Inspection on 12/12/05 for Heathfield Gardens

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heathfield Gardens 11/06/08

Heathfield Gardens 25/06/07

Heathfield Gardens 02/08/05

Heathfield Gardens 17/01/05

Heathfield Gardens 06/09/04

Heathfield Gardens 17/09/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Heathfield Gardens 163-165 High Street Tibshelf Chesterfield Derbyshire DE55 5NN Lead Inspector Ivan Barker Unannounced Inspection 12th December 2005 02:45 Heathfield Gardens DS0000002058.V272204.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 Heathfield Gardens DS0000002058.V272204.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. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Heathfield Gardens Address 163-165 High Street Tibshelf Chesterfield Derbyshire DE55 5NN 01773 872229 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) MBG Care Services Mr David Ridley Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: The home is situated within the rural community of Tibshelf, Derbyshire, which provides many local facilities. Many of the service users access these local facilities within the village. The home consists of two converted adjoining houses to provide one registered home, which provides nursing care for 10 service users with learning disabilities. There are two lounge/ dining rooms and bedrooms are situated on the ground and first floor. There is the provision of a minibus and local transport. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on several of the ‘key standards’), and the previous requirements. The person present at the inspection was: Mr D Ridley, manager/registered person. Within this inspection, which occurred over a two hour, thirty five minute period, the inspector toured the building relating to the previous requirements, spoke with service users, and staff and examined some documentation. What the service does well: What has improved since the last inspection? What they could do better: The inspector recognised that the service is focused on the delivery of care and service provision and delivers these very well. However the management of the home needs to ensure that the staff receive formal supervision six times a year and provide documentation which supports this action, and the Regulation 26 visit should meet all areas detailed within Regulation 26 of the Care Standards Act. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 6 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. Heathfield Gardens DS0000002058.V272204.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 Heathfield Gardens DS0000002058.V272204.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): EVIDENCE: The key standards were assessed at the previous inspection. Heathfield Gardens DS0000002058.V272204.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): Standards 7 and 9. Service users are able to express their opinion and be part of a decision making process. Their views are considered and acted upon as appropriate. Service users are assessed and allowed to take risks to enhance their quality of life. EVIDENCE: Service user meetings occurred on a regular monthly basis. At these meetings, minutes were recorded. The inspector saw these. There was also evidence that issues and suggestions raised in the meeting had been acted upon. The care plan documentation contained risk assessments, which identified both risk prevention and acceptable risk. The inspector established that one service user required specific equipment and the use of this equipment had been covered by a risk assessment. The inspector was pleased to find that the home had identified that there was a place for ‘acceptable’ risk, as this action did allow service users to live a more ‘normal’ life, beyond the remit of ‘in house care’. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 10 For example, unsupervised or accompanied visits to the village, swimming, horse riding, and local clubs such as model speed boat racing. Heathfield Gardens DS0000002058.V272204.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): Standards 15 and 16. Service users were able to maintain contact with who ever they wished. The staff of the home encouraged social contacted and interaction, which would enhance the service user’s quality of life. EVIDENCE: The inspector established that the service users were able to maintain their contact with friends and family and the home had an ‘open visiting’ policy. Examples given were that members of the service users family visit the home, for tea. Service users visit their family at the family home. The relatives and friends from college attended the Christmas party within the home. Also the service users went on annual holidays either with their family or members of staff. Some service users had keys to their own rooms and their lockable facilities. Service users were addressed, by their first name and the inspector established that this was their wish. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: The key standards were assessed at the previous inspection. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 13 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): Standards 22 and 23. As far as could be established the home took complaints seriously and acted upon the issues. The staff received training, which should make them more aware of Adult Protection. EVIDENCE: The complaints procedure was displayed, and copies made available to relatives, service users, and contracting units. The home had a copy of the local Derbyshire and Nottinghamshire guidelines regarding the Protection of Vulnerable Adults. The home had specific policies for the management of physical and verbal aggression, and possible abuse. Staff training regarding Adult Protection and The Management of Aggression, did occur. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: The key standards were assessed at the last inspection. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 15 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): Standards 34, 35 and 36. The necessary documentation designed to protect the service users were in the staff files. Staff had received moving and handling, fire and other training. An up to date workforce will contribute to the delivery of care. EVIDENCE: The manager was the designated responsible person and he was responsible for the training budget. The budget was of a substantial amount for the number of staff, and the inspector would commend this investment. The manager was able to provide evidence that staff undertake an induction programme and received supervision whilst working supernumerary for between 1 to 2 weeks. The home also offered training positions for NHS student nurses. On the examination of 3 staff files, all contained the information required within Schedule 2 and 4. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 16 On requesting to examine the staff training records, the inspector was advised that the records were being updated at head office. The manager contacted head office by telephone for the dates of the Moving and Handling and Fire training and was advised that the training occurred on the 10th August 2005. Also other training courses had been undertaken. On examination of the staff supervision records, the inspector found evidence that supervision had occurred on an annual basis and were not on target to achieve the six times a year supervision for each member of staff. During this inspection the inspector monitored the agreement regarding a senior care being in charge of the home and a qualified nurse being on call. The manager identified that the system was now ‘up and running’ for the last 2 months and operated 3 or 4 times per week, and during this time no calls had been received by the qualified nurse on call. The inspector discussed ways of ‘testing the system’ to ensure that all staff were aware of the ‘on call’ procedure. Also the inspector accepted that the system had only been operating for two months. Therefore he could not examine the reinvestment of monies, as indicated by the company, at this stage. He will inspect these on the next inspection. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 17 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): Standards 37 and 39. The management of the home does not comply with the requirements of the Care Homes Act, as regulation 26 visits were not fully undertaken or formal supervision given to the staff. Quality assurance systems will assist the manager and company to measure the home against expected outcomes. EVIDENCE: A registered manager was in post. He had undertaken the necessary training regarding moving and handling, fire etc. The company had quality assurance systems, which were implemented by a representative from head office. The manager advised the inspector that part of her role was to monitor the quality of the service provision, but also to incorporate the regulation 26 visits into the monitoring process. On examination of the monitoring document, the inspector found it to be an extensive quality tool, however it did not cover all aspects of the information Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 18 required for a Regulation 26 visit. Regulation 26 was discussed with the manager. He agreed to amend the quality document. As far as could be established there were no health and safety issues except if any were raised with the previous sections of the report. Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 19 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 X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heathfield Gardens Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000002058.V272204.R01.S.doc Version 5.0 Page 20 NO 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 2 Standard YA36 YA39 Regulation 18 26 Requirement The registered person must ensure that formal supervision occurs at least six times a year. The registered person must ensure that the home has the quality assurance monitoring which meet the areas stated in Regulation 26 and records such monitoring by the provision of a Regulation 26 document. Timescale for action 14/02/06 14/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Heathfield Gardens DS0000002058.V272204.R01.S.doc Version 5.0 Page 22 - 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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