Fire Log book was examined and fire checks and instruction to staff is in place at the appropriate intervals. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 21 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 OP15 Regulation 16 & schedule 4 23(2) Requirement The menus must be in sufficient detail –1. Snacks and drinks must be on the menu. - 2 Breakfast must be on menus. A deadline for the refurbishment of the kitchen must be provided to CSCI. Repair sealant around the sink area in the kitchen. Care plans must be put in place where appropriate for the arrangements for service users finances. Services users personal preferences in care plans must continue to be identified. Pre-admission assessments by the home must be completed as per Company Procedure. Timescale for action 01/02/06 2 OP19 31/12/05 3 OP3OP35O P7 15 01/02/06 Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 22 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 OP31 OP30OP18 Good Practice Recommendations The Registered Manager should have the Registered Manager’s Qualification in management by end of 2005. Senior staff should receive Protection of Vulnerable Adults training in relation to procedures as potential alerters. Heatherdale Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Residential Home DS0000000532.V257671.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
