Inspection on 18/05/06 for Heatherdene

This inspection was carried out on 18th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Heatherdene 24/03/09

Heatherdene 01/05/08

Similar services:

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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

CARE HOMES FOR OLDER PEOPLE Heatherdene 3 Upper Brook Street Oswestry Shropshire SY11 2TB Lead Inspector Janet Oxley Unannounced Inspection 18th May 2006 9.30 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 Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 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. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heatherdene Address 3 Upper Brook Street Oswestry Shropshire SY11 2TB 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) 01691 670268 01691 662073 Primecare Homes Britannia Limited Mrs Karen Edwards Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Heatherdene is a care home for older people situated in the centre of Oswestry, close to all amenities. The home is registered to provide care for a maximum of 18 service users. The home offers respite and permanent care to male and females over the age of sixty-five. It is a large adapted family house and the first floor is accessed by a shaft lift. The home is owned by Primecare Homes Britannia Limited. The registered manager of the home is Mrs Karen Edwards. The home makes their services known to prospective service users in: The Statement of Purpose, Brochure, Welcome pack and web site which also contain their contact e mail address. The inspection report is mentioned in the statement of purpose and is given out on request. Fees are reviewed annually and range from £315-345. The only additional charges to service users are for toiletries, hairdressing, newspapers and escorting to hospital for routine appointments. This is clearly laid out in the terms and conditions. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, looking at relevant records pertaining to key standards, discussions with residents, district nurse and a visitor, discussions with the staff on duty, discussion with the proprietor manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? All aspects of the paperwork and recording systems continue to be reviewed and updated and amended where necessary in light of the change of ownership. Staffing levels have been improved, all staff have now received training in First Aid and a Training Matrix is now available. Two bedrooms have been redecorated and a number of replacement carpets and laundry equipment has been provided. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 6 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. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 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 Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 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 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which includes all the required information for prospective residents. They may visit the home, stay on a temporary respite basis and also for day care before making a final decision to move. Documentation examined indicated that individuals have a comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Observations and discussions with residents, the manager and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home in a satisfactory and sensitive manner. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff and residents that individual health, personal and social care needs were being met. Residents were being treated with respect and staff were working sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives at the home and visiting health professionals continue to praise the management and care standards there. At the time of this inspection matters pertaining to the administration, recording and securing of medication appeared to be generally satisfactory. All staff who administer medication have undertaken accredited training at a local college. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 10 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): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Heatherdene are flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many activities take place, there is an open visiting policy and the menu offers a choice of well balanced and wholesome meals. EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms, enjoy good meals in the pleasant dining area or in their own rooms and have a number of activities arranged for them within the home and out in the community. Individual needs, likes and dislikes are clearly shown in the care plans. Visitors are always made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors spoken to have been complimentary regarding the quality of life for the residents at the home. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 11 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has a clear complaints procedure which is given to residents and their relatives before they move into the home. One complaint has been received since the last inspection, this was investigated and professionally dealt with. The home has all necessary documentation in relation to the protection of vulnerable adults, this subject is included in staff training and there is written evidence to indicate that all staff have received training in the Protection of Vulnerable Adults. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is generally satisfactory, providing residents with a warm, safe and homely place to live however it was identified and fully acknowledged that a number of improvements need to be made without undue delay. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Bedrooms are personalised and suit individual needs and the gardens and grounds are generally well maintained and accessible to residents and their visitors. At the time of the most recent Fire Officer and Environmental Health Officer’s inspections matters were reported to be satisfactory and recommendations made have been complied with. It was identified that some areas of the home will need refurbishment, repair and redecoration in the near future and it was agreed that a full programme Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 13 and plan for routine maintenance and renewal of the fabric and redecoration of the premises will be forwarded to CSCI within the month and that this will be implemented within timescales agreed. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 14 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): All Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users appear to be supported by a committed staff group who are meeting the needs of each individual in a sensitive and professional manner. They have received mandatory training however 50 of carers have not yet achieved NVQ 2. EVIDENCE: Recruitment at the home is thorough and all elements required by Schedule 2 of the Care Home Regulations were seen to be maintained on the file of the last staff member to be recruited. The management continue to support staff to undertake their NVQ awards and it was reported that 5 staff have recently commenced the NVQ level 2. Unfortunately, due to the turnover of staff, only 4 of the 11 current care staff have undertaken this award. A good variety of other training has been undertaken and staff on duty indicated that they were very sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the management. Recorded staff supervision and appraisals are undertaken. Staff seen and the duty rota indicated that there were generally sufficient staff in numbers and skill mix to meet the service users needs. The manager, 2 carers, one catering staff and cleaner were on duty at the time of this inspection. All care staff are over the age of 18. It was evident that on occasions at the weekends there are only two staff on Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 15 duty to care, cook, clean, and undertake laundry tasks. Given the dependency levels of the service users and size and layout of the building, it was fully acknowledged that this situation should continue to be reviewed to ensure that the critical care role is not impeded and that the service users needs are met. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 16 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home has reviewed all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer, promoting the health, safety and welfare of the residents. EVIDENCE: The home is managed by Karen Edwards, who has twelve years experience of working with older people. She had the equivalent of NVQ level 4 in management and must now complete the NVQ level 4 in care without undue delay. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 17 She is supported by a Deputy Manager and a Team Leader and works along side her staff on a daily basis and ensures her staff have formal and informal supervision. The manner in which the manager and staff responded to this inspection indicated that a sound management approach is in place and that staff are committed to achieving good practice and to developing equal opportunities. Satisfactory quality assurance systems are in place and there was evidence available to indicate the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. All staff have received necessary Health and Safety training, it was reported that a first aider is on duty at all times and the accident records were satisfactory. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 18 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 3 x 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x 3 3 x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 19 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 OP19 Regulation 23(2) Requirement Timescale for action 31/07/06 2 3 OP28 OP31 That a programme and plan of routine maintenance and renewal of the fabric and decoration of the premises be produced and be implemented within stated timescales and records kept. 18(1) That a minimum of 50 of all 31/07/06 care staff be trained to NVQ level 2 in care without undue delay. 9(1)(2)(b) That the manager complete the 31/08/06 NVQ level 4 in care without undue delay. 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 OP27 Good Practice Recommendations That the staff rota be kept under review to ensure that the critical care role of staff is not impeded. Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Heatherdene DS0000065628.V293767.R01.S.doc Version 5.1 Page 21 - 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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