Inspection on 05/09/05 for Heathlands

This inspection was carried out on 5th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heathlands 02/08/07

Heathlands 08/06/06

Heathlands 08/12/05

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 Chequers Lane Walton-on-the-Hill Surrey KT20 7ST Lead Inspector Pat Collins Unannounced Monday 5 September 2005, 10:40am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heathlands (Walton-on-the-hill) Address Heathlands, Chequers Lane, Walton-On-The-Hill, Surrey, KT20 7ST 020 8308 2900 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) The Avenues Trust Limited To be confirmed CRH 6 Category(ies) of LD Learning disability: 6 registration, with number of places Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 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 Date of last inspection 29th October 2004 Brief Description of the Service: Heathlands is a care home for six adults with profound or severe learning disabilities and other complex needs. Specialist support is available to the team to enable appropriate management of challenging behaviours. The home is managed by The Avenues Trust and the property is leased from Southern Housing Association. Heathlands is a detached, two storey building which is domestic in style and character and is located central to the pretty semi-rural village of Walton on the Hill. Local shops are within walking distance of the home. Larger shopping and leisure facilities are accessible within a short distance by car or a limited bus service. All service users have single bedrooms situated on the ground and first floor. Communal areas include a fitted kitchen, dining room, lounge, sunlounge, toilet, bathroom, shower facilities and utility room. The home has a small car park at the front and a large, secluded, secure garden to the rear. Provision includes suitable transport facilities. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first inspection for the year 2005/2006. It was unannounced therefore staff and service users were not informed in advance of the inspection being undertaken. The inspection commenced at 10.40 hrs and concluded at 17.00hrs. The recently promoted home manager was present throughout the inspection. The inspection involved follow up of progress made for meeting requirements of the last inspection. A partial tour of the home was carried out and some records, also policies and procedures, were examined. The inspector spoke with the manager and one staff member (support worker) in some depth and was introduced to other staff present in the home. The views of two service users were sought about life in the home with the assistance of the manager. The manager was skilled in the use of a combination of language, gestures, mime and signing to illicit relevant information. The service users in this home mostly have no verbal language skills. Specialist input has been obtained over a period of time to enable staff to work out the communication skills of each service users. The inspector would like to thank the service users, staff and management of Heathlands for their courtesy and cooperation during this inspection. What the service does well: The quality of information about the home was very good. It was in accessible formats to be confident that prospective service users, with the help of their family and representatives, would be able to make an informed choice as to the suitability of the home. The home had a committed, albeit depleted staff group. Staff on duty were observed in their interaction with service users to be respectful and ageappropriate. They demonstrated good knowledge of the needs of service users, ensuring appropriate communication with them at their levels of comprehension. The environment afforded a homely and positive atmosphere for service users, whilst overall taking account of the challenges of behaviours, risks and safety issues. The response to a service user’s desire and need for a low arousal environment was observed to have been positively managed, balancing the needs of this individual and other service users. Suitable strategies were in place for the management of this person’s destructive behaviours, mostly in a safe and appropriate way. It was noted that a recent lapse in safety systems had resulted in an incident in which an essential item of equipment had been damaged. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 6 Service users were actively encouraged to participate in the day-to-day running of their home within individual levels of capacity. Each service user had their own individual risk assessment enabling them to take responsible risks. Care plans reflected an individualised approach to meeting needs. Observations confirmed staff respect for service users dignity with appropriate attention given to dress and personal appearance, enhancing self – esteem. Service users each had a structured activities programme enabling access to community services and facilities. There were opportunities for socialising with people outside of the home. Administration and record keeping was well organised. Staff training files demonstrated arrangements for new staff to receive induction training and continuous further training and development. What has improved since the last inspection? What they could do better: There remained long – standing difficulties in recruiting staff to this particular home. This was related to its semi-rural location and restricted bus service. These long-term vacancies combined with an inevitable staff turnover since the home was registered had resulted in a severe shortage of approved drivers for the home’s vehicles. The adverse impact of this situation was a reduction in management hours available due to the time the manager was spending transporting service users to various appointments and day placements. Whilst minimum staffing levels were maintained through use of regular bank staff or as a last resort, agency staff to ensure continuity of care, the depleted staff numbers had delayed in-house care reviews; also had adversely impacted on other operational and management activities. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 7 Attention was required to personnel records to ensure these contained statutory documentation. Also attention required to Criminal Records Bureau records. The manager advised this was currently being addressed by the organisation. The inspection identified the need for ensuring all staff’s training and developments needs were met. Additionally for regular fire drills to be carried out. 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 H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 Prospective service users and their representatives received comprehensive information about the home. Admission decisions were based on assessment of needs. There was opportunity for prospective service users to visit and try out the home before making a final decision to move in permanently. EVIDENCE: The statement of purpose and other documentation required updating to include details of the new manager. Service users guides had been produced and personalised using pictorial and widget symbols. These were kept in the office. There had been no new admissions since the last inspection. The service users files sampled contained detailed information relating to the individual needs of service users. Past admissions were based on comprehensive needs assessments. Admission procedures confirmed a gradual approach to moving in incorporating introductory visits and trial period for deciding the suitability of the home. A new person centred planning framework was stated to have been produced by the organisation and will be shortly implemented. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, 9 and 10 Care plans sampled were clearly written and reflected needs, goals and assessed risks though it was not clear if these were current. The review programme had been adversely affected by circumstances outside of the manager’s direct control. Care practices promoted service users involvement in domestic routines within individual capabilities. Information about service users was managed confidentially. EVIDENCE: Staff shortages and the change between individual personal planning and person centred planning approaches to care plans had held up the development of some care plans and their review. Staff shortages had an impact also on the key worker system. One service user had a bank key worker. The shortage of staff drivers reduced the available hours for the manager to manage the home. Service users Personal Planning Books were updated as required. It was noted that service users no longer had allocated Local Authority care managers. This was not apparently detrimental to them as annual care management reviews continued. Matters needing discussion or notification to care management were reported to duty care managers. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 16 and 17. The home meets each of these assessed standards. This means that the home was able to demonstrate that service users were encouraged and supported to be as independent and to lead as fulfilling lives as they were able. EVIDENCE: Service users attended a variety of external activities. Two attended the Mosley Day Centre and others attended the Croft Day Centre. Service users were unable to undertake paid employment as a result of their severe learning disabilities. Service users enjoyed shopping with staff and used a range of community leisure facilities. Other activities included opportunity to attend social clubs, art sessions, movement and music sessions and engage in cookery classes and use sensory facilities. Service users also enjoyed supported holidays with staff since the last inspection, staying in rented holiday cottages near Brighton. Other holidays were planned in Devon and Cornwall for later this year. Next year one service user was going to Disneyland, Paris accompanied by a staff member. The manager stated that the team was exploring the possibility of other service users experiencing European holidays next year. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 12 It was evident that effort was made to develop and maintain positive relationships with neighbours. Continuously striving to find ways for ensuring social inclusion for service users in the community, the manager had sought membership for the home of the local residents association. The team and service users had also achieved first prize in a village competition earlier this year for “The Best Dressed House”. The front entrance proudly displayed photographs commemorating this achievement. The Inspector observed that the daily routines of the home promoted service user independence, individual choice and freedom of movement. On several occasions during the inspection visit, a service user chose to sit in the office and “take part” in the inspection process. Also service users were included in the staff meeting, which took place on the afternoon of the inspection. Staff explained their methods for ensuring confidentiality and preserving the confidences of service users during these meetings. The menu’s inspected included a variety of meal options that were both balanced and nutritious; the menu also recorded changes to the main menu. Food storage was appropriate and fridge and freezer temperatures recorded daily. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Access for support from medical and other health professionals was evidenced, ensuring needs were met. Personal support needs were being appropriately met. EVIDENCE: Staff were directly and indirectly observed in their interaction with service users. Their approach was caring and age-appropriate. There was access to specialist support and advice if required. An aromatherapy session for a service user by a visiting qualified therapist had taken place in the home on the day of the inspection. The home had minimal rules and service users were stated to have some choice of staff working with them. The inspector endeavoured to establish the views of two service users about life in the home, over a cup of coffee, in the dining room. The manager was helpful in assisting these individuals to engage with the inspector and the inspection process in a meaningful way. The manager used communication techniques to illicit some basic information. It was clear that these individuals were offered a choice of food and encouraged to be involved in every day routines in the running of their home. One resident took the inspector’s cup to the kitchen to be washed up. The other service user was noted later to be in his bedroom being encouraged by a staff member to change his sheets and Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 14 help clean his room. The appearance and body language of both individuals suggested they were comfortable in staff’s presence. Service users were registered with a general practitioner, (GP) and visited the medical practice with staff escorts. On the afternoon of the inspection a service user visited the GP practice and the GP completed a comment card as part of the inspection process. Positive feedback was received from the GP regarding the home’s arrangements for managing healthcare matters. It was evident from the information supplied that the home communicated clearly with the medical practice and worked in partnership with GP’s. The records demonstrated that staff monitored the health of service users effectively. Waking night support worker used a two - way alarm for monitoring risks relating to nocturnal seizures for a service user with a history of epilepsy. The team encouraged service users to lead healthy lifestyles by promoting opportunities for exercise. Service users had access to a treadmill and exercise bike that they had collectively purchased and stored in the sun lounge. The manager stated this activity had been fully risk assessed. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The complaint procedure was accessible to service users advocates and had been effectively implemented in the past. Communication limitations inhibited efforts made to establish from service users their feelings of being listened to by staff. Though service users were well protected by the organisation’s recruitment practices the training plan required review to ensure all staff received adult protection training EVIDENCE: Service users did not have meetings but were included in staff meetings. The home had a comprehensive complaints procedure and service users had access to a pictorial format complaint procedure in their Service Users Guides. The complaint procedure in the procedure manual was observed to require updating. There had been no complaints since the previous inspection. Procedures and policies were available for staff’s reference on adult protection, confidentiality, bullying and whistle blowing. The staff recruitment policy was for all new staff to have an enhanced disclosure issued by the Criminal Records Bureau before taking up post. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 This family-scale home provides a comfortable, good standard of accommodation to suit the needs and lifestyles of those accommodated. The home was clean and hygienic and designed to maximise independence. EVIDENCE: All service users had single bedrooms, two of which were located on the ground floor for meeting mobility needs. Bedrooms had been recently redecorated reflecting the individuality of their occupants in the choice of colour schemes, furnishings and in the way they had been personalised. One bedroom was in need of refurbishment and this was under discussion. For a service user who required and preferred a low arousal environment, staff had addressed this need by provision of a walk in wardrobe in this individual’s bedroom. This had enabled personal items on shelves to be cleared away also preventing destruction of clothing. There was an ongoing programme of redecoration and repair in this room in order to maintain this environment in a reasonable condition. This was necessary in response to the challenging behaviours displayed by this individual. Communal areas were tastefully decorated and comfortably furbished. New dining tables were a positive new development. The home was clean and tidy. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 17 A new television had been purchased. Service users had access to a large, well maintained, secure furnished garden. The environment had been suitably assessed for specialist aids and adaptations to meet individual needs at the time of carrying out conversion work that created a second ground floor bedroom. A walk in shower facility was available on the ground floor. At the time of the inspection the washing machine was not working having been damaged in a recent incident. A further washing machine was stated to have been acquired and was awaiting delivery and installation. Ventilation in the utility room had recently been reviewed and the extractor unit repaired. Plans were noted for changing the layout of the utility area in an effort to improve lighting. Damp in the ground floor shower room was stated to be a recurrent problem but had been again recently attended to. The shower unit on the first floor was not functioning properly and required replacement or repair. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Staff on duty appeared to be enthusiastic and committed to supporting service users and meeting their needs. A programme for staff training and development was evident though gaps in training for individual staff was observed. Acknowledging that minimum staffing levels were being maintained, the ongoing staff recruitment problems and delays in vetting new staff was having an adverse impact on areas of the home’s management and operation. EVIDENCE: The senior support worker interviewed at the time of the inspection demonstrated an understanding of the needs of service users. She reported enjoying working at Heathlands. Relationships between staff and service users were observed to be appropriately informal and friendly. The manager was skilled in her approach to communicating with service users. The manager informed the inspector that the home had seven staff vacancies, though it was understood three staff had been appointed but not able to take up post due to vetting procedures being incomplete. Long – term problems remained in staff recruitment for this home, compounded by the restricted bus service that did not serve the home’s shift patterns. The manager stated that it was not feasible to work shift patterns round bus timetables. Bank staff was used and as a last resort, agency staff, to maintain minimum staffing levels. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 19 The depleted staff team had adversely impacted on areas of the home’s management and operation. Examples of this included a shortage of drivers, which eroded the management hours available. Also adversely impacting on key working responsibilities, care planning and the review programme. The manager reported recent revision of procedures within the organisation specific to personnel information to be transferred to and maintained in homes. This will be compliant with statutory requirements not currently met. The information available did not include recent staff photos and the CRB record was incomplete. All staff had a training portfolio. Those sampled evidenced routine induction and foundation training though some staff needed adult protection training and first aid updated training. All staff had a detailed workbook within their sixmonth probationary period linked into NVQ level 2 training under the Learning Disability Award Framework. The home had a full time senior support worker who had attained NVQ Level 3 and two part time support workers who were both registered first level nurses and stated to be NVQ assessors. Two support workers had been nominated for NVQ Level 2 training but had not yet started the programme. It is unlikely that the home will be compliant with the requirement for 50 of support workers to have NVQ 2 or equivalent by the target date in 2005. Observations also identified the need for some staff to attend epilepsy awareness training in accordance with assessed needs and the care plan for a service user. The structured training needs analysis that was linked to the service aims and to service users needs was recognised by the manager to require review. The delay in doing so appeared symptomatic of the competing pressures on her time. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41 and 42 The manager was sufficiently experienced to competently manage the home however senior management must ensure the senior staffing structure is adequate to support the manager. Also to ensure sufficient management time available for the management of the home. Record keeping was overall well organised though inaccuracies in handover records identified need for improvement to existing handover record formats. Quality Assurance systems required further development. Though overall the health, safety and welfare of service users were protected the frequency of fire safety practices must be increased. EVIDENCE: The home manager vacancy created through the internal promotion of the registered manager earlier this year was filled in June through a promotion within the team. The new manager had not yet applied for registration but confirmed her intention to do so imminently. The manager was part way through her studies for the Registered Manager in Care Award qualification. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 21 The management team currently comprised of the manager, a full - time and two part - time senior support workers. The manager reported that her line manager had agreed to the transfer of a senior support worker from another home within the group. This will strengthen the home’s management filling the vacancy for a senior support worker. Observations confirmed shortages of staff drivers had reduced the time available for managing the home owing to the demands this placed on the manager who was the only full time driver. Additionally the frequent use of taxis had placed pressure on the home’s budget together with the cost of repairs. The manager stated that discussions with her manager regarding these matters had been productive and it was planned for the home to have an automatic drive vehicle. This would enable other staff that are able to drive this type of vehicle to share responsibilities for transporting service users to day placements and appointments. The manager reported that a new quality assurance programme had been developed by the organisation. It was stated that a manager had been appointed to implement quality assurance systems throughout the organisation. The manager did not have details of the programme at the time of the inspection. Relatives meetings were not held by the home as only one relative lived locally. Relatives, both local and living some distance away however did attend reviews and took an active interest in the welfare of service users and the operation of the home. The Avenues Trust was stated to organise relatives meetings annually. Existing quality systems included direct observation of practice and the wellbeing of service users. Also monthly unannounced statutory audits carried out by line management and other visits by the line manager. A senior support worker was stated to be developing in-house auditing systems in addition to the weekly and monthly audits taking place. The need to extended quality systems to include views of service users and their advocates also external agencies and relevant professionals was discussed. A health and safety audit was carried out annually by the organisation and a pharmacy audit by the local pharmacist. Documentation of these audits was not viewed on this occasion. The home had a comprehensive list of policies and procedures and a program for reviewing and updating procedures was evident. Staff had access to all relevant policies and procedures. Record keeping practices were discussed with the manager specific to information to be recorded by staff at handovers. The record formats required review to reduce duplication and to improve accuracy of information recorded. It was suggested these documents be streamlined. Arrangements were evidenced to mostly ensure the safety of service users and staff. The frequency of fire practices must be increased. Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 2 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heathlands Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x 2 3 2 2 x H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 23 Yes 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. Standard YA 1 Regulation 6 (a)(b) Requirement Timescale for action 05/11/05 2. YA 6 14(2)(a) (b), 15(2)(b) 13(6), 18(1)(a) (c)(i) 23(2)(b) 3. 4. 5. 6. YA 23 YA 27 YA 32 YA 33 For the statement of purpose, service users guide, complaint procedure and other written information to be updated to reflect the change of manager and revised copies forwarded to the Commission. For care plans to be reviewed 05/11/05 with service users and their representatives at least every six months. For all staff to receive adult 05/11/05 protection training. 05/10/05 05/11/05 05/11/05 7. YA 34 8. YA 35 For the first floor shower power unit to be repaired or replaced. 12(1)(a),1 For all staff to receive epilepsy 3(4)(c) awareness training and to have current first aid certificates. 18(1)(a) For the home to have an effective staff team in sufficient numbers to meet the service aims and adequately support service users assessed needs. 19(1)(a) For personnel files to contain all sched 2 statutory documentation and CRB records maintained containing all information in accordance with CRB policy. 18(1)(i) For review of the training needs of staff to ensure core statutory H09 H58 s13852 Heathlands v247419 010905 stage4.doc 5/10/05 05/10/05 Page 24 Heathlands Version 1.40 training needs are met. 9. 10. YA 39 YA 41 24(1)(a) (b) 17(3)(a) For quality assurance systems to be further developed. For handover records to be accurately maintained and it is recommended that the formats for these records be revised. For regular fire practices to be carried out and records maintained. 05/01/06 19/10/05 11. YA 42 23(4)(iii) 05/10/05 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. Refer to Standard Good Practice Recommendations Heathlands H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Wharf, Abbey Mill Business Park, Eashing, Surrey, GU7 2QN 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 H09 H58 s13852 Heathlands v247419 010905 stage4.doc Version 1.40 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!