Inspection on 31/08/07 for The Heatherfield

This inspection was carried out on 31st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

The Heatherfield 14/01/09

The Heatherfield 30/01/08

The Heatherfield 18/10/06

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 31st August 2007 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.V349241.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.V349241.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.V349241.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 18th October 2006 Date of last inspection Brief Description of the Service: The Heatherfield is a purpose built home completed in 2006. Bedroom sizes are bigger than those stated in the current minimum 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 Annitsford, North Tyneside which is a 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 reception area through eclectically controlled double doors. There are lifts to the upper floor are in the central area and at the cross section of the building. The outside of the home is turfed, paved and landscaped. The home is registered to provide care for two categories, dementia care for older people (on the first floor) and people who have a physical disability who are under 65 (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.V349241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 18th October 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 31st August and further visits were made on 12th, 17th & 24th September 2007. During the visit we: • Talked with people who use the service, relatives, staff, the manager & visitors. • Looked at information about the people who use the service & how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe & comfortable. We told the manager what we found. What the service does well: The homes has been built and furnished to a very high standard and the decoration is excellent. It is clean and well organised and staff know about how to reduce the risk of cross infection and the right equipment is used by staff to achieve this. The home is well staffed and the home has a pleasant atmosphere. Residents and staff talk to each in a friendly and caring way. People living in the home have an up to date care plan. Their care needs are met by following the guidance given in their plan of care. This was supported by relative’s views, one said, “her husband was well cared for and his needs met” and a resident said, “Staff are always helpful and provide emotional support”. The younger adults are being well supported to continue with their life goals and to take everyday risks as part of their life choices. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 6 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. Heatherfield, The DS0000065065.V349241.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.V349241.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): 3 & 6 (Older People) 2 (Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient information is made available before admission to enable people to make an informed decision about using the service. And, admission processes and assessments are well developed to enable staff to determine the right type of care to meet individual needs. The home does not offer intermediate care. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 9 EVIDENCE: The senior staff carry out a detailed assessment before the prospective resident is admitted into the home. The home uses 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. Residents said they had been given information before they arrived in the home to help them to make their decision as to if they wanted to move in. 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.V349241.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) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning is well developed and person centred and enables staff to meet the needs of residents in a way that promotes choice, dignity and risk taking. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 11 EVIDENCE: People living in the home have a well written plan, which includes a detailed assessment and a plan of care to be given. Relevant risk assessments are in place 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. All of the care plans show that the personal and health care needs of the residents are being met. Residents access NHS services and facilities as necessary and are supported to do so by the home. The care plans show that specialist advisors are used for individual residents as necessary. There is a physiotherapist employed by the home who works predominantly with the younger adults. He does however offer some support to all of the residents in the home particularly when looking at their moving and handling needs. The care being given by the staff is appropriate for personal care and health care and the staff deliver the support in a professional and courteous manner. An example of the positive comments from a resident was, “Staff are always helpful and provide emotional support”. The younger adults unit are particularly involved in developing their care plans. This was shown clearly in the documentation and the resident’s views confirmed this. 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 now completed in enough detail regarding their mental health needs. They were positive about the care being given. Comments made included “the staff look after us here” and “things in the home are good”. Two different relatives on the older persons unit said that the staff provide “good care” and the other said, “the staff well organised and the deputy is really good at managing her staff” 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.V349241.R01.S.doc Version 5.2 Page 12 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 (Older People) 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. Residents are offered social activities according to their preferences and abilities but this is not fully developed to make sure that they live satisfying and fulfilled lives. They are well supported and given encouragement to maintain contact with their families and friends. The food is balanced and nutritious but some need to be helped to make choices about what they eat and drink. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 13 EVIDENCE: There are some planned activities but this is not happening enough to fully meet the social needs of all of the residents. Although improved, the social part of the care plans is not yet detailed enough although and needs to be more individual for each resident. This will make sure that residents have their social needs met regardless of the stage they are at in their illness or their physical limitations. A relative said, “ there is not much going on, we tend to spend time in my relatives room, watching television but there is nothing much organised”. This varied between the two units and the younger persons unit was noted to have activities going on much of the time and they were enjoying taking part. The food looked well presented and at the appropriate temperature and tasted good. There was an alternative choice for the main course however all but one of the residents in the upstairs dining room was given the same meal of the same portion size with all of the same vegetables. It is unlikely that all of the residents would have chosen this selection. It was evident by the amount of food left on the plates that they some were served things they did not like. The home needs to have a better system for making sure that the resident are offered choice. It is acknowledged that this is a challenge for this client group and may need to be tried in different ways to select the most appropriate method for this home. A resident said he did not like the meat being served and there was no alternative meal available for him, he was eventually given the meal with all of the vegetables, with the meat removed. The residents were offered choice for the pudding/sweet. The residents were complementary about the food during the mealtime and appeared to enjoy it. Some did say that it had been “a bit hit and miss some days”. However the employment of new kitchen staff has resulted in improvements to the quality of the food being served. 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. 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. The relatives said that they are welcomed into the home. Residents said they were happy with the arrangements for visitors. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 14 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 (Older People) 22 & 23 (Adults) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints procedures are effective and people using the service know how to access them to raise concerns. However, some situations have left people at risk of harm where safeguarding procedures have not been adequately followed. EVIDENCE: The complaints procedure is available in the service users guide and a copy is displayed in the home. Complaints recording is appropriate and records of those investigated were detailed and included the outcome and the action taken in response to the investigations. The records were dated and signed by the manager. Relatives and people living in the home were aware of the complaints procedure. The process that was undertaking in response to a recent safeguarding adults investigation was examined. This was alerted as a result of two residents Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 15 making allegations about a member of staff. It was taken to the North Tyneside adult protection team and looked at as part of their procedures. It is acknowledged that there were problems with the external part of the process and this resulted in some delays in the progress of the investigation and some concerns about the communication between the external organisations involved. These are being looked at by the relevant organisations. The home was asked to undertake an internal investigation into the allegations, that had been made and report the finding to the Safeguarding strategy meeting. We looked at the records of this investigation as part of the inspection, in line with the Commission for Social Care Inspection responsibility make sure that the care home is conducted so as to promote and made proper provisions for the health and welfare of the residents are to make sure that the are protected from harm. There were insufficient records to demonstrate that an adequate investigation had taken place. There was also inadequate records of the risk assessment and plan to make sure that the agreed action plan for the staff involved was being followed in relation to both the level of supervision and the agreement as to the temporary restrictions in their working practice. During the second visit the manager was asked for a written report of the investigation and this was provided at the next visit. This could not be viewed as a comprehensive investigation but was an overview of the decisions that had been made. The care plan of one of the people living in the home contained an instruction to staff, which would have restricted the resident from meeting with his Social worker without the presence of a member of staff. This was put in place without discussion with the resident their family or the social worker. This was discussed the senior representatives of the home and it was agreed that is should be removed as it was in breach of their right to privacy and compromised their ability to have their wishes and feelings taken into account. The safeguarding adults policy and procedure were completed just as the inspection was completed and a copy of this was sent to the local authority adult protection team for their views. Once it has been finalised the manager has plans for it to be implemented and staff training provided. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 16 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 (Older People) 24 & 30 (Adults) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was built to high standards and the decoration is excellent. It is safe and well maintained, clean and well organised. The staff are knowledgeable about how to reduce the risk of cross infection in the home and the appropriate equipment is available for them to achieve this. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home is clean, well decorated and odour free. 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 using natural light particularly in the lounges and dining rooms. The lounges and dining rooms are very well designed with large open windows making the best of the surrounding views. 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. It continues to be well maintained and the staff are aware of health and safety issues so are vigilant about ensuring there are no risks to the people living in the home. 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. There are now facilities in all of the bedrooms for staff and residents to wash and dry their hands using liquid soap and disposable hand towels. Flip top bins are also now available. There are two bathrooms and one shower on each floor and there were tidy and clean. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 18 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 (Older People) 32, 34 & 35 (Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of skilled competent staff at such times that meet the needs of the residents, and there is an effective recruitment and selection system, which ensures that staff are employed in an effective way. The training programme is not up to date is being reviewed to make sure that staff are competent and confident in the work they do. EVIDENCE: 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. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 19 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. The manager is currently reviewing the training programme in the home and has organised for an independent training company to undertake a skills analysis. This will be a varied programme to provide a large spectrum of both clinical and statutory areas of training. The home also uses Northumberland Care Alliance for some of the training programme. 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, although some statutory training is not up to date (see standard 38). Seventy three per cent 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 are a number of staff who are currently studying for N.V.Q. at levels according to their current level of achievement. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 20 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, 15 & 38 (Older People) 37, 39 & 42 (Adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 21 There have been recent management changes and the new manager is aware of the action needed to make the necessary improvements needed to ensure a better quality of life for people living there. EVIDENCE: Mrs Jones has been appointed as the new Manager and has been in post for a short time. She is aware of the need to register with the Commission for Social Care Inspection. She has experience in care home management but the home is currently in a period of change as there have been a number of changes in senior management. There have been a number of staff changes in all areas of the home and it will need some time for staff to establish to good team working. 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 new manager consults 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 regularly tours of the building to speak to residents and relatives, however she relies on the clinical staff to ensure that quality indicators are looked at as part of their 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 training provided for first aid, moving and handling and fire training is not fully up to date and a number of staff now need to be provided with training to make sure they are working to best practice standards. There is a procedure in place for undertaking staff supervision, however this was not up to date and although it is acknowledged that this most likely been due to recent disruption during the change to the current management team there is a plan to bring them up to date. 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.V349241.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 3 36 2 37 X 38 2 Heatherfield, The DS0000065065.V349241.R01.S.doc Version 5.2 Page 23 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 YA18 Regulation 12 Requirement Resident’s rights and choices must be promoted and protected. Timescale for action 01/09/07 2. OP12 16 (2) (m) (n) 3. OP15 16 Social activities must be offered 01/12/07 to residents according to their expectations and preferences and in line with their abilities and needs. Outstanding from last inspection. Timescale 01/01/07. Meal times must be reviewed to 01/12/07 ensure that residents are supported to make choices about what they eat and drink. Safeguarding adult’s policies and procedures must be in place and evidence of implementation in the home must be provided. The staff must receive sufficient and appropriate training in moving and handling, first aid and fire prevention and action to take in the event of a fire. The manager must submit her application for registration with DS0000065065.V349241.R01.S.doc 4. OP18 13 01/12/07 5. OP38 13 01/12/07 6. OP31 9 01/01/08 Heatherfield, The Version 5.2 Page 24 the Commission for Social Care Inspection. 7. OP36 18 (2) Staff must receive formal supervision at appropriate intervals. 01/12/07 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 OP27 Good Practice Recommendations It is recommended that the manager pursue her plan to review the roles of the staff to improve the lines of communication and clearly identify individual staff responsibilities. Heatherfield, The DS0000065065.V349241.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. Heatherfield, The DS0000065065.V349241.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. 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!