Inspection on 13/09/06 for Heatherwood

This inspection was carried out on 13th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Heatherwood 01/11/07

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 Heatherwood Heatherwood 33 Station Road Orpington Kent BR6 0RZ Lead Inspector Wendy Owen Key Unannounced Inspection 10:00 13 September 2006 th 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 Heatherwood DS0000067234.V297289.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. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heatherwood Address Heatherwood 33 Station Road Orpington Kent BR6 0RZ 01322 868684 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) mandy.knighton1@virgin.net Chislehurst Care Ltd Ms Sally Ann Perry Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration of Ms Sally Ann Perry as the manager at this home and Ashling Lodge, 20 Station Road, applies to Ms Sally Ann Perry only and is subject to ongoing assessment by the Commission through the statutory inspections of both homes. February 2006 Date of last inspection Brief Description of the Service: Heatherwood has recently changed ownership to Chislehurst Care Ltd. It was first registered in April 1987 to provide care for eight older people. Heatherwood is an older style, three-storey house which has been converted to provide residential care. It is very conveniently situated for shops, transport and other local facilities very close to Orpington town centre. The home has a lounge, dining room, kitchen, bathroom/toilet and one double bedroom on the ground floor. On the first floor there is a second double bedroom and four single bedrooms. Bathroom facilities on this floor include a separate toilet with a rail surround and a wash hand basin next to a bathroom with a walk in bath and toilet facility. The administration office is located on the third floor with a flat occupying the remainder of the floor. To the rear of the property there is seating on a veranda overlooking an enclosed garden. The Manager of Heatherwood also manages another of the Providers home Ashling Lodge which is located opposite this home. There are carers and an administrator working in Heatherwood. There are no ancillary staff employed. A Service Users Guide is available for all residents. Whilst this is not up to date it does contain the information on what the home has to offer. The fees range from £345.36-£515 per week. Personal expenditure such as toiletries, clothing, newspapers and private healthcare is not included in the fee. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection included written feedback from four relatives and two residents and discussions with seven residents at lunch and four in a group in the lounge. The inspector also spoke to the Manager, Nurse Director and two staff, viewed records and undertook a tour of the home. The home is full with eight residents. Many of the requirements remain outstanding from the last inspection and are identified in the requirements section of this report. However, there is evidence that the new Provider and Manager are working towards meeting these. What the service does well: What has improved since the last inspection? Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 6 Whilst the last inspection had not raised any requirements regarding the long term assessment/care planning and risk assessment information. the inspector has noted improvements in these areas. The systems are clearer and identify most of the areas of identified need in the long- term assessment information. The lack of activities provided for residents has been an area required for improvement in the last few reports. It is positive to note that there is clear evidence that the Manager and Provider have also identified this and are beginning to address this situation with planned activities. Since the last inspection last inspection the Providers have also implemented their policies and procedures in respect of medication practices. Record keeping has improved as has the practice. There are however, still some areas required for further improvement. Previously training of staff had not been a priority for the Provider. However, there is evidence that the new Providers are placing more emphasis in this area as a way of ensuring staff meet individual needs, are aware of health and safety requirements and are able to safeguard and protect the vulnerable adults in the home. What they could do better: The home must ensure that where prospective residents are being placed by the Local Authority they obtain a copy of the Care Manager’s full assessment on the individuals needs and any care plan required. The Manager must also ensure that once they have assessed the resident and agree that they are able to meet their needs this is confirmed in writing. The new Providers must ensure that residents or their representative is supplied with a copy of the terms and conditions for the individual and where the Local Authority has the responsibility for the placement, a copy of the Placement Agreement must also be obtained. Whilst care plans and assessments had improved there is still some areas which must be addressed to ensure all the identified needs are known to staff and recorded together with the actions they are to take to address these needs. The feedback from relatives show that they are unaware of the care planning and reviewing procedures and have had little involvement in this area. Previous comments have shown that there have been improvements in the provision of stimulating activities for residents. Residents and relatives’ Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 7 feedback have confirmed this. However, there is capacity for further improvements. One resident wrote that they “Can find it boring at times”. Medication procedures have also improved but there are core areas affecting the health and safety still requiring attention. More local procedures also need to be developed. Overall the health and safety of the home is adequate, although there are some shortfalls in the chlorination testing, testing of the hot water temperatures and servicing of the fixed wiring in the home. The Manager is also responsible for producing the home’s fire risk assessment. This remains outstanding from the last inspection. The recruitment of new staff is an area of concern with less than robust practices in place. This must be addressed without delay. Previous reports have required the home to provide core training to staff. Moving and handling, infection control and First Aid remain outstanding as does the need for the home to develop more comprehensive adult protection procedures. 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. Heatherwood DS0000067234.V297289.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 Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives are not provided with the full information to enable an informed choice to be made nor does the home obtain all the information required to ensure they are aware of the full needs of the individual where placed by the Local Authority. The lack of individualised contracts means that residents may not aware of the terms and conditions of residency. EVIDENCE: A Statement of Purpose and Service Users Guide has been developed in line with the change of Provider and Manager. However, these need to be further updated as some areas are not specific to Heatherwood and may give the wrong information to individuals viewing the document. From the information viewed the inspector notes the philosophy of care is for the home to take pride in the way they care: privacy, respect, independence, dignity and equality. (See requirement 1) The home now has procedures in place reflecting the change of Providers. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 10 Since the last inspection the home has admitted one resident with records viewed showing that an assessment was made prior to admission and details recorded. However, as the resident is funded by social services the Care Manager assessment must also be obtained. There was no written confirmation that, after assessment, the home is able to meet the resident’s needs. (See requirement 2) The Provider has developed terms and conditions of residency for residents. A template copy is available in the Service Users Guide. Discussions with the Manager showed that individual terms and conditions were not in place at this moment in time as the Head Office is still processing them, nor was there a placement agreement, in the case of the social services funded resident. (See requirement 3) The home does not admit residents for intermediate care. Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. 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. The health and wellbeing of residents is adequately met although improvements are required to ensure staff have the full information required to meet their identified needs and medication practices are improved to ensure health needs are fully met. EVIDENCE: Since the last inspection last inspection there has been a change in the Provider and with this has come a change in the way records are written and maintained. The home now uses the standex system for care planning and this has shown to be an improvement on the way care plans had previously been developed. Two residents’ files were viewed and found to contain the basic information of the long-term assessment, care plans and risk assessments. Both were found to need falls risk assessments, which the inspector is aware has recently been developed by the organisation. One of the files did not contain a risk assessment in relation to pressure care, even though there are issues which would mean the resident in question is at risk. Both contained moving and handling risk assessments reflecting the current needs and both contained a nutritional risk assessment. However, both stated Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 12 that there was cause for concern but no action or intervention had been detailed. There was evidence, particularly in one file, showing some problems in this area and the home working towards the resident’s improvement. The care plans covered personal care, social activities and mobility. However there were, in both residents cases, issues over continence and healthcare which had not been identified eg anaemia, UTIs, hypertension. These must be addressed together with the interventions required from the risk assessments, if any. There was some evidence of the resident or the relative signing the assessment but feedback from relatives showed that they were not aware of what the care plans were or any involvement in reviewing their relatives care. The home has not had a keyworker system in place previously and this is one of the areas that the Manager is currently addressing. (See requirement 4 & 5) All residents are registered with a local GP who visits the home regularly. It was difficult to see from the records what access to healthcare occurred, with the exception of the GP visits. The daily records showed a District Nurse visit to one of the residents. However, to identify all appointments, visits etc it would mean going through all the daily records to see when other visits took place. A simpler and more organised record must be maintained to enable staff and other agencies to view access to healthcare. It was also evident from a very small number of relatives providing feedback that staff are not always aware of their role in monitoring and referring on healthcare needs or how their healthcare affects their general day to day well-being. (See recommendation 1) The home now has more comprehensive procedures in place for the ordering, receipts, administration and disposal of medication. Development of more local procedures is now required to provide guidance on the home’s practices in line with the organisation procedures. Medication practices have also improved since the last inspection with records for receipt and administration clearer and more organised. Receipt of medication is now entered onto the medication record with amount, date and initials of the two staff signing in the medication. There were some gaps in this, particularly where medication had been prescribed mid cycle and had not been recorded in nor was the hand transcription countersigned. However, the medication records were generally complete with full details including any known allergies or, if none, known this was also recorded. To ensure safe storage of medication the Manager must ensure that the keys are maintained by the designated person in charge for the shift. It was positive to see all medications with an expiry date had the date of opening recorded and that medication amounts were carried forward each month to ensure accountability. Where medication is prescribed, “as required” the Manager must ensure that there are clear guidelines for their use. In the case of “prn” tramadol, guidelines for when the medication is to be given must be recorded to provide staff with the necessary guidance. No residents self medicate at present and nor are any residents prescribed controlled drugs. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 13 A list of staff authorised to administer medication must be produced together with their signatures and a homely remedies policy must also be developed and agreed by the GP. (See requirement 6 and recommendation 3) The previous inspection report showed that hairdressing of all residents took place in the double room on the ground floor. The Manager and Nurse Director have tried to accommodate this elsewhere but space, especially on the ground floor is very limited. The Manager is to discuss the use of the residents’ accommodation with the residents affected and their relative to gain possible agreement for this use. Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. 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 are now provided with some activities which provide them with a more stimulating environment. The food provided is of a good quality with adequate choice and quantity and served in a relaxed and pleasant environment. EVIDENCE: The previous inspection reports have all highlighted the need to provide residents with activities and stimulation. With the change of Provider and Manager there is evidence that there has been significant improvement in this area. Residents and a relative spoke of entertainment arranged in the home, regular bingo and movement to music. Staff spoken to also appeared to have found this to have a positive impact, not only for residents but for their working day. It is apparent that the Manager is leading this and that there is capacity for improvement in this area, particularly staff being proactive and creating and participation in activities to stimulate body and mind as well as interacting with residents. This will ensure that staff become focussed on the individual rather than the tasks to be completed. Heatherwood has always maintained good relationships with family members and visitors and this continues. Relatives wrote of being welcomed into the Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 15 home and friendly staff. One relative was visiting their family member on the day of the inspection and joined them in the game of bingo being held. The care staff continue to prepare and cook meals for the residents. This is highlighted on the roster. The Manager is developing new menus inline with the choices offered by the sister home opposite (Ashling Lodge) and therefore printed menus have not yet been produced. Another reason for the delay is the lack of administrator employed, until very recently. The choices for the day were two meat dishes. There are no residents with special diets or vegetarian needs. Residents were spoken to during the lunch and all said that the food was good or excellent. The generally clean plates confirmed this. Soft drinks and condiments were available during the meal which was taken by most of the resident in the dining room. From the records viewed one resident had recently suffered with a poor appetite. There were few records relating to this and the record of food taken was variable. There was no evidence of food supplements being supplied or provided. Where there are issues with eating or drinking the home must ensure that the records detail actions taken and how the nutritional needs are being met including wherever possible monitoring of the residents’ weight and appropriate action. (See requirement 4) Heatherwood DS0000067234.V297289.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 inspected at least once during a 12 month period. 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. may not be fully protected or safeguarded. Residents and relatives feel that their concerns are listened to and acted upon to ensure improvements in the care are made. However, the lack of comprehensive procedures and guidance for staff means that vulnerable residents. EVIDENCE: Heatherwood has a complaints policy and procedure which meets with the regulations. A copy of this is in the Service Users Guide but is not on display anywhere in the home. Residents spoken to said that they felt the Manager to be very approachable. This was confirmed by the written feedback from two residents and four relatives and the verbal feedback from one relative. The pre-inspection questionnaire and records viewed on the day show that there have been no complaints raised nor has the Commission received any information regarding concerns about the quality of care. There is a system for recording and investigating complaints if they do arise. (See recommendation 2) The last inspection required the home to develop more comprehensive adult protection procedures. There was evidence of a very basic procedure and whistle-blowing policy. This is not sufficient to give staff the information and guidance they require in the event of management of incidents or allegations. (See requirement 7) However two members of staff spoken to were clear in what they would do given a certain scenario and had some understanding of Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 17 other agency involvement and the possible consequences to staff if found guilty of any such offence. Although this must be further clarified to ensure all staff have this knowledge and understanding. There is also evidence that staff including new staff are provided with information on adult protection through the use of a DVD and questionnaire to be completed at the end to test their understanding. Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Heatherwood provides individuals with a homely and comfortable environment to live in. It is reasonably maintained, clean and fresh. EVIDENCE: Heatherwood offers a small, homely and comfortable environment for residents. A brief tour of the premises showed them to be well maintained and reasonably decorated and furnished. The bedrooms, two of which are double, are personalised and have furniture and furnishings of a good quality. The shared rooms have screening for privacy. The home is very clean and fresh. The laundry has a washing machine and tumble dryer of industrial quality, although the washing machine does not have a sluice facility there is currently no identified need for this. The home should however consider the purchase of such a machine. There is a need, however, Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 19 for clinical waste disposal sacks to ensure continence pads are disposed of with regard to infection control. (See requirement 8) The home has one bathroom and one shower room. Standard 38 comments on the need to ensure the hot water is tested to ensure it meets the health and safety regulations. There is no lift in the home and the new Providers are in the process of obtaining a quote to have a stair-lift fitted. This would be beneficial to the residents who struggle with their mobility. Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. 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. The recruitment procedures are not robust enough to safeguard the vulnerable people living in the home and the lack of core training or NVQ qualification means that staff do not always have the knowledge and understanding to provide a safe environment for residents and themselves. EVIDENCE: During the daytime two staff members undertake care, ancillary tasks and activities and one member of “waking staff” and one “sleep in” at night. The “sleep in” is provided by a member of staff working at another of the Provider’s homes. There is no roster showing this and no records in relation to the member of staff. The Provider must show how they are providing appropriate staffing levels at night, including the cover for when the individual living in the flat is not able to provide the “sleep in” and records as required by Regulations. Rosters must include management hours and sleep in. (See requirement 9) The files of the last three members of staff recruited were viewed. There is a need to ensure a more robust system is implemented and for the Manager to ensure the checks undertaken by the Head Office are supplied to the home. There were gaps in references in the three files viewed, lack of exploration of inconsistencies in the application form, incomplete application form and evidence of working in the care sector but not detailed on the application form. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 21 There was also a lack of interview schedule in two cases. There was no verification in respect of one staff member in their previous care employment. The files did, however, contain proof of identity, health declaration and, in some cases certificates relating to training undertaken. (See requirement 10) Induction training is mainly provided via videos. This is not always the most beneficial way of training staff, especially where there is a need for a competent person to provide training and a need to determine competency in the practice eg moving and handling/hoist training or whether clarification is needed in particular areas. Adult protection and infection control guidance is provided at this stage. The home must review their induction training to ensure it meets Skills Sector specifications. One file contained staff orientation for Fallowfield but not for Heatherwood. There was no orientation records on the two other files viewed. (See requirement 11) Staff files were viewed along with supplementary training records. There was evidence of food hygiene training, although not recent and First Aid although for some this had expired. Moving and handling and infection control training was required at the last inspection and remains outstanding. This must be addressed without delay. There is evidence of some training taking place, including two staff on safe administration of medication and one member of staff currently undertaking indepth health and safety training. One member of staff has undertaken the four- day First Aid training. The Manager and Provider should consider the use of the Skills Sector website which provides details of infection control, dementia and medication training and guidance for staff. (See requirement 12) Two staff have NVQ 2 or above. This falls well short of the 50 required. (See requirement 13) Heatherwood DS0000067234.V297289.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new Manager has the knowledge and experience to ensure a good, consistent standard of care is achieved and there is a capacity for such improvement. However, the lack of information in relation to quality assurance systems means the Providers may not always recognise or address the shortfalls in the care provided. EVIDENCE: The Manager has recently been registered with the Commission to manage Ashling Lodge and Heatherwood. She is qualified with NVQ 4 in Care and has achieved the Registered Manager’s Award. She has made a positive impact on the home with one relative saying that the home is more organised and business like but also improvements have been made in core areas, such as activities. Residents, staff and a relative spoke of how approachable she is and Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 23 they would have no difficulties in raising any concerns. Staff told the inspector of how supportive she has been and how well the change has been managed. “Not too quick giving us time to understand what we have just been told.” This has worked well with many staff remaining yet changes occurring where required. There is still capacity to improve and the inspector is of the belief that the Manager, at this stage, is able to make these changes to improve the lives of the residents, given time. The Nurse Director makes monthly visits to the home as required by Regulation 26. These visits are to monitor the systems and the quality of care, taking into account residents and staff views. The Commission is receiving the written reports on the findings of the visits and they reflect the stage at which the home is at with the change of Provider. However there is little other evidence of quality assurance taking place. The Nurse Director has been made aware of the requirements during inspections of other homes within the organisation. (See requirement 15) The home does not manage individual residents’ monies. Any purchases are made by the home with the agreement of the resident or family and the person responsible for the finances is invoiced each month. A record of the expenditure is made and receipts maintained by Head Office to enable audits to take place. The new administrator is still “getting to grips” with her role and therefore a further and fuller examination of the practices will take place at the next inspection. A number of records were viewed in relation to the health and safety of the home. These were found to be in the main satisfactory although the fixed wiring required examination, chlorination testing is required and the hot water must be tested regularly to ensure it discharges within the required range. (See requirement 16) The records pertaining to the fire safety were in place and included testing of the fire alarm weekly and regular drills carried out. Fire extinguishers had been serviced in February 2006 and a new fire panel recently fitted. Fire training must be documented for staff and night drills must be undertaken in line with the fire authority guidelines. Although the Provider is currently looking to a professional to develop a fire risk assessment for their homes in light of recent changes to the fire regulations the manager must also in the meantime develop risk assessment to ensure the current safety of the home. (See requirement 17) Heatherwood DS0000067234.V297289.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 2 2 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 4 Requirement The Registered Provider must ensure the Statement of Purpose contains information which reflects Heatherwood. Specifically, the staffing and organisational structure must be accurate. The Registered Person must ensure the home obtains the assessment from the Care Manager or other professional where placements are funded by other agencies. The Manager must confirm upon assessment that they are able to meet the needs of the prospective resident. The Registered Person must ensure the home provides residents with the terms and conditions of residency and where funded by other agencies the placement agreement is also obtained and provided to the resident or their relative. The Registered Person must ensure the care plans reflect the support required to meet the DS0000067234.V297289.R01.S.doc Timescale for action 01/12/06 2 OP3 14 01/12/06 3 OP2 5 01/12/06 4 OP7 15 01/12/06 Heatherwood Version 5.2 Page 26 5 OP8 13 6 OP9 13 7 8 9 OP18 OP26 OP27 13 13 18 10 OP29 17 & 19 identified needs of the residents. Review of care plans must be undertaken in consultation with the residents and/or resident representative. The Registered Person must ensure that risk assessments are developed for pressure care and, where risk assessments identify a risk, appropriate interventions or actions required by staff to minimise the risks are recorded in the individual’s care plan. The Registered Person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medication. Specifically, procedures must be developed for local arrangements; all medication must be recorded when received into the home; a list of authorised signatures with initials must be developed; as required administration guidelines must be provided; and keys to the storage of medication must be kept safe. Timescale expired 04/06 The Registered Person must develop comprehensive adult protection procedures. The Registered Person must ensure all clinical waste is disposed of safely. The Registered Person must ensure rosters detail the working hours of all members of staff. Including night staff and the Manager. Timescale expired 04/06 The Registered Person must ensure recruitment procedures are robust. Specifically, the information required under Schedule 2 of the Regulations is obtained and maintained in the DS0000067234.V297289.R01.S.doc 01/12/06 01/12/06 01/12/06 01/12/06 01/12/06 01/12/06 Heatherwood Version 5.2 Page 27 11 OP30 18 12 OP30 18 14 OP28 18 15 OP33 24 16 OP38 23 home for all new staff. Timescale expired 04/06 The Registered Person must ensure all staff new to the home undertake specific induction of the home and ensure induction training to Skills Sector specifications is provided. A record of this training must be maintained for each individual member of staff. The Registered Person must ensure all staff are provided with core training and this training is updated regularly. Specifically, staff must received First Aid, moving and handling, food hygiene and infection control training. Training must be provided by a competent person, particularly for First Aid and moving and handling. Timescale expired 04/06 The Registered Person must ensure they meet the requirements to have 50 of care staff qualified to NVQ 2. Please supply an action plan without delay on how this is to be met. Timescale expired 04/06 The Registered Person must ensure any review of the quality of care includes consultation with service users and their relatives. The Commission must be provided with a copy of the report written detailing the outcome of the review and, if any, the action plan to address the shortfalls identified. The Registered Person must ensure that regular testing of the water tanks is undertaken; the fixed wiring is examined to ensure it continues to meet the standards and the hot water is tested regularly to ensure it DS0000067234.V297289.R01.S.doc 01/12/06 01/12/06 01/12/06 01/12/06 01/12/06 Heatherwood Version 5.2 Page 28 17 OP38 23 discharges within the required temperature for safety. The Registered Person must develop a fire risk assessment pertaining to the home which identifies any risks and how the action the home is taking to minimise the risks. Timescale expired 04/06 01/12/06 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 2 3 Refer to Standard OP8 OP16 OP9 Good Practice Recommendations The Registered Person should develop another format for recording individual residents access to healthcare. The Registered Person should place a copy of the complaints procedure clearly on display for residents and visitors to view, if required. The Registered Person should ensure there are two signatures where hand transcriptions are made on medication records. Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Heatherwood DS0000067234.V297289.R01.S.doc Version 5.2 Page 30 - 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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