Inspection on 16/08/05 for Heathlands

This inspection was carried out on 16th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Heathlands 12/01/10

Heathlands 10/11/09

Heathlands 06/10/09

Heathlands 05/05/09

Heathlands 22/08/07

Heathlands 06/06/06

Heathlands 28/12/05

Heathlands 04/01/05

Heathlands 09/06/04

Heathlands 09/02/04

Similar services:

Maple Lodge

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Heathlands Station Road Pershore Worcestershire WR10 1NG Lead Inspector Annie OMara Unannounced 16 August 2005 08:00am 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 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. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heathlands Address Station Road, Pershore, Worcestershire WR10 1NG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01386 562220 Heart of England Housing and Care Limited Candida Aloha Baker Care Home 60 Category(ies) of DE(E) Dementia over 65 (60) registration, with number LD Learning disability (1) of places OP Old age (60) PD(E) physical disability over 65 (60) Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The property is not used for any purpose other than that of a care home, without appropriate consultation and agreement from the CSCI. 2. The service is able to accommodate one named service user who has learning disabilities and associated mental disorder Date of last inspection 4 January 2005 Brief Description of the Service: Heathlands is a new purpose built home situated close to the town centre of Pershore. The home is registered to provide a residential care and respite service for up to sixty older people who may have physical disabilities and/or mental health needs. A separate eight-bedded unit provides a service to older people with dementia type illnesses. A separate day care unit provides a service to older people living in the community five days each week. Twelve places are available each day. The service is for frail, older people who are living in their own homes in the local community.The stated aim of the residential service is to provide care for frail, older people who are unable to live independently in their own home because of their frailty, physical, mental or social needs. The home is located within walking distance of the town centre where there are shops, restaurants, public houses, churches and good pubic transport. The home is on two floors and there is a passenger lift. Rails are provided throughout the home. All bedrooms are single and with ensuite toliets and showers. Adapted bathrooms are available on each floor. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place at the beginning of a week day shift. Care plans and records were looked at, four residents were spoken and a visitor was asked for comments. Management records were also inspected and a brief tour of the building undertaken. The inspectors were assisted by the registered manager, the clerk and senior staff. What the service does well: What has improved since the last inspection? Tasks that were set following the previous inspection had all been carried out. Details in the information documents now correspond to those in the residents’ contracts. This avoids confusion. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 6 Bath water is manually tested each time and the temperatures are recorded. These measures protect people from scalds. A checking system has been introduced to ensure any problems that arise as the result of an accident are identified and acted on. 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. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 8 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 standard(s) 1, 2, 3, 4 Information is available for prospective residents and their families to help them to make an informed decision about moving into the home, and the assessment process ensures that residents’ needs are understood at the point of admission. EVIDENCE: Copies of the statement of purpose and the service users’ guide were available and the manager confirmed that a copy of the service users’ guide was placed in each bedroom. The current documents were in the process of being up dated and amended. When this task has been completed copies will need to be sent to the Commission for Social Care Inspection. Some inconsistencies between these documents and the terms and conditions of residency (Contract) had been addressed. This had initiated a requirement following the previous inspection. The manager said that a second requirement to ensure that charges for extras were included in the document had also been addressed. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 9 Prospective residents were assessed prior to moving into the home. The home has a comprehensive assessment form for this purpose. One file observed had a community care assessment in place but there was no homes’ assessment form filled in. The registered manager stated that all residents were assessed prior to moving to the home and that the assessment form was probably still with the assessing member of staff. Parts of the other assessment form filled in had not been dated or signed. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 10 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 standard(s) 7, 8, 9, 10. Care plans in place were in the main kept up to date to ensure that residents’ needs were being met and personal support is offered in a way which promotes the privacy and dignity of the residents. EVIDENCE: It was pleasing to note that two new residents admitted three days prior to the inspection already had care plans in place which covered their care needs. A care plan of a resident who had lived at the home for a longer period of time also had a social history which provided staff with background information about them including interests. Care plans were regularly audited by the registered manager and shortfalls commented on and corrected. One care plan had not been reviewed since May 2005. There was evidence of health care needs being monitored and regular visits by the primary health care team. Daily notes kept by staff indicated that a resident did not wish to receive personal care from male members of staff. This information had not been transferred to their care plan. Additionally, the daily notes written on the first evening of two residents who were admitted both indicated that they had Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 11 “settled in” but gave no information as to how they had been supported by family and staff on that day. Medication systems were managed well and residents were able to selfadminister their own medication. Staff received medication training and all the required policies and procedures were in place. Residents who were asked about how staff maintained their privacy and dignity all said that they were very good. One resident said that having a bath was a “Delightful experience, they don’t make you feel uncomfortable” and “They do not lack respect”. Another resident stated that “Everyone treats you as though they love you”. Observations made during the visit indicated that staff spoke respectfully to residents and maintained their privacy by knocking on doors. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 12 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 standard(s) 12, 13, 15. Routines in the home are flexible and allow for individual residents to live their lives as they wish and the choices for meals and standard of food meets the residents’ dietary needs. EVIDENCE: Residents spoken to did not feel that there were any routines in the home other than mealtimes. There was no program of weekly activities displayed in the home although there was news of outings being arranged in the future. Residents spoken to said that they had enough to do although one felt that care staff did not have time to spend with them. Another resident said “There is not enough to do but I don’t know what we could do”. Records indicated that a younger adult was given many opportunities to go out and use communal resources. Care staff said that they did not have time in the mornings to spend with residents but there was more time available in the afternoons and evenings. The home employs an activities co-ordinator. A resident said that he had access to talking books and newspapers. Visitors were able to visit as they wished and stated they were welcomed into the home. Residents were consulted about food and meals regularly and three choices were offered at the main meal of the day. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 13 Comments about the food included “Improving” “Very good” and “Quite passable”. Snacks were also available in each kitchenette on the separate units. Residents had access to cold drinks at any time and tea and coffee was freely available. Menus were drawn up following consultation with the residents and records were maintained that demonstrated what food had been provided. Residents were able to make choices and these documents were retained. In addition the manager said that people who needed special diets for health reasons were closely monitored and detailed records were maintained of their consumption. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 14 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 standard(s) 16, 17, 18 Residents confidently use the complaints procedure and their concerns are addressed appropriately. Their legal rights are protected and they are protected from abuse by the policies and procedures, monitoring and training provided to staff. Residents are able to exercise their legal rights and are protected from abuse by the systems in use in the home. EVIDENCE: A corporate complaints procedure and the in-house complaints procedure were available. The manager confirmed that every resident received a copy when they moved into the home. Complaint records had been well maintained and indicated that appropriate investigation and action had been taken in relation to the nine complaints that had been received since April this year. A record was also maintained of compliments, sixteen of which had been received since April, from residents and their relatives. Advocacy services had been obtained for residents when needed and all people resident at the time of the general election were on the electoral roll and had had an opportunity to vote if they wished. It was observed that policies and procedures were readily available regarding ‘whistle blowing’ and ‘adult protection’. This had been reviewed in 2005 and 2003 respectively. The staff records indicated that virtually all staff had received training in the protection of vulnerable adults. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 15 Residents’ monies and valuables, held for them in safekeeping, were appropriately managed. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 16 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 standard(s) 19, 20, 21, 23, 24, 25. The standard of the environment is very high and provides residents with a safe, comfortable home. EVIDENCE: The environment is built to a high standard and provides the required space individually and communally for the residents. Residents have access to kitchenettes and the dining space is domestic and well laid out. Adaptations provided meet the needs of the residents living at the home. The home was clean and well maintained on the day of the visit and residents expressed their satisfaction with their individual rooms. Rooms visited were personalised and comfortable and all have en-suite shower and toilet facilities. The garden area was attractive and accessible. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 There are sufficient suitable staff that are able to meet the needs of the residents and the home and appropriate training is provided to ensure the well being of all. EVIDENCE: Duty rosters were maintained that demonstrated who was scheduled to work at all times. The member of staff allocated to work on Cherry unit at night needed to be identifiable as he/she held responsibilities relating to health and safety. There were sufficient staff rostered to attend to the current needs of the residents and the home. The care staff team numbered 50 persons 22 of which were qualified to NVQ level 2 or 3. In addition 19 others were undertaking courses of which 6 were nearing completion. This is an excellent achievement and indicates good progress towards meeting the 50 required by the standard. The files of two staff were assessed. They were complete and indicated that an acceptable recruitment process was implemented. Both staff had undertaken Induction Training. The manager said they tended to try to put all new staff on to NVQ courses. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 18 A requirement was made following the previous inspection in relation to foundation training however the inspector believes that the standard will be changed within the next few weeks. Therefore compliance was not checked during this inspection and the requirement has not been repeated in this report. The standard will be re-assessed in the light of the changes during the next inspection. Other training records indicated that staff undertook training throughout the year in all core care subjects. A training matrix and record was maintained in addition to the individual records. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 The home is well managed so that staff are trained, supervised and monitored in the delivery of quality care that meets the needs of the residents. The views of residents, their supporters and staff were sought and used to develop the service in an acceptable manner. Fire safety management ensures the safety of those in the home. The accident procedure has been improved by structured monitoring. EVIDENCE: The home has a stable management team and a registered manager who is trained, experienced and meets the requirements of the standard. Acceptable arrangements are made to cover any absence. She has achieved the Registered Manager’s Award and is aware of the range of her responsibilities and authority. It was observed that the manager related well to the residents and the staff found her approachable and responsive. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 20 Records were seen of meetings that were undertaken with and by staff and residents. Minutes were maintained that indicated that the occasions were opportunities to dispense information and guidance, and promote discussion and ideas. People were also able to express their opinions through one to one contact, questionnaires, the compliments and complaints system, suggestion boxes and staff supervision. The quality assurance system was based on a programme of monitoring and questionnaires. These tasks were all diarised to ensure none were overlooked and the ‘Head Office’ was supplied with the resulting information. In addition to a corporate plan an internal development plan for the home was seen. The policies and procedures for the home were reviewed as an on going process. It was observed that staff were informed when changes or new documents became available and were required to read them. Monitoring sheets were seen. The clerk demonstrated sound financial procedures for the home and the residents were being used. Records were well-maintained and correct documentation retained. The home was appropriately insured. Secure storage was acceptable. The staff team was allocated to the senior team members for supervision. A programme was displayed and sessions were entered when completed. Personal records were held in staff files. Acceptable records were maintained in accordance with the regulations. Standard 38 was not assessed in full. However the fire safety records were examined and found to be acceptable. Staff training was ongoing and a copy of the training achieved this year will be sent to the Commission for Social Care Inspection. A tall bookcase observed in one lounge was considered to be unstable. The manager was advised that it should be secured to the wall for safety. Other furniture should be similarly assessed for stability and action taken if warranted. A requirement was made following the previous inspection to ensure bath temperatures were recorded. The manager confirmed that this was now the practice. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 21 The manager said that a system had been developed that required staff to monitor people for a minimum of twenty-four hours after an accident in order to ensure latent injuries were identified and attended to. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 4 4 x 4 4 4 x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 x Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 23 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 7 Regulation 15 Requirement All aspects of residents care needs must be recorded. Timescale for action Immediate 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 3 7 12 Good Practice Recommendations Assessments should all be signed and dated. Daily care records should contain more information about how residents emotional needs are addressed by staff. An activities program should be on display for residents. Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 24 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Heathlands E52 S41859 Heathlands V242518 160805.doc Version 1.40 Page 25 - 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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