Inspection on 13/10/06 for Heathers, The

This inspection was carried out on 13th October 2006.

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 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

Heathers, The 27/07/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Heathers, The The Heathers 35 Farnaby Road Shortlands Bromley Kent BR1 4BL Lead Inspector Wendy Owen Announced Inspection 13th October 2006 08:45 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 Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathers, The Address The Heathers 35 Farnaby Road Shortlands Bromley Kent BR1 4BL 020 8460 6555 020 8697 6979 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) The Heathers Residential Care Home Ltd Mrs Heather Hall Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 12 Elderly men and women Date of last inspection Brief Description of the Service: The Heathers is two adjoining, older style converted and extended semidetached houses located in a quiet residential area of the London Borough of Bromley. It is within a short walking distance of local shops and public transport. The home is on three levels with service users accommodation on all three, accessed by a lift. There is limited off street parking to the front of the house which has an attractive, well maintained garden to the rear. The home has recently been purchased by new Providers and the previous owner/manager is continuing to manage the home until the end of October 2006. A new manager has been appointed. The staff team remain in post to provide continuous care to residents. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of one day with one inspector undertaking the inspection and for approximately one hour on the second day with two inspectors. The visit included a tour of the premises, viewing of records, discussions with residents, a relative, a member of staff, the Provider and manager and written feedback from six residents and five relatives. The inspector also observed practices. This key inspection is the first one since the change of Providers. Some, but not all, of the requirements arising from the last inspection have been implemented and therefore some remain outstanding. There is evidence that the Provider is aware of what is required to address any shortfalls. What the service does well: The written and verbal feedback received from residents and relatives was unanimous in its praise of the high quality of care provided by The Heathers and in particular the management of the home. They mention the very good care with kind and supportive staff. One relative wrote: “The Heathers is the best residential home I have ever visited……..I cannot fault her or her staff. It is a joy to visit The Heathers.” Whilst another wrote “The dedication, commitment and understanding of the staff to our father has meant such a lot. Myself plus my sisters and our families consider the care at the Heather to be the nearest thing to our father being cared for within a family setting. We consider that Heather hall provides the highest possible standard of care in everyway.” “Wonderful care and support” said one resident “They will do anything for me. Most helpful and kind.” The home ensures residents access the appropriate healthcare with positive feedback from health professionals. It is clear from the feedback that the home promotes residents independence. A resident spoke of how he was able to come and go as he pleased, visiting places whilst another told the inspector that staff do not take over when assisting with tasks. A relative wrote “I have been extremely impressed with the homes attitude to maintaining my fathers quality of life.” Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 6 Routines are flexible with residents choosing when to get up and go to bed, how they wish to spend their days. There are scheduled activities which stimulate the mind whilst general interaction and communication forms part of the way in which people are involved, valued and kept in touch with what is happening. One resident wrote “Heather tries to create a homely atmosphere where no-one is left out.” The home provides “Good home cooking. Always presented nicely and hot and cold as appropriate.” All residents reported favourably on the food provided in surroundings which once again promote interaction and discussions in an informal yet pleasant environment. The Heathers offers a warm and comfortable environment to residents which values the importance of personal belongings and mementoes making a homely feel. The home is “spotless” said one resident. Without exception feedback showed the Manager to be approachable and listens to concerns. “she provides the human touch that makes the residents lives so much more meaningful and gives reassurance and peace of mind to their families.” What has improved since the last inspection? What they could do better: The inspection process has shown the home to provide a good standard of care. However, there are areas which need to be addressed to ensure residents are safe and well cared for. The current procedure for assessment of prospective residents does not ensure that the full information is available for staff or to determine that the home is able to meet their needs. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 7 The medication practices require changing to ensure staff only sign that medication has been taken when they have observed this to be the case. Healthcare records must be maintained in a format which allows easy access and examination and with care plans reflective of the support required at that time. The complaints procedures require amending to ensure residents, relatives and visitors are aware of how to make a complaint and what can be expected of the home and Providers in managing the complaint. The inspector also recommends a more formal approach to recording and investigating complaints. Adult protection procedures should also include details of the actions the home will take if a member of staff is to be reported to the protection of vulnerable adults register. The staff roster must be fully completed with full names of staff and their designation and must include which member of staff is the person designated to manage the shift. Training for all staff must be improved with induction training provided to new staff which is fully documented and meets Skills Sector specifications. Ongoing training must also be provided and core training including that which requires updated should not be allowed to lapse. The home addresses many of the health and safety issues. However, there were gaps, including lack of regular weekly fire checks and appropriate number of fire drills for night staff. Systems for monitoring and improving the standard of care have not been implemented. Previous reports have detailed the need to implement a system for reviewing and improving the quality of care. This has not yet been addressed. The inspector also recommends that the system for ensuring expenditure on residents’ behalf is reviewed to ensure full and complete records are in place. 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. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 8 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 Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5,& 6 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home’s pre-admissions procedures require some improvement to ensure that staff have all the information recorded to ensure individual needs are met without reliance on word of mouth. The lack of documentation relating to residents’ property means that there is no accurate record maintained and therefore lack of security of property. EVIDENCE: One resident wrote of the admissions process that, “Heather was very welcoming on my visit and made me feel that I would be living in my own home.” The majority of residents were aware of contracts for their care provision being in place. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 10 Two files were viewed in relation to assessments, contracts and supporting documentation. The manager has discontinued the assessment form used previously. This is disappointing, as this required little improvement to ensure more information on the individual’s needs were recorded. The home now writes the information in a narrative form as part of the daily record. This is not formal, although provides some good information and staff did have a good understanding of the individuals needs and likes and dislikes. However, this method of assessment means certain information may be left out of the assessment. The manager should provide an assessment based on the areas covered in standard 3. In one case, where social services were responsible for the placement, the assessment obtained was very limited. (See requirement 1) It is clear from the feedback that, where residents are not able to visit the home prior to admission, families often are. However, there is little information on the residents’ property brought in to the home on admission. The files viewed contained contracts which had been signed by the resident or relative. Where social service are involved in the purchase of care the placement agreement must also be obtained. (See requirement 2) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff provide a good standard of care based on individual needs. However, the care planning and supporting documentation and medication administration procedures do not match the standard of care. This means there is a potential for the health needs of the residents not to be met. However the capacity for improvement is good with the inspector expecting the required improvements in a short period of time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident wrote of staff “They will do anything for me. Most helpful and kind.” A relative wrote of “the relief and peace of mind at finding “The Heathers” to care for X…. We consider that Heather Hall provides the highest possible standard of care in everyway. She also provides the very important “human touch” that makes the residents lives so much more meaningful …” Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 12 Discussions with residents showed that staff have a good understanding of their needs including likes and dislikes. The manager is currently implementing a new care planning system, which when viewed for two residents, contained a good deal of information on their health, personal and social care needs. Not all residents have benefited from this new system and the manager must ensure that the “old system” is in place until implementation of the new format. This must be accessible to staff to ensure care needs are being identified and adequately met. (See requirement 3) The care planning documentation included supporting risk assessments on falls, moving and handling, pressure care and nutrition. This is good practice. There is evidence that, in one case, the nutritional assessment was not reflective of the current needs of the resident. The assessment noted no issues and low risk but viewing of other documentation showed concerns over weight loss etc. One resident is quite independent and is able to come and go as he pleases. This is very positive and ensures independence is promoted. An assessment of risk must be completed to ensure all areas of risk are covered and strategies are in place in case the resident does not return when expected. (See requirement 4) A resident wrote “ I am very pleased with the care and treatment here.” Whilst to the residents spoken to said they were very happy with the care and support provided and the residents written feedback also supported these findings. Whilst in practice the standard of care is good and health needs are being met the lack of supporting records which are easily accessible, such as details of healthcare access eg dentist, optician and chiropody and lack of records in relation to individual weights means that the home cannot easily identify when visits were last made or if there is a problem with the residents’ weight which may require the home to take action. Much of the information is passed on verbally which means that some information may be missed. The new care planning system allows for recording these details, although this has not yet been utilised. (See requirement 5). The District Nurse visited on the second day to provide flu jabs to residents and take further examination eg blood pressure and weights. The daily record showed positive feedback from a consultant regarding the good care provided by the home. One relative wrote that, The Heathers “….gives reassurance and peace of mind to their relatives. We are extremely confident that any matters to do with medical attention are dealt with swiftly and efficiently.” Another wrote that “ re my relatives health problems, Heather has bent over backwards to get this diagnosed and treated as soon as possible.” A resident wrote “ I have a sore right hand upper jaw which Heather has kept an eye on it ie sending me to the dentist and getting the doctor in. And now has arranged for me to see a consultant. Wonderful care and support.” Medication practices were audited and found to be, with the exception of one area, satisfactory. Medication administration records (mar) were fully completed and medication, in the main recorded in. There were two signatures where medication is hand transcribed. The inspector observed a member of staff undertaking medication administration. The practice showed that staff Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 13 sign that the medication has been taken prior to the resident actually taking it. On that morning night staff had dispensed the medication into a pot, signed for it and then the resident refused. The “mar” showed the medication to be taken, although there was a note to alert staff of the issue and the medication was kept stored in the cabinet with no name. This raises risks with potential to affect the health of the resident. One resident self-administers medication. This is shown on the “mar” with records of when the medication is distributed to the resident (with amounts and date). The medication is stored securely in the resident’s room. There is also a risk assessment and confirmation from the GP that there are no risks. The “mar” also showed that there is a monitoring procedure to ensure medication is taken. Some, but not all staff, have received medication training. One member of staff stated that they would like to undertake some training and suggested the safe administration of medication through a college distance-learning course. The recent pharmacy audit showed that the systems in place were satisfactory. They did however, recommend that a min/max thermometer be purchased for the medication fridge. (See requirement 6) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,& 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ independence is promoted with flexible routines. Individuals are stimulated through regular activity and day to day interaction. The quality of food is of a good standard. This ensures that residents nutritional needs are being met along with their emotional and mental well-being. EVIDENCE: The feedback from residents included discussions with three residents and written feedback from six. All the feedback showed that the quality of food to be of a high standard. One resident wrote of the standard of food as being “excellent” whilst another said “very good food with lots of variety.” It was clear from the observations on two days that, residents’ routines are flexible. Breakfast is served on trays in bedrooms when the resident gets up. The inspector saw staff preparing individual trays at various times throughout the morning. Main meals are served at set times in the dining room or, if preferred, in the resident room. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 15 Care plans viewed that had been completed showed that residents are able to take baths or showers when they wish. Heather tries to create a homely atmosphere where no one is left out” said one resident whilst a relative wrote “I have been extremely impressed with the home’s attitude to maintaining my fathers quality of life. They allow him freedom to come and go as he pleases, with his own front door key.” Of the six residents who provided written feedback five said there were always activities on offer and one said sometimes. Scheduled weekly activities include a weekly art and exercise class. Some of the art-work has been sold at a coffee morning to raise funds for McMillan nurses! The staff and the manager try and ensure that there is interaction with residents whilst undertaking routine tasks. Occasional activities include the piano playing prior to lunch being served, quizzes, musical evenings with birthdays well celebrated. One resident is going on holiday which he planned. Residents have papers delivered, talking books, musical tapes and a visiting library. Some residents enjoy their own company. It was positive to note that the new care-planning format includes details of the residents’ social history, their likes/dislikes and their interests. This must be continued for all residents and included in residents’ daily lives. The inspector visited one resident who has visual impairment and it was positive to note that she was sat facing the window which to her was particularly beneficial as she was able to see movement outside and the colours of the trees etc. It is clear that staff understand that what they perceive as tasks such as personal care etc are viewed as an activity whereby support can be given, not only in the physical task of assisting and maintaining independence but also the social interaction that occurs between the residents and member of staff at this time. It is also positive that the new providers are looking to increase staffing levels to provide more opportunities for residents to be stimulated and the inspector also suggests that relative involvement would be beneficial. Residents’ feedback confirms the visiting arrangements are not restricted. “Heather looks after the clients, staff, visitors, relatives in a totally professional and friendly manner. I cannot fault her or her staff. It is a joy to visit The Heathers” wrote one relative. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home listens to and acts upon any concerns or allegations raised by individuals and staff are aware of how to protect and safeguard residents. The lack of formal systems detailing the role of the Provider and investigating issues raised means that there is a potential for the resident not to be fully protected and issues not fully resolved. EVIDENCE: It is clear from the relatives’ feedback that the Manager listens to any concerns raised and resolves any issues “without fuss” and within reasonable timescales. One resident said that he felt able to raise concerns and complaints and would not feel intimidated to do so. He also stated that he had choice and that his independence was promoted. Residents’ written feedback showed that most are aware of what to do if they wished to raise concerns. The complaints policy viewed was reflective of the previous provider. This must be amended to provide details of the procedures which include the role of the Provider. As the manager is due to leave by the end of October and a new manager appointed, the inspector hopes that concerns will continue to be resolved effectively. The inspector also requires the new provider to provide details of the amended complaints procedures to residents and relatives in a format appropriate to the individual eg written, Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 17 visual or oral. (See requirement 6) There is a complaints register in which complaints are logged. However, this remains devoid of any complaints. This system may not fully meet the investigatory role, if and when, a complaint is raised. (See recommendation 2) Social services are not aware of any complaints being raised nor are the Commission. The adult protection procedures refer to the Bromley Local Inter-agency guidelines and where these are located. The procedures include, reporting the allegation to the Commission, but does not give any detail about referring to Social Services or the Police. It must also detail the need to refer to the POVA register where investigations have substantiated the allegation. The Commission are no aware of allegations raised through the home, social services or the Commission. Discussions with one member of staff showed them to have a sound knowledge of responding to any allegations raised, including involvement of the police, social services and the Commission. However, the training records viewed showed of the five only one had received POVA training. (See recommendation 3 & requirement 8) The home has developed policies and procedures to ensure staff do not benefit from gifts or are beneficiaries in wills. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,& 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a warm and comfortable environment for residents to live in which is clean and fresh. EVIDENCE: A brief tour of the home showed that it is comfortable and reasonably maintained. Communal and private accommodation is personalised and many of the residents have a very homely and “lived in” feel. There is a need to ensure areas are updated in the decoration. The inspector noted that the sash window in room 5 still requires replacement. (See requirement 9) Discussions with the provider showed that there is an action plan (not yet completed fully in writing) for improvements in some areas. These include a Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 19 seat fitted in the lift; a new cooker, followed by changes to the layout of the kitchen; new washing machine and tumble dryer (the inspector recommended one with a sluice facility). There are plans for easier access to a number of areas internally and externally and for some updates in the bathrooms. It is hoped that next year the windows will be replaced at the front of the home. The home looked clean and fresh with a clean food award being awarded for the kitchen and food preparation. All residents felt that the home was clean and fresh and in one resident’s words “spotless”. There is a need for a washing machine with a sluice facility and for alginate bags to be used for soiled articles. (See recommendation 4) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,& 30 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. Staff are not fully provided with the induction and core training to ensure the needs of the residents are being met and that they are safe. EVIDENCE: The home has not employed any new staff since the last inspection. However, discussions with the Manager showed that she is aware of the experience” student. These included two references, criminal records bureau checks, proof of identity and an application form. Where agency staff are used, the agency provides the service user ie the home with details of the staff member, including a photo, record of experience and qualifications, as well as training undertaken. This is good practice. The agency endeavours to provide consistent staff and this was evident on the day of the inspection. One member of staff who has worked in the home for a period of time is currently waiting permanent employment with the home. This ensures that the home can monitor work and care practices and observe how well they fit into the home and relate to residents. The staff roster for week commencing 9/10/06 was viewed. This was completed in pencil with no full names of staff or designation. (See recommendation 5) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 21 The home has also developed a shift planner which gives staff details of the duties, tasks and responsibilities for that shift. This is good practice. The number of staff with NVQ 2 or equivalent is improving. There are currently eleven members of staff, four have NVQ 2 or equivalent; two are registered for the award and one member of staff is currently studying for a counselling degree and cannot take on any further study at present. There are four staff without the qualification. Training records were also viewed in respect of five staff. Core training includes moving and handling; first aid, food hygiene, health and safety, medication and infection control. Some but not all had received all the training with some, such as moving and handling and first aid, have lapsed. Safeguarding of adults has not been included in the core training, Supplementary training includes chiropody and podiatry care, supervisory development; hospice and cancer care, dementia care and communication in the elderly. Not all files contained certificates for the training undertaken. (See requirement 11) Induction training is still no formalised and therefore it is difficult to judge whether it meet skills sector council specifications. The inspector advises the Providers to view the Skills Sector website for details of what must be included in induction training and also to view the training specification in relation to medication and infection control. (See requirement 10) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 28 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home is well managed the lack of formal systems for managing the home, ensuring the health and safety of individuals and monitoring the quality of care do not ensure that the shortfalls are addressed and care continuously improved upon. However, the capacity for improvement is good with the Providers identifying areas of shortfall. EVIDENCE: This inspection took place during the last few weeks of Ms Hall managing the home. This is difficult time for the home and discussions with a number of individuals, shows she will be sorely missed and that there is concern about Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 23 her departure. It is hoped that the home can continue the good standard of care provided over all these years with the independence and individuality of the residents remaining central to the support provided. “It is like a family” said one resident/relative and this is due to Ms Hall…” The appointment of a new manager means that the home will not be without someone to provide leadership, guidance and support. The Commission awaits the application for registration within the next few months. It is also positive to note that a computer system will be in operation in the near future with access to the internet etc. This will be of great benefit to the administration of the home and will allow for easier updates of policies and procedures as well as daily administration tasks. Previous inspections have shown that there is a lack of any formal quality assurance system in place. This remains outstanding. However, the Provider is aware of this requirement and has plans to implement a system in due course. (See requirement 12) The inspector was able to have discussions with the new Provider and to alert him as to the Providers responsibilities for monthly monitoring visits as required under Regulation 26. Since the last inspection change of provider in the last few months the Commission has not received any reports. The Provider is now aware of the responsibility. (See requirement 13) Service contracts were viewed and found to be generally satisfactory. However the fixed wiring examination was due in August 06 and had not yet taken place. The fire practices were also in need of some improvement. Whilst the fire risk assessment was comprehensive, the weekly checks on the fire alarm system were incomplete with many weeks left unchecked. There was also limited information in relation to fire training which requires an annual update and the number of fire drills for night staff must be increased to four per year. (See requirements 14 & 15) Residents’ monies were also audited and as previous inspections have shown the home does not keep residents’ monies but any monies spent on their behalf is invoiced to their representative. The last report did recommend more clarity in the keeping of records of expenditure. This would ensure a full audit trail. The inspector continues this recommendation. (See recommendation 6) The comments made in the previous outcome group shows that staff receive core training, although this is lapsed in some areas. For example moving and handling; fire training and, in some cases, first aid. It is positive to note most staff have received food hygiene and health and safety training over the last few years. Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X x X 2 3 X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Person must ensure full assessments are undertaken on all prospective residents, prior to admissions. They must confirm in writing that, after assessment, it is able to meet the service users assessed needs. This is a repeated requirement. Previous timescale of 1/4/06 has expired. The Registered Person must ensure all property entering the home is fully recorded. The Registered Person must ensure care plans are in place for all residents identifying their health and social care needs. The Registered Person must ensure a risk assessment is developed in respect of a resident going out independently ensuring there are measures in place in case of the resident going missing. The Registered Person must ensure there are records of residents’ weights and any DS0000067267.V317819.R01.S.doc Timescale for action 01/12/06 2 3 OP37 OP7 17 15 01/12/06 01/12/06 4 OP8 13 01/12/06 5 OP8 17 01/12/06 Heathers, The Version 5.2 Page 26 6 OP9 13 7 OP16 22 8 OP18 13 9 OP19 23 healthcare visits with treatment or action taken. The Registered Person must ensure that medication records are not signed until the medication has been taken by the resident. The Registered Person must ensure that a complaints procedure is reflective of the new providers. The Registered Person must ensure that staff are provided with Protection of Vulnerable Adults training. The Registered Person must repair the sash window in room 5. This is a previous requirement with timescale of 1/12/05 expired. 01/11/06 01/12/06 01/02/07 01/12/06 10 OP30 18 11. OP38 13, 18 12 OP33 24 The Registered Person must 01/02/07 ensure that new members of staff are provided with formal induction training. A record of this training must be maintained. This requirement has not been met. The previous timescale of 1/4/06 has expired. The Registered Person must 01/02/07 ensure staff are updated in core training. This requirement has not been met. The previous timescale of 1/4/06 has expired. The Registered Person must 01/02/07 establish a system for reviewing and improving the quality of care. A copy of any report in respect of any review must provide the Commission with a copy of the report. Any such review undertaken must include consultation with service users. (The remains outstanding from the last inspection. Previous timescale 01/12/05.) Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 27 13 14 15 OP33 OP38 OP38 26 24 24 The Registered Person must ensure monthly monitoring visits are undertaken by the providers. The Registered Person must ensure the fire alarm is tested weekly. The Registered Person must ensure fire drills are undertaken and records maintained as required by the Fire Brigade. 01/11/06 01/11/06 01/11/06 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 OP23 Good Practice Recommendations The Registered Person should provide an action plan for the redecoration of the bedrooms. This should be done in consultation with the residents. There should be a procedure for fully recording any complaints made together with the record of the investigation and outcome with action taken by the home to resolve the complaint of concern. The adult protection procedures should include details of the protection of vulnerable adults register and how to access and make referrals to the register. The home should purchase alginate bags for the laundering of soiled laundry. The staff roster should have the full names of all staff working in the home written in pen with the designation of the worker recorded. When the home makes any expenditure on behalf of residents there must be full records of the expenditure including receipts for all purchases on their behalf. 2 OP16 3. OP18 4 5 6 OP26 OP27 OP35 Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Heathers, The DS0000067267.V317819.R01.S.doc Version 5.2 Page 29 - 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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