Inspection on 08/11/05 for Heatherway Resource Centre

This inspection was carried out on 8th November 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heatherway Resource Centre 17/05/07

Heatherway Resource Centre 09/08/05

Heatherway Resource Centre 04/03/05

Heatherway Resource Centre 26/11/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Heatherway Resource Centre 11 Heatherway Monks Hill Estate, Selsdon Croydon Surrey CR2 8HN Lead Inspector Lee Willis Unannounced Inspection 8th November 2005 02:30 Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 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 Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Heatherway Resource Centre Address 11 Heatherway Monks Hill Estate, Selsdon Croydon Surrey CR2 8HN 020 8657 7763 020 8651 1374 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) London Borough of Croydon Ms Susan Marie Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Heatherway Resource Centre is owned, managed and staffed by the London Borough of Croydon. The Centre is registered with the Commission for Social Care and Inspection to provide temporary respite care for up to five younger adults with learning disabilities. The duration and frequency of service users stays varies considerably, along with their needs, which ranges from moderate to high. Need is determined by an assessment carried out by Care Managers representing the Local Authority. Sue Smith continues to be in operational dayto-day control of the Centre, which she has managed for the past five years. This two-storey detached building is situated in the heart of Selsdon and is well placed for accessing local amenities, including shops, cafes and public transport links. The property comprises of five single occupancy bedrooms, one of which is located on the ground floor, to meet the needs of service users with physical disabilities. There is also a staff sleep-in room on the first floor. Other rooms in the house include a large L shaped lounge/dining area, a separate kitchen, and laundry facilities. There are sufficient numbers of toilets and bathrooms located throughout the premises to meet service users needs. The gardens at both the front and rear of the property are well maintained. A concrete ramp with suitable grab rails attached ensures the centres entrance is accessible for wheelchair users. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 2.30pm and took three hours to complete. As this inspection did not finish until after 5pm the Commission considers it an out of hours visit. It was the Centres second unannounced visit of the year. The Commission has not received any more comment cards in respect of the service since it was last inspected in August’05. The majority of this inspection was spent talking to the centres registered manager, several of the staff on duty at the time and two out of three of the service users who were staying over that night. The rest of this inspection was spent examining records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: The two service users met during this visit said they were both extremely ‘happy’ with the care they received during their short stays at Heatherway. Furthermore, both service users said all the staff working there were extremely caring and kind. The staff team has changed very little in the past twelve months, which ensures the service users receive continuity of care from a small group of well trained and dedicated support workers who are familiar with their unique needs, wishes and preferences. The two members of staff who noted discrepancies in the information received by the centre in repesct of a service users medication are commended for the prompt action they took to resolve the matter. It was also evident from comments made by service users and care practises observed that staff continue to actively encourage and support the service users to maximise their independence and make as many ‘informed’ choices as practicable during their time there. Both the service users spoken with said they could choose what they ate and did while at Heatherway, and that staff always took their wishes and feeeligns into account. Care plans sampled at random were all very person centred and contained detailed information about each individual service users needs, wishes and preferences, which included food likes and social interests. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 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. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The centres Statement of purpose and guide provides prospective new service users and their representatives with all the information they need to know about the suitability of the project, although this document will need to be amended to ensure the format is far more accessible for the people for whom the service is intended. EVIDENCE: The Centres Statement of purpose and service users guide contains all the information prospective new service users and their representatives need to know about the facilities and services provided. The manager explained that the centre was waiting for the bedrooms to be redecorated before updating its guide so these environmental changes could be incorporated into the document. The manager is very keen for all the service users who access the centre are provided with up to date information about Heatherway and that this information is presented in a format which they will be able to understand. It was therefore agreed that the previously agreed timescale for action to be taken to address this shortfall would be extended to the New Year while the bedrooms were repainted. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans accurately reflect the service users personal, social and health care needs, as well as their likes and dislikes, ensuring staff can plan for and met them. Suitable arrangements are in place to ensure service users who are willing and able to take responsible risks are allowed to do so. EVIDENCE: Two care plans in respect of individuals who had arranged to stay the night were inspected in some depth. Both plans were extremely detailed and contained up to date information about these individuals’ personal, communication, dietary, mobility, supervision and recreational needs, to name but a few areas covered. During this afternoon/evening visit the manager was observed handing over information to the two staff who had just arrived for the late shift about the needs and wishes expressed by the three service users who were staying over that night. Care plans sampled at random had all been reviewed in the past twelve months and updated accordingly to reflect service users changing needs. The manager explained that the process of up dating all the service users care plans was almost complete with only one plan now overdue its annual review. It was noted that this particular individuals name Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 10 was conspicuously displayed on a notice board in the office as a reminder to staff that this persons care plan was now overdue its annual review. It was positively noted that in accordance with the centres philosophy of care staff continue to actively support service users who choose to manage their own spending money during their time at the centre. This is based on a thorough assessment of the individual’s needs, wishes and capabilities. As a precautionary measure staff always keep a signed record of the exact amount of money all the service users bring with them when they first arrive at the centre, which also includes all those who wish to look after their own finances. It was positively noted that risk assessments were in place, which detailed all the action to be taken by staff to minimise any identified risks and/or hazards. As previously mentioned, handover was extremely comprehensive and it was also evident from conversations with both staff working the late shift that they had been made fully aware of the needs, wishes and possible behaviours of all three of the service users who were staying over that night. Furthermore, it was positively noted that the evening meals each service user had chosen from the published menus early that day had also been passed on to staff working the late. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 & 16 The number and range of social, leisure and recreational opportunities the service users have to engage in, both at the centre and in the wider community, are extremely varied and evidently based on their individual preferences. EVIDENCE: All three of the service users currently residing at Heatherway returned together in a taxi around 4pm having all spent the day at the same day centre. One service user spoken to at length said they were not aware of any restrictions on visiting times and felt sure her friends could come for a visit if they wished. This same service user said she had been given a key to lock her bedroom with, if she wanted. The centre has a non-smoking policy and service users and staff spoken with at the time were all very clear that anyone who chooses to smoke may do so in the confines of the back garden. The two service users who were relaxing in the lounge watching television having just returned from their day centre both said they liked staying at Heatherway because there were always plenty of things to do. One service Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 12 user pointed the games cupboard in the lounge and said she particularly enjoyed playing Bingo. It was positively noted that the walls of the lounge were covered in pictures drawn and/or painted by the service users, as well as photographs taken of numerous day trips and parties. A member of staff was able to point out all three of the service users who were staying over night at the centre in these photographs. This same member of staff said day trips to the south coast continue to prove very popular with most of the service users, especially in the summer months. It was positively noted that the one service user who chose to spend a lot of their time at the centre in the privacy of their bedroom was allowed to do so. Staff said that this particular individual, who was not met during the course of this inspection, would be invited to join everyone at the dining table for the evening meal. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The centres policies and procedures for dealing with medicines, which includes the receipt, recording, storage and administration of medication, are sufficiently robust to ensure the service users are protected. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 14 EVIDENCE: One service user spoken with at length said that they are able to go to bed when they liked and choose what activities they participated in at the centre. This individual said they liked watching soap operas on television and that they were looking forward to seeing Emmerdale Farm that evening. The centres accident book revealed that none of the service users had been involved in any significant incidents in the past twelve months. Consequently there has been no unplanned admissions to accident and emergency during this time. The manager and staff on duty at the time were all very aware that the occurrence of any significant event in the home, including any accidents, allegations of abuse, fire and/or theft, must always been reported to the CSCI without delay. Only one of the service users who were staying over at the time of this inspection was prescribed any medication. It was noted that all the medication received into the centre was being securely stored in a locked cabinet in the first floor office. Appropriately maintained medication administration records were available on request which showing staff always cross reference the information displayed on medicines received each service users individual medication administration sheets. The two members of staff who recently noted that the dosage highlighted on a bottle of medication they received did not match the information displayed on the individual service users medication administration record are commended for their diligence. The two members of staff who discovered the error immediately contacted the service users next of kin to clarify the situation. These members of staff are highly commended for talking such prompt actoin to resolve this matter. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The centre has a complaints policy and service users met were confident that any concerns they had would be taken seriously by staff and acted upon. Furthermore, suitable arrangements are in place to enable service users who are willing and capable of retaining control of their own spending money, to do so, ensuring they are, so far as reasonably practicable, protected from harm/abuse. EVIDENCE: According to the centres official complaints log no formal complaints or concerns have been made about centres operation in the past twelve months. One service user met said staff always listened to her point of view and she felt able to talk to any of them about any concerns or problems she might be experiencing, either at Heatherway, her home, or even the day centre. There have never been any allegations of abuse made within the home, although the manager was very aware of his responsibilities in relation to vulnerable adult protection procedures. The manager was very clear that Croydon Social Services and the Commission would be notified without delay about any allegations of abuse. The centre looks after any service users money who is not willing and able to manage it themselves. The balance entered on one service users financial record sheet tallied with the amount held in the centres safe on the individual’s behalf. This money was kept secure in a separate purse for the individual. As previously mentioned in this report, service users who are willing and able to manage their own spending money are encouraged to do so. In order to minimise the risk of service users experiencing financial abuse staff always Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 16 record the exact amount of spending money each service user brings with them when they first arrive at the centre, which includes those individuals who choose to look after their own money. Receipts are retained for all the goods and services purchased by staff on service users behalves. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 27, 28 & 30 The overall layout of the centre, which is furnished and decorated to a reasonable standard, ensures the service users have a comfortable environment in which to stay. The arrangements the centre has in place with regard infection control are sufficiently robust to protect the health and welfare of the service users, their guests and staff. EVIDENCE: There have been no significant changes made to the physical environment of the centre since its last inspection. It was positively noted that a time specific rolling programme to redecorate all the bedrooms has now been agreed with the Local Authority. The manager was able to produce a letter on request confirming that the Council planned to start painting the centres bedrooms early in the New Year. Progress made on this matter will be assessed at the centres next inspection. The manager also said that service users would be surveyed about which colours they would like the bedrooms to be painted. One service user met said they would like one of the bedrooms to be painted green. It was also positively noted that as required in the centres previous report all six of the service users bedrooms and the staff sleep-in room have been provided with new mattresses and bedsteads. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 18 Having tested the temperature of water running from the hot tap attached to a first floor bath it was found to be a safe 42 degrees Celsius at 14.04. The Centre has a corporate contract with a local water company who check the centres thermostatic mixer valves on a monthly basis to ensure hot water temperatures never exceed 43 degrees Celsius. Furthermore, staff keep a record of weekly hot water temperature checks. The Centres kitchen remains hygienically clean and suitably equipped for storing and preparing food. However, as highlighted in the centres previous report the entire kitchen, especially the storage units, have all seen better days and will need to be replaced sooner rather than later. Nevertheless, these units continue to be suited for there stated purpose and the manager is confident that some money will be set aside in the forthcoming financial year to have the entire kitchen upgraded. Consequently, the recommendation made in the centres previous report is merely repeated in this one and progress on this matter will also be assessed at the centres next inspection. Having toured the premises it was found to be spotlessly clean. The Centres washing machine has a sluice programme and is capable of thoroughly cleaning foul laundry at appropriate temperatures, in accordance with infection control guidelines. It was positively noted that clinical waste previously stored in a laundry basket lined with a black bag in the ground floor bathroom has now been replaced with a more suitable container, which meets infection control standards. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 & 36 Service users continue to benefit from being supported by a relatively small, suitably competent and stable staff team, who are familiar with the service users unique needs, wishes and preferences. Sufficient numbers of staff must up date their basic food hygiene training to ensure service users are protected from avoidable harm. EVIDENCE: The manager stated that three out of five of the centres permanent staff team have now achieved a National Vocational Qualification in care, Level 2 or above and that the other two were currently studying for theirs. Consequently, the centre has met Government training targets for support workers by ensuring that at least 50 if its staff team, excluding the manager, have achieved the aforementioned award. The manager was able to produce documentary evidence of this training on request. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 20 There have been no changes made to staffing levels since the centres last inspection, which remain extremely flexible, in order that the centre can meet the ever-changing needs and numbers of the service users. At the time of this inspection two members of staff, including the manager were working the early shift and two other members came on duty to work the late shift and receive a handover before the service users returned from their day centre. A minimum of two staff, one of whom was going to be sleeping in, is adequate to meet the assessed needs of the three service users who were going to be staying that night, all of whom had been assessed as having ‘moderate’ needs. Staff turnover has been extremely low in the past twelve months and consequently the manager has not needed to recruit any new members of staff since the centres last inspection. One member of staff spoken with said all the staff had now worked together for sometime and had built up a good team spirit in the process, consequently staff morale continued to remain high. The centres staff team have attended a number of core training courses that are relevant to the work they are perform, including fire safety and prevention, first aid, moving and handling, and basic food hygiene. However, as pointed out in the centres last report, although all staff had attended a basic food hygiene course, not all had done so in the past three years, country to food hygiene standards. The manager said she had raised the matter with the local authorities training department and arrangements had now been made for this training shortfall to be addressed by April 2006. Consequently, the requirement made in the centres last report is not considered unmet. The requirement is merely repeated at the end of this report with the previous timescale for action extended. The staff files for one member who was on duty at the time of this inspection contained the minutes of three formal supervision sessions they had with the centres manager since August 2005. This number exceeds national minimum standards regarding the frequency of staff supervision, which must be at least bi-monthly, for which the local authority and the Manager are commended. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 In the main the fire safety arrangements are sufficiently robust to ensure potential risks to service users, their guests and staffs health are, so far as reasonably practicably, minimised. The results of any quality assurance surveys undertaken by the centre should be published to enable service users and their representatives to assess and monitor them. EVIDENCE: The centres long standing manager, Susan Smith, has been in operational day to day control of Heatherway for the past five years and is consequently very familiar with the organisations policies, individual service users needs, as well as staff strengths. The manager holds a qualification, which is equivalent to an NVQ level 4 in both the management and care. There are clear lines of accountability within the local Authority and the manager says her line manager is always on hand to offer support and advice as and when required. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 22 The centre continues to ask the service users for their comments at the end of their stay which are used to monitor the centres performance. The manager says the results will be available to anyone who requests them, but they are not necessarily published. It is recommended that the outcome of these survey and satisfaction questionnaires are made more widely available and the results published in the centres new service user-friendly guide. The fire extinguisher attached to the wall at the top of the stairs had been checked by a suitable trained professional in the past twelve months in accordance with fire safety legislation. The fire exit signs in this area were also clearly visible easy to read and follow. The fire exit door located in the first floor sleep-in room has been fitted with a push bar device for ease of access purposes. The fire escape route (external metal staircase) at the rear of the property were unobstructed and appeared to be in a good state of repair. A fire officer from the London Fire and Emergency planning Authority last visited the centre in August’05 at the local authorities request and no requirements or recommendations were made in the subsequent report for the centre to act upon. Nevertheless, the Commission still recommends the centre should consider fitting effective smoke seals around all fire resistant doors as an extra protection, even if the fire door closes flush into its frame. It was positively noted that the centre has already agreed to fit textile covers over all the centres fire extinguishers to minimise the risk of one service user pulling the extinguisher rings off. Progress on this matter will be assessed at the homes next inspection. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 3 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heatherway Resource Centre Score 3 3 4 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000039508.V265210.R01.S.doc Version 5.0 Page 24 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 YA1 Regulation 12(4)(b) Requirement Timescale for action 01/03/06 2. YA35 18(1) The Centres guide must be amended to make it far more ‘friendly’ and therefore ‘accessible’ for the people for whom the service is intended, (i.e. Be written in plain English and illustrated using pictures, photographs and symbols, where appropriate). Previous timescale for action of 1st October 2005 not met. Sufficient numbers of staff must 01/04/06 attend a refresher course in basic food hygiene. Documentary evidence of this training must be avialable for inspection on request as proof of compliance. Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 25 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 YA28 Good Practice Recommendations Serious consideration should be given to establishing a time specific rolling programme to replace all the Centres old kitchen units. This recommendation is carried over from the centres last report. The results of all the quality assurance surveys/questionnaires undertaken by the centre should be pushed and made more accessible to all the relevant stakeholders. The Commission suggests using the service users guide to publish these results. Serious consideration should be given to fitting effective smoke seals around fire resistant doors, even if they close flush into there frames. 2. YA39 2. YA42 Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heatherway Resource Centre DS0000039508.V265210.R01.S.doc Version 5.0 Page 27 - 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. 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