Inspection on 08/12/05 for Heathlands

This inspection was carried out on 8th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heathlands 02/08/07

Heathlands 08/06/06

Heathlands 05/09/05

Heathlands 29/10/04

Heathlands 28/07/04

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Thorndene

Insight - Eastchurch

Southfields

Magenta

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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 Pat Collins Unannounced Inspection 8th December 2005 15:45p Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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 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) The Avenues Trust Limited Ms Madeleine Sorensen Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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 5th September 2005 Date of last inspection 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 Avenues Trust manages the home and the property is leased from Southern Housing Association. Heathlands is a detached, two storey building which is domestic in style and character. The home’s location is central to the pretty, semi-rural village of Walton on the Hill. Local shops are within walking distance and larger shopping and leisure facilities are accessible within a short distance by road or public transport. All service users have single bedrooms situated on the ground and first floor. Communal areas include a fitted kitchen, dining room, lounge, sun - lounge, toilet, bathroom, shower facilities and utility room. There is car parking facilities at the front of the home and a large, secluded, secure garden to the rear. Service provision includes sole use of a vehicle. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/2006. It was unannounced therefore staff and service users were not informed in advance of the inspection being carried out. The inspection commenced at 15.45 hrs and was concluded at 19.00hrs. The senior support worker acting in the manager’s absence competently managed the inspection process for part of the inspection. He was out of the home for the other part of the inspection and a support worker left in charge. The senior support worker was the only approved driver on shift and was required to transport service users to and from various activities and to collect a member of staff from home. This was necessary owing to constraints on staff without their own means of transport as the bus service is limited. Requirements made at the time of the last inspection were reviewed and some progress had been made for compliance. A partial tour of the home was carried out. The management of medication and catering was inspected and a number of records sampled. Observation of care practice focused on communication, interaction between staff and service users and on users’ choice specific to catering and aspects of personal care. The inspector consulted all staff on duty and was introduced to all service users. Due to the communication difficulties of the service users living in this home it was not possible to establish their views about life at the home. The inspector would like to thank the service users and staff for their courtesy and cooperation at the time of the inspection. What the service does well: The home had a committed, albeit long – standing very depleted staff team. Staff were friendly and caring in their approach towards service users, encouraging and enabling independence within individual capabilities. Although communication was mainly through non-verbal means, individual service users were observed to confidently approach staff and make their wishes known. Methods for communicating with service users and to enable them to express their needs included a combination of language, gestures, mime and signing. The environment offered a ‘ homely’ and positive atmosphere for service users, whilst appropriately taking into account challenging behaviours, risks and safety issues. The response to a service user’s need for a low arousal environment had been positively managed, balancing the needs of this individual and those of the group. Suitable strategies were in place for the management of this person’s destructive behaviours, mostly in a safe and appropriate way. The number of incidents involving this service user and Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 6 others had substantially reduced since the home was first commissioned four years ago. Observations confirmed staff respect for service users’ dignity and due attention given to their personal appearance, thereby enhancing self – esteem. Service users each had a structured activities programme enabling access to community services and facilities. Opportunities were available for service users’ to socialise with friends living in other care settings. On the evening of the inspection a service user was enabled by staff to attend a social event where she could socialise with friends. What has improved since the last inspection? What they could do better: A person centred approach to care planning was still at an early stage of implementation in this home. It was noted that planning meetings and care Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 7 plans were discussed with key workers during formal supervision meetings. Of concern however was that two of the three care plans and other care documentation sampled including risk assessments had evidently not been reviewed since 2004. This was discussed with the home manager by telephone the day after the inspection. Requirements include the need for priority to be given to updating current care plans and risk assessments for these individuals. Medication practices also required attention, specifically for medication prescribed with instructions for administration ‘as required’, to be documented on medication administration records. Additionally for the pharmacist to be requested to record the general practitioners’ full instructions for administration on medication records and on medicine labels. Observations of practice and routines identified the need to review areas of the home’s operation to ensure adequate opportunities for service users’ to express choices and preferences. For example service users should be offered choice of taking sugar in beverages unless there are mitigating clinical or dietary reasons against this. This should not effect staff’s role for ensuring service users receive adequate guidance and encouragement to promote healthy eating options without excessively restricting users’ choice unless determined by individual needs. Routines specific to aspects of personal care also required review to ensure practices were underpinned by service users’ needs and / or expressed choice. The continuing delay in submitting an application for registration of the manager is concerning and requires urgent action. 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 (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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.V271099.R01.S.doc Version 5.0 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 the following standard(s): 1 The quality and comprehensive content of information produced by the organisation regarding the home would enable prospective service users, with assistance from their families and representatives, to make an informed choice about the home’s suitability. EVIDENCE: It was not possible to ascertain whether the statement of purpose and other documentation that needed to be updated at the time of the last inspection had received attention. On the basis that an amended statement of purpose and service user guide had not been copied to the Commission as required it was concluded that this requirement was outstanding. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 The home is in transition regarding a new person centred planning approach to care being implemented. Some of the current care documents, including risk assessments and care plans had not been regularly reviewed. Records and care practices demonstrated provision of an enabling and supportive environment commensurate with individual service users’ levels of ability. A review of some care routines and practices is necessary however to facilitate increased choice in service users’ lives. EVIDENCE: At the time of commissioning the home individual service users had been enabled to contribute to parts of the care planning process using picture symbols as a method of communication. A framework for implementing a person centred approach to care planning was being introduced across all Avenues Trust care homes, accompanied by new care documentation. The new framework was underpinned by a training programme for staff teams’, which included video learning materials. The manager of Heathlands and one of the service users had actively contributed to making a training video for this purpose. Observations confirmed that a person centred approach to care had not yet been implemented. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 11 The care documentation sampled for three of the service users were contained in care profiles. These contained needs assessments, care plans, risk assessments, social care programmes and review records. Two of the three profiles had evidently not been reviewed since 2004. Discussed at the time of feedback and with the manager following the inspection, was the importance of ensuring care plans and risk assessments were reviewed as a matter of priority. This will ensure needs continue to be met and risks identified and managed. It was recognised that long term staff shortages and the impact of this on the key worker system, also the need to deliver staff training before a personal centred planning approach can be introduced, were the underlying reasons for this shortfall in standards. It is imperative however to find solutions to overcome barriers to maintaining care plans and risk assessments up to date. Observation of care and review records demonstrated that in the past service users had been enabled to express preferences at review meetings. Whilst most service users had no verbal communication skills and two had minimal use of language, it was evident that service users could make some of their wishes clear to staff. Observations confirmed this was possible through gesticulating, by leading staff to show them what they wanted or by other nonverbal means of communication. Service users were observed to be confident in their approaches to staff and staff appeared skilled in understanding their needs. Individuals living in this home were reliant on staff knowing them well. Staff confirmed that facial expressions or behaviours of individuals’ often informed them of what service users want or may be feeling. Care records indicated that service users were encouraged to make decisions in their daily lives. Observation of routines and practices however and discussions with staff identified the need for review of practices to increase opportunities for choice. Specifically to ensure choice is offered in relation to provision of beverages and food unless there are medical constraints in which case this must be documented in care plans. It is acknowledged that a choice of cereal is offered for breakfast. Service users should be offered opportunity to have sugar in drinks with appropriate staff guidance to ensure healthy food choices continue to be promoted. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13, 14, 16, 17. Organising a variety of activities that are both appropriate and developmental can be a challenge for this home, due to the needs of the service users who live there. Observation of records and information provided by staff indicated that service users were being encouraged and supported to be as independent as possible within individual capabilities and enabled to lead fulfilling lives. Service users were offered a healthy diet with opportunities for some choice, which could be further extended. 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. They enjoyed shopping with staff and used a range of community leisure facilities. Other regular activities included attendance at social clubs, art and movement and music sessions, cookery classes and access to sensory facilities. Service users had enjoyed supported small group holidays this year with staff from the home. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 13 The home’s day – to – day operation promoted service user independence and freedom of movement. Two service users were observed spending time alone in their bedrooms at the time of the inspection. The remaining service users’ were mostly in the lounge supervised by a support worker who was observed to engage in frequent, age appropriate interaction with them. A video was playing and one service user appeared to be enjoying the choice of film. The home was tastefully decorated for Christmas. At the time of the inspector’s arrival a support worker was engaging service users in an activity in the dining room, making Christmas cards. Soon after the inspector’s arrival two service users came home following an activity session at a day care establishment, transported by the senior support worker who was in charge of the shift. Later the same senior support worker transported another service user to a social event where she had opportunity to meet current and former friends. 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. Consultation with staff confirmed that service users’ were offered a choice of breakfast cereals. The menu was compiled by the manager and a senior support worker and promoted healthy eating food and drink. Record keeping systems ensures staff were aware of service users’ individual dietary needs. Observations confirmed that arrangements for catering and provision of drinks could introduce increased opportunities for choice. Food storage was of a good standard and fridge and freezer temperature records were maintained daily. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 A review of elements of personal support was necessary to ensure practice and routines are based on needs assessments and/or individual choice. Attention was also required to the home’s medication procedures in consultation with the local pharmacy supplier. EVIDENCE: All service users living in the home required assistance with personal care and this was part addressed in the care plans sampled. Observation made of daily personal care routines; specifically daily showers for some service users were not evidently on the basis of individual needs or choice. This was concluded from details in care plans and from the information obtained from staff. The need to review this element of care practice and routines was discussed to ensure practice is needs led and not based on service users’ gender. The homes principles and values around privacy and respect were evident through observation and discussion. Staff safeguarded the privacy and dignity of service users at the time of the inspection. Service users were stated to be encouraged to do what they can for themselves in respect of their personal care, with staff being mindful of the need to offer opportunity for privacy where possible. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 15 The needs of a service user were noted to determine the deployment of female night staff. The home had a monitored dosage medication system. Medication storage, administration and record keeping were sampled. Observations identified attention necessary to record keeping to ensure medication prescribed for administration ‘as required’ is recorded on individual MARR charts. The manager should consult the pharmacist to request that medication labels and MARR charts be produced containing general practitioners directions for administration; also to request printed adhesive labels for MARR charts for medication prescribed in between the repeat prescription cycle. Records of receipt, administration and disposal of medication were satisfactory. The home’s metal medication cupboards included one for controlled drugs, were secure and access to medication keys was restricted. There were no controlled drugs prescribed at the time of the inspection. None of the service users’ had capacity for self-administration of drugs and this was the role and responsibility of staff. There was a medication-training programme, which included an element of assessed practice. Clear protocols were in place relating to administration of medication prescribed ‘as required’. Systems were in place for the daily monitoring of the temperature in medication cabinets to ensure safe storage. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. The home meets each of the assessed standards and provides a good standard of accommodation appropriate to the needs of the current service users. EVIDENCE: The environment was warm, comfortable, clean and tidy and well maintained. Services and facilities were appropriate to meet the needs of service users and the home’s location was central to village shops and other community amenities. The all-single occupancy bedrooms afforded a good standard of accommodation that had been decorated to reflect the individual tastes and interests of service users. The individual needs of a service user who required a low arousal environment were balanced against the groups needs. Particular attention had been given to provision in this individual’s bedroom. There was an ongoing programme of redecoration and repair in this room in order to maintain this environment in reasonable condition. This was necessary in response to the challenging behaviours exhibited by this individual. Communal areas were domestic in character and suitably equipped. Service users had access to a large, well maintained, secure furnished garden. Exercise Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 18 equipment was available for service users’ to use in the pleasant sun lounge overlooking the garden. The environment had been suitably assessed for specialist aids and adaptations to meet individual needs at the time of carrying out conversion work to provide a second ground floor bedroom. A walk in shower facility was available on the ground floor. Since the last inspection a new washing machine had been purchased and a new shower power unit had been fitted in the first floor bathroom. A new system for maintaining hygiene in the home had been installed in the kitchen and laundry room. The home was seasonally decorated for Christmas, creating a lively, stimulating environment that service users appeared to enjoy. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Staffing arrangements were in accordance with minimum staffing levels. Staff were well motivated to meet service users needs though there were ongoing constraints due to recruitment difficulties for permanent staff. The relationship between staff and service users was observed to be positive and friendly. EVIDENCE: Since the last inspection a part time support worker had been recruited and was on duty at the time of the inspection. It was understood that there remained seven support worker vacancies. In discussion with the most recently appointed support worker recruitment procedures described were in accordance with good practice guidance and statutory vetting procedures followed. It was noted that these procedures took approximately five months from start to completion. Personnel records were not accessible for inspection to enable cross – referencing this information and to follow up the relevant requirement. These records were securely stored in the home and will be followed up at the time of the next inspection. Regular bank staff continued to be used, supplementing the staffing establishment, ensuring minimum staffing levels were maintained and continuity of care. The depleted staff team continued to have an adverse impact on areas of the home’s operation and management identified at the time of the last inspection. Specifically this was the shortage of approved drivers that detracted from available management hours and impact on key Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 20 working, care planning and reviews. Relationships between staff and service users appeared positive and respectful. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 This standard was not met on the basis of the failure to submit an application for registration of the day – to - day manager. Registration of a manager is a legal requirement and delays in making application for registration could have a bearing on the manager’s ‘fitness’. EVIDENCE: The manager was off duty at the time of the inspection. It was not therefore possible to clarify with her the adequacy of the home’s management structure. Observations identified shortfalls in the home’s operation, specifically the need to ensure adequate frequency of reviewing service users care plans and risk assessments. The manager was promoted to the vacant manager post in June 2005. This vacancy was created through the internal promotion of the registered manager within the organisation. The home has not had a registered manager for a substantial period. The ongoing failure to make application for registration and for a CRB Disclosure through the Commission is an ongoing concern and for this reason this standard is not met. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 22 Since the last inspection a health and safety representative had been appointed. Improvement was noted in fire safety and regular fire tests were carried out. A fire drill had also been recently undertaken. Observations confirmed the need to develop the home’s fire risk assessment. Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 23 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 x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x x x x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heathlands (Walton-on-the-hill) Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score 1 x x x x 2 x DS0000013852.V271099.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 6(a)(b) Requirement Timescale for action 08/01/06 2. YA6YA 6 6(a)(b) 2. YA6 14(2)(a)(b) 15(2)(b) 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. This requirement is brought forward from the last inspection as unmet within the set timescale of 05/11/05. For service users care 08/01/06 plans and risk assessments to be reviewed by key workers and monitored by the manager to ensure these are up to date. For care plans to be 08/02/06 formally reviewed with service users and where practicable their representatives at least six monthly. This requirement is brought forward from the last DS0000013852.V271099.R01.S.doc Version 5.0 Page 25 Heathlands (Walton-on-the-hill) 3 YA7YA 7 12(2) 4 YA20YA 20 13(2) 5 YA23 13(6), 18(1)(a)(c)(i) 6 YA32 12(1)(a), 13(4)(c) 7 YA33 18(1)(a) inspection as unmet within the set timescale of 05/11/05. For review of personal care practices and catering to ensure service users receive appropriate opportunities for choice in their daily lives. For MARR charts to include medication prescribed for administration ‘as necessary’. The manager must also consult the pharmacist to request details of GP’s instructions on MARR charts and medication labels. For all staff to receive adult protection training. This requirement was not inspected and is brought forward from the last inspection report and the timescale for completion extended. For all staff to receive epilepsy awareness training and to have current first aid certificates. This requirement was not inspected and is brought forward from the last inspection report and the timescale for completion extended. For the home to have an effective staff team in sufficient numbers to meet the service aims and to adequately support service users 08/02/06 08/01/06 08/01/06 08/01/06 08/03/06 Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 26 8 YA34 19(1)(a) Sch 2 9 YA35 18(1)(i) 10 YA37YA 37 YA39YA 39 7(1)(2) 11 24(1)(a)(b) 12 YA42 23(4)(a) assessed needs. This requirement was unmet within the timescale of 05/11/05. For personnel files to contain all statutory documentation and CRB records maintained containing all information in accordance with CRB policy. This requirement was not inspected and is brought forward from the last inspection report and timescale for compliance extended. For review of staff training portfolios to ensure core statutory training needs are met. This requirement was not inspected and is brought forward from the last inspection report and timescale for compliance extended, For submission of an application for registration of the dayto-day manager. For quality assurance systems to be further developed. This requirement was not inspected and is brought forward from the last inspection report and the timescale for compliance extended. For the fire risk assessment to be reviewed and further developed. DS0000013852.V271099.R01.S.doc 08/03/06 08/03/06 31/12/05 08/03/06 08/02/06 Heathlands (Walton-on-the-hill) Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heathlands (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Surrey Area Office 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 (Walton-on-the-hill) DS0000013852.V271099.R01.S.doc Version 5.0 Page 29 - 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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