Inspection on 02/08/07 for Heathlands

This inspection was carried out on 2nd August 2007.

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 08/06/06

Heathlands 08/12/05

Heathlands 05/09/05

Heathlands 29/10/04

Heathlands 28/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Heathlands (Walton-on-the-hill) Heathlands Chequers Lane Walton-On-The-Hill Surrey KT20 7ST Lead Inspector Pauline Long 2nd August 2007 09:30 Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 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 (Walton-on-the-hill) DS0000013852.V338374.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 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. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathlands (Walton-on-the-hill) Address Heathlands Chequers Lane Walton-On-The-Hill Surrey KT20 7ST 01737 817882 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) Heathlands@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Limited Mrs Phyllis Joan Gabriel Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 46-60 YEARS OF AGE 8th June 2006 Date of last inspection Brief Description of the Service: Heathlands is a care home providing personal care for six adults of mixed gender with profound or severe learning disabilities. The home admits service users with complex needs including challenging behaviours and autistic traits. The premises is a detached, two storey building which is domestic in size and character. Its location is central to the pretty, semi-rural village of Walton on the Hill. Local shops are within walking distance. Larger shopping facilities also a range of leisure amenities, countryside and parkland are all within easy travelling distance. All bedrooms are single occupancy and are situated on the ground and first floor, accessible by stairs. Toilet and bathing facilities are on both floors. Communal areas comprise of a fitted kitchen with separate utility room, dining room, lounge and sun - lounge. The home has a car park and a secure, large, secluded garden also dedicated transport facilities. The organisation operating the home is a registered charity and major provider of support service for adults with learning disabilities in the South East of England. Prospective service users and their representatives are informed about the home’s services and facilities in a Service Users Guide document available from the Avenues Trust. Also a copy of the home’s latest CSCI inspection report. The fees at the home range from £1570.71 per week to £1572.39 per week. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 and was in the service for 4.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Communication with some of the service users was limited due to their communication difficulties. However their apperance and body language evidenced a sence of wellbeing. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the residents, the managers and for their hospitality, assistance and co-operation during the site visit. What the service does well: The service users and staff benefit from a person centred management approach to the running of the home and service users are included in all aspects of the running of the home. Some of the staff team have worked with the service users for some time, and this was reflected in the level of knowledge and understanding of the needs and preferences of the service users and from the positive interactions and relationships observed. The care plans and daily records sampled were person centred, and comprehensive, providing the reader with a good insight into the service users holistic needs and goals. The home promotes and encourages contact with family/friends and the local community. The environment provides a very good standard of accommodation, which maximises the service users independence. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 6 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 8 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 Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective service users would only admitted to the home following a comprehensive assessment of their needs. EVIDENCE: The service users have lived at the home since it opened in 2001, and no new service users have been admitted since the last inspection. There was no evidence of a pre admission care needs assessments on either of the service user’s files. There was however a Cultural care needs assessment on the file. This was comprehensive and included an assessment of all daily living activity’s as well as any health care needs. The assessments related to an individuals particular needs, for example their mode of communication, their personal care needs in respect of bathing or showering and their likes and dislikes in respect of food. The manager stated that the care needs assessments would be carried out by herself or a member of staff qualified to do so. She also stated that the organisation had a comprehensive admissions policy, committed to supporting service users with their choice of home. The admissions policy and procedure documents were sampled and evidenced that if procedures were appropriately followed, the care needs assessment and subsequent admission would be tailored to meet an individual needs. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Comprehensive person centred care plans are in place and clearly identify service users needs and choices. Service users are encouraged to make decisions and to take responsible risks. EVIDENCE: Two of the service users care plans were sampled and evidenced improvements in the care planning process. The care plans were very detailed, gave a holistic view of the service users goals. They contained photographs of the service users in respect of the goals they wished to achieve, for example carrying out chores or attending activities. There were clear guidelines and action plans as to how the goals could be met. The manager stated that the service users were involved in developing the care plans and that they had been encouraged to stick their own photographs in the plan. The care plans sampled had been regularly reviewed. There was evidence to indicate that the service users had recently had a care management review. Whilst the manager acknowledged the improvements in the two care plans Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 11 sampled, she stated that further work was required to ensure the remaining care plans were to the same standard. Through out the site visit, service users were observed moving around the home freely. Staff, were observed offering them choices, for example going out for a drive, going to an outside activity or staying at home to help prepare the lunch. It was noted that some of the residents have restraint guidelines in place, however these had not been reviewed since 18/09/06 discussions were had with the manager in this respect. Improvements have been made in the risk assessment process. There was Evidence to indicate that risk assessments had been undertaken in respect of the service users access to toiletries. Comprehensive risk assessments had also been documented on all daily living activities. All assessments had been reviewed and signed by staff. A recommendation has been made in respect of these areas. Please refer to page 27 of this report. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 People who use the service experience excellent quality outcomes in this area. The residents are encouraged and enabled to maintain fulfilling lifestyles in and outside the home and have regular contact with family, friends and the local community. Mealtimes were observed as being a positive and pleasant experience for the service users. EVIDENCE: Service users were observed to engage in a structured and individualised program of activities. It was noted that the life programmes and life goals were displayed in pictorial format in the service users bedroom. The programmes included dedicated time for service users to spend with staff in order to develop and practice daily living skills and promote independence. The manager stated that she was enrolling some of the service users in the local college, this was evidenced in application forms sampled. Service users were observed carrying out different chores, for example, washing the dishes, hovering the floor, stripping and making their bed, setting Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 13 the tables for lunch and clearing away after their meal. Staff commented that some of the service users like to help with the weekly shopping, this was evidenced in the care plan and activities plans. The manager stated that the service users are involved in maintaining and feeding the pet rabbits. The manager stated that the home promotes contact with families and friends, and that some visit regularly others kept contact by phone. The home enables one of the residents to go and spend time at her mother’s home. One relative commented that “ In my opinion they do everything to the best of their abilityI am pleased with everything that is done for my relative” Service users are encouraged to attend local day services outside the home, for example a local garden centre, the Croft Day Centre. They engage in activities at the local social club, art lessons, cookery classes and some enjoy carriage rides. On the day of the site visit, all of the service users were observed going out to various activities. The home is a member of the Local Residents association. This year they entered the village competition and won third prize for their “ Alice in Wonder Land” theme. Photographs of the Pageant were displayed in the home and evidenced many smiling and happy faces. All of the service users have the opportunity to attend the local church. One care manager commented that the home did not take all of the service users to church at the same time due to the lack of drivers. This was discussed with the manager, she stated that they would only take three service users at a time to church in order that their dignity could be protected and maintained. The manager commented that food and meal times were an important part of the day at the home. She stated that the staff, were involved in developing pictorial menus for the service users benefit, and that staff were actually taking photographs of meals they had prepared in order to build the pictorial menus. Some work has been completed in this respect. A lunchtime activity was observed for a time. Service users were encouraged and supported to set the tables ready for the meal. The meal served looked appetizing and appealing, and was served in a way that met the individual needs for example, food cut up in to small pieces for those service users with swallowing difficulties. One service user was asked if he enjoyed his meal and he commented “yes”. The staff were observed sitting at the table with the service users and were offering support and encouragement in a dignified and sensitive manner. It was noted that was lots of “banter” between the manager and the service users, which resulted in some of the service user laughing. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the residents physical, emotional and health support needs, this was evident from the positive interactions and relationships observed. EVIDENCE: All of the service users living at the home require support with their personal care needs. The care plans documented the need for only female staff to attend to the female residents personal care needs, this was in accordance with the organisation’s gender policy. However discussions were had with the manager in respect of the shortage of female staff employed at the home and the need for the organisation to review this. Subsequent discussions were had with the service manger in this respect, he stated that a further female member of staff had been seconded from one of the other homes in order to ensure the organisations gender policy was adhered to. Staff were observed providing various aspects of personal care support for the service users, this support was offered in a manner that promoted the service users dignity and privacy. For example, doors not left open whilst attending to personal care, doors being knocked prior to entering a service users bedroom. One care Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 15 professional commented that the staff were good, that good practice had been observed and that it had been a pleasure to watch. One care manager commented that at times care reviews were held in the homes dining room and that privacy was an issue. This was not discussed with the manager at the time, but should be taken under consideration by the organisation. Care plans and daily records daily records evidenced visits to the doctor, various health related appointments and reviews of care. Health action plans were in place, and it was noted that, Well-women appointments were made for the female service users. Discussions were had in respect of the male service users and similar health checks being carried out. The manager commented that she had discussed this with the local GP service, but that the surgery were somewhat reluctant to proceed with these checks. It would be good practice to follow up these discussions with the GP surgery. Comments were received from the Consultant Psychiatrist who visits the home, he commented that the home manager is very professional, that the quality of life for the service users has improved greatly. Staff are good at asking for the appropriate support and that they work well with the local Mental Health Team, and that they do not give up on people and keep trying to get satisfactory outcomes. Medication procedures, storage and records were sampled. None of the service users are responsible for their own medication. The storage of medication was safe, and it was noted that there were no gaps in signatures in the medication record sheets. The manager discussed a recent incident, where some medication had been dispensed from the wrong blister pack. She has investigated this issue, however was unable to identify the member of staff responsible. As a result of this issue all of the staff must undertake further training and assessment in order to ensure that they are competent in the administration of medications. She stated that this had been discussed with all of the staff and had been recorded in the homes communication book. The communication book was sampled and confirmed this, staff spoken with also confirmed that they would have to undertake further assessment. The manager has implemented a medication audit in respect of the senior member of staff checking all of the medications at the beginning of each shift, again this was confirmed with staff. Staff commented that all staff hat the home had to undertake training in respect of the safe handling of medications and that they were not permitted to administer medication until they had been assessed as competent. Training records were checked in respect of medication training and evidenced that all of the staff at the home had undertaken this training. However one of the staff on duty had not been assessed and was not permitted to administer medications. A recommendation has been made in respect of these areas. Please refer to page 27 of this report. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 16 Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who use the service are protected by the policies and procedures in place for dealing with concerns, complaints and protection. EVIDENCE: No complainants have contacted the Commission with a complaint since the last inspection. The home has received two complaints in the last twelve months. These complaints and the homes responses were sampled and evidenced that the complaints were responded to according to the homes complaints procedures. The manager commented that the service users do not have meetings, however they are included in the staff meetings. The home has a comprehensive complaints procedure, it is available in written and pictorial format, which enables the service users to access it. The manager was aware that due to the profound communication difficulties, service users were somewhat disempowered from using the procedures. The manager commented that the home had discussed the need for advocacy with the service users care management teams. Care staff commented, that service users body language and behaviour was a good indicator of displeasure. One relative commented that she was not aware of the complaints procedure, but was confident that complaints would be addressed appropriately. No referrals have been made under the Local Authority Safeguarding Adults procedures since the last inspection. Discussions were had with staff in about the homes safeguarding adults procedures, scenarios were put to them in Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 18 respect of potential abusive situations. They demonstrated a good understanding of the homes procedures and how to report their concerns. A recommendation has been made in respect of these areas. Please refer to page 27 of this report. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home provides a very homely environment, with a good standard of accommodation, which maximises the service users independence. The home is clean and hygienic. EVIDENCE: The home was comfortable, clean and tidy. The furniture and equipment were appropriate for the needs of the service users. Overall the home was well maintained, however it was noted that the decoration in the hall, stairs and landing require attention, as there were various marks and chips on the paintwork. Some of the rooms have been redecorated, with plans in place to complete all of the room by years end. New furniture, lighting and ornaments have been introduced making the living areas more homely. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 20 Service users bedrooms offered a good standard of accommodation and had been decorated to reflect the individual tastes and choices of the service users, with many pieces of sensory equipment, which was good for those residents with communication difficulties and to maximise independence. The manager discussed the plans in place for looking to the future, and the needs of an ageing service user group. She discussed the need to adapt some of the areas in the home, for example the bathrooms, the garden and the conservatory. Some of the communal areas in the home will require decoration in the near future as the paint work in the hall stairs and landing was soiled and chipped in places. The home was clean and hygienic with good infection control measures in place. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35,36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s staff recruitment and selection procedures and practices, however improvements are required in respect of staff gender, to ensure that service users needs in respect of gender issues are met. EVIDENCE: The home has considerable challenges in respect of staff recruitment. The manager stated that there was a shortage of permanent staff, for example the equivalent of 6 full time staff. This was further evidenced in the homes staffing rotas. A total of 122 shifts have been covered by bank/ agency staff in the last three months. The manager stated, however that all of the agency staff used, had worked at the home for some time and had a good understanding of the service users individual needs. This was evidenced in discussions with one of the bank staff and in observations of the staff interactions with the service users. The manager was hopeful that recruitment would be ongoing and that particular attention would be given to recruiting the appropriate numbers of staff in respect of the service users gender, as discussed earlier in this report. These areas were discussed with the Service Manager, who stated that a Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 22 review would be undertaken in this respect, and that arrangements would be put in place to ensure any gender related issues would be addressed. The organisation has agreed with the commission that staff application forms and other recruitment documentation will not be kept at the home. They have provided a list of the documentation they have received in respect of each member of staff, which includes references, CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adult) checks. Six staff files were sampled and evidenced that these check lists were in place. There was no evidence to indicate that the agencies recruitment and selection procedures reflected equal opportunities, because there were no records on file of the interview process in respect of the questions asked and the responses received. The manager stated that service users are encouraged to be involved in the staff interview process, however this could not be evidenced or confirmed with the service users. Discussions were with the manager and the staff in respect of the training opportunities at the home. The member of staff commented that the training at the home was good and that they had attended many training courses, for example, fire safety, infection control, breakaway techniques, challenging behaviours, care and control of medication, report writing, valuing diversity, driving training and NVQ training. These training courses were evidenced in the homes training records. A recommendation has been made in respect of these areas. Please refer to page 27 of this report. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39, 41,42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced and competent manager and service users and staff benefit from her management approach. Service users views are listened to and their health and safety are promoted and protected. EVIDENCE: The manager has worked at the home for several years, and has been the registered manager since 2006. She has been until recently been undertaking the Registered Managers award and NVQ 4(National Vocational Qualification). However she has submitted her resignation and will leave the organisation on the 4th of August 2007. Discussions were had with the service manager in respect of the future management arrangements at the home. He stated that he would be visiting the home on a regular basis, and that a manager from another of the organisations homes would be seconded to the home, until a Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 24 permanent replacement was recruited. He also commented that a new deputy manger was due to start work at the home. Care staff spoken with stated that the manager had an open and inclusive management approach to the running of the home. During the site visit she was observed speaking with the service users, it was evident that she knew them well and they all appeared relaxed and confident in her company. Staff commented that the manager had a “ hands on” approach to the running of the home and that it would be a loss to the home when she left. The manager has implemented internal quality assurance and monitoring systems in the home, for example, medication audits and health and safety checks. The organisation regularly carries out monthly visits to the home in order to focus on the outcomes for the service users, the report for the most recent visit was sampled. The organisation produces a yearly service user survey, in order to seek the views of families and other stakeholders. The most recent surveys were sampled and evidence a good deal of satisfaction with the care service provided at the home, for example one relative commented “ a big thank you, my relative looks so well and contented” and that “ the care was all given with love”. The arrangements in place for the health, safety and welfare of the service users and staff have improved. Doors are no longer wedged open, new magnet closures have been fitted, service users had individualised fire risk assessments. A night fire drill had been carried out. The electrical appliance testing had been completed. The home now displays the current public and employers liability insurance certificate. Evidence of other health and safety checks being carried out at the home was sampled, for example, water temperature checks, fire bell checks, records in respect of food hygiene regulations being kept. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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. 1. 2. Refer to Standard YA18 YA18 YA34 YA22 Good Practice Recommendations Consideration should be given to providing private facilities in order for care management reviews, This would enable meetings to conducted sensitively. The organisation could review the staffing arrangements at the home in order to ensure the service users needs in respect of the Organisations Gender policy are being met. The organisation could consider reminding all of the stakeholders, about the homes complaints procedures. Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Heathlands (Walton-on-the-hill) DS0000013852.V338374.R01.S.doc Version 5.2 Page 28 - 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. 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