Inspection on 26/07/07 for Heathside

This inspection was carried out on 26th July 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

Heathside 30/07/08

Heathside 22/06/06

Heathside 28/12/05

Heathside 30/06/05

Heathside 03/11/04

Heathside 28/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Heathside Heathside Coley Avenue Woking Surrey GU22 7BT Lead Inspector Sandra Holland Unannounced Inspection 08:55 26th July 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathside Address Heathside Coley Avenue Woking Surrey GU22 7BT 01483 765046 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) michelle.saville@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust Ms Michelle Saville Care Home 51 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (21), Physical disability over 65 years of age (8) Heathside DS0000013671.V339902.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: OVER 65 YEARS OF AGE 22nd June 2006 Date of last inspection Brief Description of the Service: Heathside is run by Anchor Trust Ltd, a national care organisation. The home can accommodate up to 51 older people, including up to 20 people who may have dementia. The home was purpose-built and is located in a residential area close to the centre of Woking town, with its range of shops and facilities. The home has seven units over two floors and each unit has a combined dining room, lounge and kitchen. All bedrooms are for single occupancy. There is a large lounge/day room on the ground floor that is usually used for activities. There is also a small seating area on the first floor as an alternative place to sit. There are extensive gardens and there is ample parking to the front of the home. The fees at this service range from £457.52 to £600.00 per week. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI), under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulatory Inspector, carried out the inspection over eight hours. Ms Michelle Saville, Registered Manager, was present representing the service. A tour of the premises was carried out and a number of records and documents were sampled, including medication records, residents’ individual files and staff recruitment and training files. A number of residents and staff were spoken with on units during the tour of the home. An Annual Quality Assurance Assessment (AQAA) was supplied to the home and this was completed and returned. Information supplied in the AQAA will be referred to in this report. A number of CSCI feedback forms were sent to residents, their representatives and healthcare professionals, to obtain independent feedback as to how the service meets residents’ needs. The responses to the feedback forms are referred to at Standard 33 which refers to quality assurance and at other applicable standards. The people living at the home prefer to be known as residents so that is the term that will be used throughout this report. The inspector would like to thank the residents and staff for their time, hospitality and assistance. What the service does well: Positive feedback has been given regarding the home, including: “The home keeps a happy and cheerful atmosphere”; “They have the ability to make time for individuals and speak to residents in a caring way to make them feel important” ; “Staff are busy, but do all they can to ensure people are happy with their living arrangements, and “The home is clean and some of the staff are dedicated, helpful and pleasant”. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 6 Residents healthcare needs are very well met and positive feedback has also been received from visiting healthcare professionals. A range of activities are offered to residents and they are actively supported to maintain their links with family, friends and the community. Residents are offered a choice of meals each day as the meal is served, so residents do not have to try and anticipate what they might enjoy tomorrow. A clean, fresh and homely environment is provided, which is equipped and furnished to meet the needs of residents. Residents have been encouraged to bring their belongings into the home to make their rooms their own. What has improved since the last inspection? What they could do better: Residents’ care plans must be drawn up as soon as possible after admission so that care staff can be aware of residents’ care and support needs. A record of the care provided and any other events in the residents’ lives should be recorded each day on the “daily notes” form provided as part of the residents’ care plan. Risk assessments, mobility assessments and other areas of the residents’ care plans should be clear for staff to use and understand. Where assessments have been reviewed on a number of occasions and are no longer clear, it is recommended that they are renewed completely. Medication records must be maintained to ensure that an audit trail can be followed. Handwritten entries onto medication record charts should be signed by the person making the entry. It is good practice for a second trained member of staff to check the entry and to countersign that they have done so. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 7 It is recommended that the home’s policy and procedure is reviewed to ensure that the correct actions are taken to safeguard residents in the event of a suspicion or allegation of abuse. A record of staff induction must be maintained and kept in the home. It is good practice to carry out induction of staff as soon as they are appointed, so that they understand their roles and responsibilities. Staff must receive formal supervision and this should be to the recommended frequency of six times each year. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are assessed before they are admitted to the home. EVIDENCE: The files of a number of residents were seen including those of recently admitted residents and it was noted that the needs of prospective residents had been fully assessed prior to their admission. The manager stated that a high proportion of residents in the home are supported financially by the local authority. Where this is the case prospective residents have been assessed under the care management process and if residents decide to move into the home, a copy of the assessment has been obtained. The manager stated that intermediate care is not provided at the home, so Standard 6 does not apply. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are available to guide staff to the needs of residents, but these need to be completed as soon as a resident is admitted, be completed more fully and should include assessments of all risks to residents. Residents’ healthcare needs are very well met. Medication records must be maintained to enable an audit trail to be followed. EVIDENCE: Detailed individual care plans have been drawn up to guide staff to the care and support needs of residents and these had been recorded as having been reviewed each month. The manager stated that these are gradually being changed over to a new style of care plan that has been developed by the Anchor organisation. The new style of care plan is being drawn up for any newly admitted residents. It is planned to change the care plans of existing residents to the new style over a period of months, completing a unit at a time. The manager advised that she and three other staff have received training in the use of the new style plans. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 11 It was noted that the care plan for a recently admitted resident had not been fully drawn up until three weeks after their admission. It is not clear how staff would have known how to meet the needs of this resident, particularly for personal care, where there was a recorded risk of self-neglect. Elsewhere in the care plan for this resident was a sheet marked “baseline assessment to be completed with 24 hours of admission”, but this had not been completed. Assessments of risks to residents have been included in their care plans, including risks associated with mobility and the use of oxygen. It was noted that an assessment of the risks of falls had not been completed for two residents, one of whom had been admitted for many months. It was also noted that some assessments have been reviewed on a number of occasions and the essential information is no longer clear. Where this is the case, it is recommended that the whole assessment is renewed. A falls assessment record sheet is included in the care plan, but had not been completed for two residents, one of whom was at risk of falling according to other information in the care plan. The National Minimum Standards for Older People (NMS) recommend that residents’ care plans should “include a risk assessment, with particular attention to the prevention of falls”. “Daily notes” are included as part of residents’ care plans, to record care given and other day to day events in the residents’ lives. It was noted that a number of these did not record “daily” notes as there were gaps in the entries, and a gap of nine days was noted for one resident. This resident appeared to be quite frail from other information in the care plan, but the daily notes have not recorded any care or support given for a nine day period. The manager stated that a record is only made in the daily notes when there is an event to be recorded, rather than writing something for its own sake. From the records and documents seen it was clear that residents’ healthcare needs are very well met and a number of healthcare professionals are involved in the support of residents. These include general practitioners (GPs), district nurses, specialist nurses, optician, hospital specialists and chiropodist. Details were included in residents’ care plans of visits by, or appointments with, healthcare professionals and the results of these. Positive feedback was received from healthcare professionals including ”They (staff) seem to ask for medical advice appropriately and staff have a good knowledge of the residents’ needs and medical condition” and that staff treat the residents as individuals and “Respect their (residents’) dignity”. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 12 Overall, medication appeared to be effectively managed. Senior staff advised that two staff take the lead in ordering and receiving medication. A monitored dosage system is used, in which medication is supplied in “blister” packs, with each medication supplied in individual packs, appropriately labelled with the required information. Printed medication administration record (MAR) charts are supplied by the pharmacy which supplies the medication. Where handwritten entries had been made on MAR charts, most of these had been signed by the person making the entry and signed by a second member of staff to show they had been checked, although one resident’s MAR chart was handwritten and had not been signed by the person making the entries. Medication was seen to be appropriately stored in an allocated room and a lockable fridge was available for the storage of medication that required chilled storage. The amounts of medication held were randomly sampled and checked against the record held. Most of these accurately matched, but it was noted that for one resident where a variable dose of medication could be given, the amount actually administered was not always recorded. As a result it was not possible to know exactly how much should be present, or to accurately follow an audit trail. Staff were observed to speak to residents with respect and to promote residents’ privacy whilst providing support. Staff were seen to knock before entering residents’ bedrooms and assistance with personal care was provided sensitively and discreetly. Requirements have been made regarding Standard 7, that residents’ care plans must be completed and must include assessments of all known or identified risks to residents and Standard 9, that the records of medication administration must be maintained to enable an audit trail to be followed. A recommendation has been made that assessments in residents’ care plans should be renewed if the information is no longer clear. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities is available to residents. Residents are supported to maintain links with the community and are encouraged to be independent and to make their own choices. A well-balanced and varied diet is offered. EVIDENCE: The manager stated that an activities co-ordinator is employed at the home for twenty hours each week to support residents with their social and recreational interests. The manager advised that she has requested additional funding in next year’s budget, to enable her to provide increased activities staff hours. The activities co-ordinator is currently undertaking training in the provision of activities in a care setting to develop their knowledge and skills, the manager advised. An activities programme was seen displayed on the noticeboard in each unit and it was positive to note that this was available in both pictures and words on a unit that cares for residents with dementia. The activity programme included a quiz, ball games, sherry morning, walk in the park or town, piano Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 14 music session, pampering sessions, films and helping in the home, such as laying tables and folding laundry. A small shop is provided within the home and is open for a short period each day to enable residents or their families or friends to buy items such as toiletries, sweets, stationery and biscuits. The home has a large garden which has been enclosed to ensure that it is safe for residents to use. Information supplied in the AQAA stated that representatives of local churches and schools are invited into the home to ensure that residents maintain links with their community. Schools are invited to be involved in Christmas concerts and harvest festival events, for example. Photographs of events that had taken place were displayed in the home, including a summer fair, a resident’s 103rd birthday party and a fashion show. Staff were seen to offer residents choices, such as meals and drinks, and to encourage residents to be independent as far as possible. A cool drink dispenser was seen in each unit dining area and staff advised that they contain a juice drink which has been enhanced with vitamins. The drink is available in a variety of flavours, is changed regularly and residents’ preferences are taken into consideration. Staff advised that this is designed to encourage residents to drink more to maintain and ensure good levels of hydration. Residents were spoken to as they were served their lunchtime meal, which was served in the dining area of each individual unit. Tables to seat small groups of residents were attractively laid with tablecloths and napkins. Residents advised that there is a choice of main meal each day and they are offered both so that they can make a choice. A small number of residents stated that they did not like the choice of meal on the day of inspection, but others were seen to be enjoying it. The main meal options on the day of inspection were minced beef and onion pie or barbecued sausages. Residents were aware that they could request alternative meals, such as salad or filled jacket potatoes, if they did not like the main meals on offer. Information supplied in the AQAA stated that the home uses a nutritional screening tool and the results of the nutrition screening are used as a guide towards menu-planning. Records of residents’ weights were included in their care plans and information in the AQAA stated that extra nutrition is supplied if required. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any complaints received have been appropriately managed. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: Information supplied in the AQAA stated that eight complaints have been received in the last year, of which three were upheld and one is awaiting an outcome. The manager stated that she welcomes compliments, comments and complaints as these enable the home to make improvements in the service provided. The manager advised that a compliments record is maintained and it was noted that six letters and cards of compliment have been received already this year. The home’s complaints record was seen and it was noted that complaints had been responded to in writing, and the letters were numbered with the complaint for tracking purposes. Since the last inspection the CSCI has received information from one person, who wished to remain anonymous, about their concerns regarding the home. The person was advised to contact the home and to address their concerns through the home’s procedures. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 16 The home’s policy and procedure regarding abuse is incorporated into the policy regarding rights and responsibilities, and links with other policies including risk management, whistle-blowing and violence and aggression. It was noted that the abuse policy and procedure mainly refers to staff actions, but makes little reference to safeguarding the resident in the event of suspected or alleged abuse, or of preserving any evidence that may be available and it is recommended that the policy is reviewed. The abuse policy and procedure also links with and refers to the Surrey Local Authority Multi-Agency Procedure for Safeguarding Adults. An up to date copy of the Surrey procedure is kept in the home for staff to refer to if needed. Referrals under the Surrey procedure for safeguarding adults have been made in the past. Staff who were spoken with understood the types of abuse that may occur and were clear that any suspicion or allegation of abuse should be reported to the manager or person in charge. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 24. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment which has been furnished to meet their needs, and was clean and freshly aired. EVIDENCE: The manager advised that a major improvement programme has been planned for the home and this is scheduled to start in two or three months. It is planned to change the downstairs units into units specifically for residents who require dementia care and to incorporate specialist decoration techniques, which make it easier for residents to find their way around the home. These techniques have been used in other Anchor Trust homes and include, for example, painting all toilet and bathroom doors in the same colour which is not used anywhere else in the home. The aim of this is to guide residents directly to recognisable and regularly used places. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 18 Another technique is to paint doors to staff only areas, in the same colour as the surrounding walls, so that the doors do not attract attention from residents. All areas of the home that were seen were clean and tidy and most areas were freshly aired. A number of areas looked worn, but these will be addressed as part of the refurbishment programme already planned. Information in the AQAA stated that new armchairs and carpets had been purchased for the main communal lounge and it was noted that the lounge was very well presented and looked colourful and attractive. A visiting healthcare professional commented positively on a CSCI feedback form of “A pleasant environment” in the home. It was observed that paper towels and liquid soap were provided in all appropriate places, to maintain hygiene and prevent infection. Staff were seen to use personal protective equipment, including gloves and aprons, when assisting with personal care or housekeeping, to safeguard against infection or the spread of infection. Housekeeping staff advised that the management team inform them of any infection that may be present, so that appropriate measures can be taken. A colour coded system of cleaning materials is also used to ensure that equipment is only used in the specified areas to maintain effective hygiene. Information supplied in the AQAA stated that staff have undertaken infection control training and training in the Control Of Substances Hazardous to Health (COSHH). A well-equipped laundry room is provided and is situated away from food preparation and serving areas. Staff are allocated to work in the laundry and an effective system of collecting and delivering laundry to and from residents was seen in operation. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full team of appropriately recruited staff are employed to meet residents’ needs, and staff are offered a wide range of training opportunities. EVIDENCE: From information supplied it was clear that a full complement of staff is employed to meet the needs of residents. The majority of the team are care staff, but housekeeping staff, catering staff, an administrator, an activities co-ordinator, a maintenance worker and a receptionist are also employed. Information in the AQAA indicated that the majority of staff are female which reflects the resident group and there is cultural and racial diversity amongst both the staff team and the resident group. A number of staff have achieved or are undertaking a National Vocational Qualification (NVQ) to Level 2 or above in Care, according to information provided in the AQAA. When staff have completed their NVQ training the home will meet the recommended 50 of staff trained to this level. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 20 Recruitment of staff has been effectively carried out and all required documents and information have been obtained before prospective staff were employed. These included two references and Criminal Record Bureau (CRB) disclosures. Where staff have been employed to work before their CRB disclosure has been received, a check has been carried out as required of the POVA (Protection Of Vulnerable Adults) list. A query was raised at the time of inspection regarding a reference supplied for a recently employed person and the manager followed this up immediately. A full range of training is made available to staff and this includes training required by law, such as first aid, food hygiene, fire safety and other training to develop knowledge and skills such as NVQs, dementia care and infection control. The manager maintains a training plan for ease of reference and individual training records are also held for each member of staff. A detailed induction programme has been developed by Anchor Trust to guide staff to their roles and responsibilities. These are usually maintained in the home, but for one member of recently recruited staff, their induction record was not available. The manager stated that staff occasionally take their induction record home to complete it. A requirement has been made regarding Standard 30 that staff induction records must be maintained and must be kept in the home. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed and is run in the best interests of residents. EVIDENCE: The manager stated that she has worked at the home for twenty years, carrying out a variety of roles, including senior carer and deputy manager before her appointment as manager nine years ago. The manager has achieved a certificate in management, the NVQ Level 4 in Care and the NVQ Registered Manager’s Award (RMA). The manager advised that due to changes in her personal life, she has submitted her resignation to Anchor Trust and will be leaving the home in September. Residents and staff have been advised of this during the regular resident and staff meetings that are held. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 22 It was clear from the outcomes for residents and the standard of record keeping, that the home has been effectively managed and it was evident that senior staff work well together to achieve this. Staff advised that a management team provides support to the manager, including an acting deputy manager and a team of senior care officers. The senior team were accessible to residents, staff and visitors and displayed an informal but professional approach. Information in the AQAA stated that the “views of people who use our service are important to us”. The manager stated that quality assurance surveys are carried out each year to ask residents, their representatives and healthcare professionals their views on the service provided. Changes have been made in the home as a result of the quality assurance surveys, the manager advised. These include the recruitment of a receptionist and an activities co-ordinator, the introduction of staff uniforms and name badges and photographs in the entrance hall of the senior staff team. A number of CSCI feedback forms were supplied to residents, their representatives and visiting health care professionals, to obtain an independent view of how the service meets residents’ needs. Three were completed and returned by residents, three from residents’ representatives and two from healthcare professionals. The responses from healthcare professionals are referred to at Standard 8 which refers to healthcare. The responses from residents indicated that residents get the medical support they need, they usually receive the care and support they require, there are usually activities for them to take part in and the home is usually fresh and clean. Residents indicated that they usually know who to speak to if they are not happy and two of the three residents knew how to make a complaint. All three residents who responded indicated that they like the meals ‘sometimes’, when given the options of “always, usually, sometimes and never” to respond to. Relatives responses to the CSCI feedback forms indicated that the home always keeps relatives up to date with important issues affecting residents, usually meets the needs of the residents, and the expected level of care or support is usually provided. All three relatives indicated that they knew how to make a complaint and all three indicated that the home had responded appropriately if any concerns had been raised by, or about, a resident. A number of positive comments were made by residents’ representatives and they have been included in the summary at the beginning of this report. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 23 The administrator stated that monies are held for safekeeping on behalf of a number of residents. Procedures are in place to ensure that these are safeguarded, including secure storage, access limited to specified staff and detailed record keeping, both handwritten and computer-based. The amounts of monies held were checked with the records held and these accurately matched. From the records seen it was noted that formal staff supervision is taking place, but is not being carried out to the recommended frequency of six times each year for each member of staff, and for some staff supervision is taking place very infrequently. Although a number of supervision meetings had taken place recently, it was clear that for some staff there are long periods without supervision taking place. This was particularly noticeable for night staff and also for bank staff who may work irregularly. The manager stated that it can be difficult for night staff to attend supervisions because of their work patterns. It is important that supervision is carried out to the recommended frequency as this provides staff with the opportunity to discuss any issues arising, their training and development needs and ensures that they feel valued by the organisation. Information supplied in the AQAA indicated that equipment and systems in the home are maintained and serviced to the appropriate frequencies to safeguard all who live and work there. Fire safety records were sampled and these indicated that fire alarm testing is carried out on a weekly basis and the fire safety system in the home had recently been serviced. The home maintains effective accident records and operates a monitoring system to ensure that any links or common themes regarding accidents are identified. Notifications are made to CSCI under Regulation 37 of any significant events which affect the health, safety or welfare of residents. Regulation 37 of The Care Homes Regulations requires homes to notify CSCI of serious events which affect residents, such as serious illnesses, serious accident, outbreaks of infectious illnesses or death. A requirement has been made regarding Standard 36, that staff must be appropriately supervised. Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement A care plan for each resident must be drawn up as soon as possible after their admission, to record and specify their individual care and support needs. Medication records must be maintained to enable an audit trail to be followed. This must include the dose of medication actually administered if the dose is variable. A record of the induction of staff must be maintained and kept in the home, to be available for inspection. Persons working in the home must be appropriately supervised. Timescale for action 23/08/07 2 OP9 13 (2) 23/08/07 3 OP30 17 Schedule 4 & 18 (1) (c) (i) 18 (2) (a) 23/08/07 4 OP36 25/10/07 Heathside DS0000013671.V339902.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The information contained in a resident’s care plan should be based on the information obtained at the pre-admission assessment. A record of the care provided should be recorded each day on the “daily notes” form provided as part of the residents’ care plans. 2 OP7 Risk assessments, mobility assessments and other areas of the residents’ care plans should be clear for staff to use and understand. It is recommended that they are renewed completely, if they are not clear once they have been revised. It is recommended that any handwritten additions to the medication administration record (MAR) chart is signed by the person making the entry. It is good practice for a second member of appropriately trained staff to check the handwritten entry and to countersign to show that they have done so. It is recommended that the home’s abuse policy and procedure is reviewed. It is good practice to carry out induction of staff as soon as they are appointed, so that they understand their roles and responsibilities. It is recommended that staff receive formal supervision six times each year. 3 OP9 4 5 OP18 OP30 6 OP36 Heathside DS0000013671.V339902.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 Heathside DS0000013671.V339902.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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