Inspection on 18/10/06 for The Heatherfield

This inspection was carried out on 18th October 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

The Heatherfield 14/01/09

The Heatherfield 30/01/08

The Heatherfield 31/08/07

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Heatherfield, The Lee Street Annitsford Northumberland NE23 7RD Lead Inspector Suzanne McKean Key Unannounced Inspection 18th October 2006 09:30 X10029.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 Heatherfield, The DS0000065065.V321874.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 and Care Homes for Adults 18 – 65*. 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. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heatherfield, The Address Lee Street Annitsford Northumberland NE23 7RD 0191 250 4848 0191 250 2424 paul.herrity@theheatherfield.com 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) DAV Developments Limited Mr Paul Fergus Owen Herrity Care Home 54 Category(ies) of Dementia - over 65 years of age (34), Physical registration, with number disability (20) of places Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three people can be admitted between the age of 60 and 65 years within the DE category of registration Date of last inspection Brief Description of the Service: The heather field is a purpose built home completed in 2006. The room dimensions are in excess of the minimum current standards. It is of traditional brick build design with a tilled apex roof. The home provides accommodation on two floors, both of which have lounges, dining rooms and bedrooms as well as toilet and bathroom facilities. The home is in situated in Annitsford, North Tyneside. It is a predominantly residential area of the small village between Dudley and Cramlington. There are shops in the village as well as public houses and restaurants. Access to the building is through the private car park in the foyer / reception area through eclectically controlled double doors. The lifts to the upper floor are in the central area and at the cross section of the building. The outside of the home are turfed, paved and landscaped. The outside of the building is to be developed further to include a barbeque area in time for the summer. The home is registered to provide care for two categories, Dementia Care Elderly aged over 65 years and Physical Disability aged under 65.years. The Dementia Care Elderly is provided on the first floor and Physical Disabled is provided on the ground floor. The home charges fees of between £395 and £684 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a total of 10 hours during three visits. Ten residents and four staff were spoken to at some length and others chatted to briefly. Five relatives were spoken to directly as they were in the home. Six care plans, and records for medication were examined. Also staff files, training records and health and safety documentation was looked at. This was the first inspection of the service since it was registered so there have been no requirements made at previous inspections. This is a mixed category home accommodating both older people with a dementia and younger adults for which different standards apply. The report takes this into account the different standards, which apply to these groups. Where information relates specifically to one of the groups it will be stated, other comments refer to the whole home and both of the units. Three requirements were made as a result of this inspection however one was repeated in the requirements section of the report at it refers to both of the client groups so has to be made for each group. What the service does well: What has improved since the last inspection? It is the first inspection of this newly registered service. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted into the home after they have had a detailed assessment by the home staff. This then forms the basis for the development of the care plan. Residents are given information to show that they can be cared for by before they move in and there is a service user guide and statement of purpose available. The home does not offer intermediate care. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 9 EVIDENCE: Each resident has a contract which gives the terms and conditions of the stay in the home. This included the accommodation to be provided, fees, care and service provision, additional services, and rights and obligations for both the resident and the home. The unit manager carries out a detailed assessment before the prospective resident is admitted into the home. The home use the assessment from the care manager or nurse assessor to determine if the potential residents needs can be met before anyone is admitted to the home. Potential residents are encouraged to visit the home before admission. They are able to visit for part of a day and have a meal with other residents and join in any activity event in the home. A perspective resident’s families were visiting during the first inspection visit. Residents spoken to had been given information prior to arrival to held them to make their decision. All residents have a six-week trial period after which a multi disciplinary review is held with the resident and their representative. Following the review the decision to stay in the home is then made. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 (Older people) 6, 9, 16 19 & 20 (Adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All resident have an up to date care plan and the personal and general health care is given as it describes in these plans. The care plans on the older persons dementia care unit are not in sufficient detail regarding their mental health needs. The social care element of the assessment and care planning is not detailed enough on both units. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 11 The younger adults are being supported to continue with their life goals and to take risks as part of their life choices. The residents are having their needs met. They are being given their care with courtesy and in privacy. The residents receive their prescribed medication according to safe working practices. The medicines in the home are well managed. EVIDENCE: Residents have a care plan which includes a detailed assessment and a plan of care. Six care plans were looked at closely during the visit and were a good standard. Relevant risk assessments are completed for, prevention of falls, wound care, moving and assisting, and continence promotion. There is an assessment to look at resident’s food and fluid intake. If a resident has any unplanned weight loss a plan is drawn up to address this. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. There are no residents currently in the home who have pressure damage wounds. All of the care plans show that the personal and health care needs of the residents are being met. The care being given during the visits also showed this for personal and health care areas. The younger adults unit are particularly involved in developing their care plans. This was shown clearly in the documentation and the residents confirmed it. The care plans showed that they were being supported to continue with their life goals including education and they are assisting them to adapt to their changing personal needs. The care plans on the older person / dementia care unit are not completed in sufficient detail regarding their mental health needs. They lack detail of the specific interventions required to meet the behavioural needs of the residents particularly those presenting challenging behaviours. Social assessments in the care plans on both units were brief and did not describe fully the resident’s social needs. The planning in this area was therefore not in sufficient detail to reflect the way the resident would have their social needs met. There are a number of social opportunities available in the home and this is not fully reflected in the individual care plans. The residents were dressed for the activities they were undertaking and looked smart and tidy. The ten residents who were able to speak to me were positive about the care being given. Comments made included “we get good care here” Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 12 and “the staff are very kind”. Two different relatives on the older persons unit said that the staff provide “good care” and the other said, “the staff are very good and well led” Medicines management was appropriate. The staff record the medicines correctly when they are ordered. The prescriptions are then checked when they are received in the home from the General Practitioners and are then sent to the Chemist for dispensing. The medicines received from the pharmacy are checked against the record of what was ordered and prescribed so that any errors can be picked up. Medicines no longer required are disposed of safely. No resident on either of the units manage his or her own medication, this is due to the particular needs of the current resident group. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 (OP) 12, 13, 15 & 17 (Adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are offered some social activities and are encouraged to take part in those they find interesting and able to take part in, and this is being developed further. The residents are being encouraged and supported to maintain contact with their families. The residents are given a balanced, nutritious diet given at appropriate times in a pleasant environment. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home has previously employed an activities co-ordinator however this individual is no longer in this post and the Manager has recently appointed a replacement. There is some evidence of planned activities advertised throughout the home however this is not happening enough to meet the social needs of the residents. There are plans to assess, plan, record and evaluate the social activities in a more individual way for each resident and this will ensure that there is a more specific social plan developed. A lunchtime meal was observed on the first visit the main choice at lunchtime was well presented served at the appropriate temperature and tasted pleasant. Alternatives were offered for both the main mean and the pudding/sweet. The residents were complementary about the food during the mealtime and appeared to enjoy it. The morning drinks offered a varied selection of drinks. There was tea, coffee, or cold drinks of either juice or milk. There were biscuits provided. The younger adults congregated mostly in the dining room and there was a pleasant atmosphere and residents were chatting with staff and visitors. The bedrooms are of a very high standard, they are personalised according to the taste of the resident. Six residents from both units said they were happy with their rooms and that they had a lot their own personal items around them. Residents have visitors at any time and are able to use their own rooms, or the lounges to see them. Three relatives said that they are welcomed into the home. Residents said they were happy with the arrangements for visitors. Residents said, “ not much going on, we listen to music and watch television but there is nothing much organised” Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 (OP) 22 & 23 (A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and relatives know about the complaints policy and how they would make a complaint or give their views. There is a system for managing and dealing with complaints. The residents are protected form abuse by staff training, recruitment and selection and effective documentation and training. EVIDENCE: The complaints procedure is available in the service users guide and a copy is displayed in the home. There has been one complaint recorded since the home was registered. The record of complaints made and investigated was looked at. These were detailed and included the outcome and the action taken in response to the investigations. The records were dated and signed by the manager. Three relatives who were visiting the home were aware of the complaints procedure but had not needed to use it. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 16 Staff are given protection of vulnerable adults training both as part of the inhouse training package. There have been two protection of vulnerable adults investigations undertaken since the home was registered. One of which was alerted by the hospital following the admission of a resident. The outcome of this was that the home did not act inappropriately in delivering the residents care. The second was an example of internal whistle blowing that the home reported to the POVA team themselves. The investigation has been concluded. No regulatory action was necessary by the Commission for Social Care Inspection. The Manager provided additional supervision and support to the staff involved as a preventative strategy. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 (OP) 24 & 30 (A) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has been constructed to a high standard in excess of the National Minimum Standards. The decoration is excellent and the building was designed to take advantage of good natural light. The building is safe and well maintained. The home is clean and well organised and the staff are knowledgeable regarding the ways to prevent the risk of cross infection in the home. A Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 18 recommendation has been made for liquid soap, disposable hand towels and foot-operated bins to be put in the on-suites. They are already provided in the communal areas. EVIDENCE: A tour of the home was conducted both with staff and alone; the home is clean and was odour free on the day. The building has been constructed to a very high standard. The corridors and room sizes are larger than the National Minimum Standards suggest and there is an emphasis on natural light. The lounges and dining rooms are very well designed with large open windows making the best of the surrounding views. The home is very well decorated and maintained. The home is very well decorated and maintained. The Manager is aware of the need to have a strategy to deal with any wear as and when it occurs. Bedrooms are large, well decorated and furnished and offer a good personal space. The residents’ and relatives who were asked about the bedrooms said they were very happy with the decoration and that they were kept clean by the staff. The laundry was clean, organised and well equipped. The laundry staff use gloves and aprons as necessary. There are sufficient washers and dryers, for the number of residents in the home. The washer has a sluice facility. The laundry is equipped with a roller press and domestic type iron. The sluices were tidy and clean and the disinfectors operational. Staff follow infection control policies and use appropriate equipment. The kitchen area was clean and well organised and there is an up to date cleaning schedule which identifies all areas to be cleaned, how often they are completed and who was responsible for undertaking it. There are two bathrooms and one shower on each floor and there were tidy and clean. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 (OP) 32, 34 & 35 (A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective recruitment and selection system, which ensures that residents are cared for by well-trained, skilled staff and are in safe hands. A varied programme is in place to provide a large spectrum of both clinical and statutory areas of training. EVIDENCE: Staff records are completed according to the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check is applied to all of the staff in the home. At the first visit three staff files examined did not have the second reference in place, Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 20 they were relatively newly recruited staff. The system for monitoring the references received suggested that they had been received back but could not be found. By the last visit these had been obtained and were in the staff files. The home must have two written references prior to staff commencing their employment. During the visits to the home there were sufficient staff to meet the needs of the residents including qualified nurses, carers, domestic and catering staff. The Manager was available for the second visit allowing the examination of confidential records. The training records were looked at. There is training in both statutory and clinical areas and staff are given training in line with the company policy. Training provided includes Health and Safety, induction, first aid, medicine awareness training, food hygiene and infection control. Fire training was not fully up to date but the training arranged for November will address this. Moving and handling training has been provided to the staff and ongoing updates have been arranged for November and December. 73 of the care staff have achieved National Vocational training level 2 or three and a programme is in place for others to complete at level 2, 3, and 4 depending upon the training needs of the individual staff member. There is four staff currently studying at N.V.Q. level 4. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 (OP) 37, 38, & 42 (A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 22 Mr Herrity, the Manager has put in place systems manage the home effectively taking into account the needs and wishes of the residents. The home has effective health and safety systems, which include staff training and risk assessments. There is a programme in place for staff supervision, which has just been implemented as the home is newly registered. Resident’s personal finances are managed appropriately. EVIDENCE: There is a system and records to review health and safety; it involves the staff. There are records of some staff meetings and the contents suggest that there is broad spectrum of relevant issues discussed. The Manager continues to consult the residents, staff and other interested parties to review the service provided and manage the staff in a way to improve care delivered. There are plans to undertake resident and relative satisfaction surveys in the future. The manager does regular tours of the building himself when he speaks to residents and relatives, however he relies on the unit Managers to ensure that quality indicators are looked at as part of their management role. There is an audit programme including care plans, medication administration and the kitchen, as well as accident analysis for each of the units. Staff meetings are conducted for qualified and care staff as well as the other ancillary staff. The fire records are up to date and the training is being provided to staff as necessary and there is a fire risk assessment. There is a procedure in place for undertaking staff supervision. This will include delegating the role of supervisor to the relevant senior staff, which will require them to have initial training. Some of this has been done. The supervision programme has been commenced and will continue as planned. The personal records kept in the home of residents who are receiving assistance to manage their finances were examined and are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. Heatherfield, The DS0000065065.V321874.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 3 2 3 3 3 4 3 5 3 6 N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 4 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 24 No applicable 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 OP7 Regulation 15,17 Requirement Timescale for action 01/01/07 2. OP12 16 (2) (m) (n) 3. YA14 16 (2) (m) (n) 4. OP29 19 The care plans on the older persons / dementia care unit must be completed in sufficient detail to reflect the mental health needs of the residents. Social activities must be offered 01/01/07 to residents according to their expectations and preferences and in line with their abilities and needs. Social activities must be offered 01/01/07 to residents according to their expectations and preferences and in line with their abilities and needs. The home must obtain two 01/12/07 written references before staff commence employment. 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 OP26 Good Practice Recommendations It is recommended that the residents on-suites are DS0000065065.V321874.R01.S.doc Version 5.2 Page 25 Heatherfield, The provided with liquid soap, disposable hand towels and a foot operated bin in line with control of infection advice. Heatherfield, The DS0000065065.V321874.R01.S.doc Version 5.2 Page 26 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. 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