Inspection on 16/01/08 for Heathlands

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Adequate service.

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 13/07/06

Heathlands 05/02/06

Heathlands 19/07/05

Heathlands 08/02/05

Heathlands 04/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Heathlands Constitution Hill Road Parkstone Poole Dorset BH14 0PZ Lead Inspector Martin Bayne Key Unannounced Inspection 16th January 2008 09:00 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 Heathlands DS0000004047.V358185.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. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathlands Address Constitution Hill Road Parkstone Poole Dorset BH14 0PZ 01202 676858 01202 684643 heathlands@care-south.co.uk www.care-south.co.uk Care South 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) Mr Nicholas Robin Holman Care Home 51 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (45) Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person (as known to CSCI) who is under the age of 65 and whose primary care needs are due to a physical disability may be accommodated for periods of respite care. 13th July 2006 Date of last inspection Brief Description of the Service: Heathlands is situated at the bottom of Constitution Hill Road. The home has pleasant gardens and provides for some off road parking. The land is leased by the Borough of Poole and is shared between Heathlands and a day services centre run by the Borough. Heathlands was built as a care home approximately 40 years ago. It is registered with the Commission to provide care for 51 service users, 45 in the category of old age and 6 in the category of either dementia or mental disorder. The care home is registered to accommodate people over the age of 65. Bedrooms are provided on the three upper floors of the home. Care South, a not for profit company are the Registered Providers of the home. The bedrooms are for single occupancy and there is sufficient communal space of a large lounge and dining room, smaller lounge areas, staff office space and utility services of main kitchen and laundry. There are shops within half a mile of the home and the main town centre of Poole is one and a half miles away. Bus and train routes serve the main shopping areas of Poole and Bournemouth. A short drive to the top of Constitution Hill Road reaches the viewpoint from which there are views over Poole Harbour and the Purbeck Hills. Weekly fees range from £450 - £545. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We, (the Commission) carried out an unannounced inspection of Heathlands, the aim of which was to evaluate the home against the key National Minimum Standards for older people and to follow up on seven requirements and four recommendations made at previous inspections. The last key inspection was carried out in July 2006 and two random inspections were also carried out, one in April 2007 and another in August 2007. Mr Holman, the Registered Manager of the home and his deputy assisted throughout the inspection by providing information and records about the home. They also informed of how the home was managed and the care provided to residents. As part of the inspection we toured the premises and tracked the records and paperwork for three residents, two of whom had been admitted since the last key inspection. The other person tracked was chosen as an example of how the home met the needs of a person who required a high level of care. We spoke with nine residents about their experience of living at the home and also with one member of staff. We provided comment cards to be sent out for residents, relatives, care managers and health professionals by the manager. The returned comment cards and also the Annual Quality Assurance Assessment document were used to help form the judgements contained within this report. At the time of the inspection the home had six vacant beds. The home has a block contract with a local council for eight long-term beds. One place at the home is reserved for respite care. What the service does well: Residents’ needs are assessed before decisions are taken to admit a person to the home. There is a good system of care planning that ensures that residents’ health needs are fully met. Medication is administered safely by trained members of staff. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 6 The home is welcoming to visitors and residents are able to make choices about their care. There was good feedback about the quality and standard of food provided in the home. The home has a well-publicised complaints procedure and there was evidence that complaints are taken seriously and investigated thoroughly. The organisation has a good record in training the staff tea. The home is well managed by Mr Holman and in general was found to be run in the interests of the residents. What has improved since the last inspection? What they could do better: Recruitment to the vacant post of the activities co-ordinator will greatly benefit residents, as there was some feedback that residents’ leisure and recreational needs were not being met. All staff must receive training in adult protection. Tiles in the upper floor bathroom need re-grouting. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 7 Cleaning staff should be reminded about the need for storing harmful cleaning products so that vulnerable residents cannot have access to them. References must be taken up consistent requirements of Regulations. The staff application form should be amended to seek references in line with the Regulations. Management visits required under Regulation 26 must be re-instated. The fire safety system must be tested and inspected to the required timescales. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Heathlands DS0000004047.V358185.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 Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from their needs being assessed before being offered a place at the home. EVIDENCE: Mr Holman informed that the majority of people move into the home directly from hospital. He told us that in all cases, he and the deputy manager carry out a pre-admission assessment of a referred person’s needs to ensure that these can be met at the home. Should the person have family, they are invited to visit the home and be involved in choosing a placement. Where a person is referred from their home, they are invited to visit Heathlands for a day, so that they can make an informed decision about moving into the home. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 10 Mr Holman informed that in all cases, the person referred (or a family member if more appropriate), are given a copy of the Service User Guide that provides full information about the home and the way it is run. We tracked the records and paperwork for three residents throughout the inspection and found that for each person a pre-admission assessment of their needs had been carried out. This had been recorded on a form that covered all of the topics detailed within the National Minimum Standards. When a person moves into the home they are offered a trial period and a letter is sent to them confirming the placement and that their needs can be met at the home. We spoke with two residents who were able to tell us how they had been involved in choosing the home, as they had stayed at the home for respite care before making the decision to move to the home long-term. The home does not provide an intermediate care service. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from their health needs being met through care plans being developed through an assessment of their needs and from having medication administered safely by trained staff. EVIDENCE: We saw the personal files for the three residents tracked through the inspection. A photograph of the resident was displayed on the front of their file together with key information and contacts. We found a care plan had been developed for each person from the assessment information. The format of care plans has changed since the last key inspection. These are now written up and updated on the home’s computer and a printed copy kept on the person’s file. We found the plans easy to read, and they provided sufficient Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 12 information for a new member of staff to provide care to the person concerned. The care plans we saw had been signed and dated by the resident and were up to date with evidence of reviews taking place. A requirement concerning care plans was made at the random inspection in April 2007. This inspection had been carried out following an anonymous allegation that residents were being got up early whether they wanted to or not. A requirement was made that care plans, where possible should detail the preferred times residents normally wish to go to bed and be assisted in getting up. A further requirement was made that information should be provided concerning a person’s psychological and social needs with evidence that they were involved in care planning. We found at this inspection that care plans now complied with these requirements. We also saw memos to the staff from the manager making it clear that residents must be given choice on the times that they wish to get up and go to bed. We discussed with Mr Holman the needs of one person whose health had rapidly deteriorated over a short period of time and we were able to see that an up-to-date care plan was in place for this person. We saw evidence within care planning that health needs of residents were being met. Each resident was registered with a GP and we saw that district nurses were involved appropriately. One comment card from a relative informed how the home had worked with the Community Mental Health Team in supporting one resident appropriately. Mr Holman informed us that a chiropodist visits the home every fortnight and the optician annually. Should a person have hearing needs, a person is referred to their GP. On the day of inspection a dentist was visiting the home. The residents we spoke with told us that if they reported health concerns, the staff made appropriate referrals to health professionals on their behalf. At the last key inspection in July 2006 a recommendation was made concerning the administration of liquid medicines. It had been found that one person was decanting the medicine for other members of staff to administer at later times during the day. Mr Holman informed that practice had changed so that now the same person who decanted the medication administered this to residents. At the last inspection the procedures for administering medication were found to be safe and in line with good practice. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. With a vacant post for the activities co-ordinator, the home is not currently meeting some residents’ needs concerning social activities. Residents benefit from a good standard of food and through being able to maintain contact with friends and relatives. EVIDENCE: At the random inspection in April 2007 a requirement was made that the registered person must consult with residents about their social interests. We found at this inspection that care plans drawn up with the involvement of residents had addressed this issue. We were informed that an activities coordinator is employed at the home as part of the staff complement. Mr Holman told us however, that the post was vacant and that an advert was currently out for the recruitment of a new Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 14 person to this post. He informed that this had impacted upon the level of activities that are normally provided within the home. This was born out by four of the eleven comment cards returned by residents informing that there were not sufficient activities. Mr Holman informed us of some recent communal activities that had taken place, such as a country and western singer who visited the home the previous week, an entertainer on New Year’s Eve and a visiting pantomime at Christmas time. He also informed that last year groups of residents were taken twice to the theatre and that residents of the home can sometimes access entertainment put on in the day centre that is located on the same site as the home. Generally, residents we spoke with said that they were happy with the level of activities provided in the home, although one person informed that they did find it difficult to occupy their time. One resident informed that she enjoyed books provided by the visiting library and another informed that they knitting. Some residents told us that they preferred to occupy themselves. The requirement will remain in force and be followed up at future inspections. Concerning spiritual needs, a Church of England service is held in the home each month and there is also monthly communal hymn singing in the lounge. Mr Holman informed there was one Jehovah’s Witness accommodated and it had been arranged for a member of that faith to visit this person. There are no restrictions on visiting times to the home and residents confirmed that visitors were made welcome at the home. A returned comment card from one relative also reported the same. Residents are able to receive visitors in the communal lounges or in the privacy of their room or one of the small quiet rooms. All of the residents spoken with said that the food was of a good standard. Breakfast is generally served between 7:45 am and 9:30 am. Residents can choose from a range of cereals, porridge, fruit and toast or they can have a cooked breakfast if they choose. Breakfast is generally served in the dining room but meals can be provided in residents’ rooms on request. The main meal of the day is served at lunchtime. We were told that there is usually a choice of three meals provided and that the chef goes round to residents the night before, to elicit their choices in planning for the next day. One resident told us that the home is very flexible and that if they requested something different from the menus, this would generally be catered for. At the inspection in April 2007 a requirement was made, as at that time a resident was accommodated on a gluten free diet and some foodstuffs for that person were not available. Mr Holman informed that this person was no longer accommodated at the home and that specialist diets were being catered for, such as diabetic diets or soft or pureed food. High tea is served at around five o’clock, which is generally of a light cooked meal or sandwiches. During the evening time residents have a drink and biscuits or can request something else, if they are hungry. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents will be better protected once all the staff have received training in adult protection. EVIDENCE: Since the last key inspection in July 2006 two concerns have been brought to our attention. One resulted in our carrying out a random inspection in April 2007, at which seven requirements were made. The Borough of Poole coordinated an investigation under adult protection protocols into the other concern in November 2007. It was concluded that the allegations were unfounded. We were told by Mr Holman that two complaints had been made through the complaints procedure of the home. We were shown the complaint’s log, which provided evidence that the complaints had been investigated and taken seriously. The complaints procedure is detailed within the Service User Guide and within the Terms and Conditions of Residence and both residents and relatives have Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 16 access to these documents. The home has a policy and procedure to respond to allegations of abuse or neglect and has copies of all relevant policies and procedures relating to adult protection. Training records revealed that not all staff had received training in adult protection and a requirement was made at all staff should receive this training. Within a week after the inspection the manager informed us that training had now been arranged for all staff in this field. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean and well maintained environment but cleaning staff should be more mindful of locking away cleaning materials in the interests of protecting residents. EVIDENCE: As part of the inspection we carried out a tour of the premises. We found the home to be clean, free from any unpleasant odours and well maintained with the exception of finding some loose tiling in one of the bathrooms on the upper floor. This was pointed out to the manager who agreed that he would arrange for the tiles to be re-grouted. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 18 One concern raised in November 2007 as part of the adult protection investigation was that the kitchen was not clean. This was not substantiated. A food hygiene inspection carried out by the Environmental Health Officer in December 2007 found that the kitchen met environmental standards. At the last key inspection it was noted that the bags used to collect laundry were faulty and did not allow effective sluicing. The annual quality assurance assessment informed us that new bags have been purchased to rectify this. The staff spoken with informed that protective clothing such as gloves and aprons were always available and it was noted that alcohol gel sanitises were available in key areas of the home. The home has dedicated cleaning staff and also a laundry assistant who works seven days a week. The home provides sluicing facilities for the cleaning of commodes. It was agreed with the manager that the cleaning staff would be reminded of COSHH (Control of Substances Harmful to Health) arrangements for storing of cleaning materials as some products were not locked away in one of the sluicing rooms, to which residents could have had had access. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The employment of an activities co-ordinator will benefit residents in meeting their recreational needs. Amending the staff application form will ensure that references are taken up in line with the Regulations. EVIDENCE: We were told that between 7am and 8:30am, there are six care staff on duty, between 8:30am and 1pm seven care staff, between 1pm and 4 pm four care staff and from 4pm to 10pm six care staff. During the night time period there are three awake members of staff on duty. We were told that a Care Team Manager is always on duty in charge of a particular shift. The Care Team Managers work across all shifts to ensure that there is continuity of care practice maintained in the home. In addition to the care staff, the Registered Manager and deputy manager work office hours during weekdays. The home also employs a laundry assistant, cleaners 12 hours a day, a dining room assistant to 3 ½ hours a day, cooks for nine hours a day and a kitchen assistant 12 hours a day. Mr Holman informed us that on occasion he visits the home out of hours to ensure that the routines and expectations of staff are being carried out. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 20 We found at this inspection that the recommendation that the home achieve a level of 50 of staff trained to NVQ level 2 or above had been complied with. 46 of the care staff had NVQ level 2 and 8 of the staff NVQ level 3. Overall 68 of staff were either in training or had achieved level 2 or above. We saw the recruitment records for two members of the care staff team who had started working at the home since the key inspection in July 2006. We found that all the recruitment checks of Schedule 2 of the Regulations had been complied with, save taking up the wrong reference for one member of staff, (a reference being taken from their last employer instead of the last place of work where the person worked with vulnerable adults or children). It is recommended that the organisation’s staff application form be amended to seek a reference where applicable relating to a person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration. A requirement was made that references must be taken up that comply with the Care Home Regulations 2001. We were shown the staff training records, which demonstrated that the organisation had a good commitment in developing the staff team. Staff are trained in core areas such as induction, health and safety, manual handling, infection control, basic food hygiene and fire safety. Training is also available in first aid, loss and bereavement, catheter and stoma care pressure area care, healthy bowel and constipation and dehydration. At the random inspection in April 2007, a requirement was made that more staff be offered training in the care of people with dementia. The records seen showed that this had been addressed and a high percentage of staff have now received this training. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lapses in testing the emergency lighting and visual inspection of the fire fighting equipment could compromise fire safety arrangements for residents. Failure of senior management to visit the home as required under Regulation 26 compromises the overall good management of this home. EVIDENCE: Mr Holman is registered with the Commission as Registered Manager of Heathlands and has many years of experience in senior management. He has an NVQ level 4 in management and care and has the Registered Manager Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 22 Award. Returned comment cards from the staff informed that there were good working relationships between staff and management. In general the home was found to be well managed and run in the interests of the residents. One area of concern however, was in respect of unannounced visits by a representative of the organisation under Regulation 26. The responsible individual or one of the partners of the organisation should carry out these visits unannounced each month. A report should also be available on the conduct of the home resulting from these visits. The last report pertaining to one of these visits to Heathlands was in December 2006. A requirement was made that these visits are recommenced and the requirements of Regulation 26 complied with. The home safe keeps small amounts of money on behalf of some residents. We saw the records and accounts and these tallied with the balance of money held. We saw the fire log book and found that inspections of the emergency lighting and of the fire fighting equipment had not been carried out to the required timescale. A requirement was made that these tests be carried out. At the last random inspection a requirement was made that height adjustable beds be provided for residents where moving and handling assessments of a resident indicated such a need. Mr Holman informed that some beds should be in place in the home before April. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 X X 2 Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP12 Regulation 16(2)(m)( n) Requirement Timescale for action 29/02/08 2. OP18 3. OP29 4. 5. OP32 OP38 You are required to consult with service users about their social interests and about a programme of activities in providing facilities for recreation. 13 (6) You are required to make arrangements by training staff or other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse Schedule You are required, in respect of 2 persons carry on, managing or working at the home, to obtain two written references; including where applicable, a reference relating to the person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration. 26 The Registered Provider is required to ensure that there is compliance with the Regulation. 23 (4) (c ) You are required to ensure that (v) tests and inspections to the fire safety system are carried at the required timescales. 29/02/08 29/02/08 29/02/08 29/02/08 Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 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. 2. Refer to Standard OP19 OP29 Good Practice Recommendations It is recommended that cleaning staff are reminded of COSHH arrangements and the need for cleaning materials, potentially harmful to residents, being locked away. It is recommended that the organisation’s staff application form be amended to seek a reference where applicable relating to a person’s last period of employment, which involved work with children or vulnerable adults, of not less than three months duration. Heathlands DS0000004047.V358185.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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