Inspection on 30/01/06 for Heathside

This inspection was carried out on 30th January 2006.

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 10/01/07

Heathside 03/10/05

Heathside 24/02/05

Heathside 17/08/04

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

CARE HOMES FOR OLDER PEOPLE Heathside Plank Lane Leigh Greater Manchester WN7 4ND Lead Inspector Julie Conrad Unannounced Inspection 30th January 2006 09:35 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 DS0000005739.V268682.R01.S.doc Version 5.1 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 DS0000005739.V268682.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heathside Address Plank Lane Leigh Greater Manchester WN7 4ND 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) 01942 602328 01942 682937 Wigan Social Services Department Mrs Carole Evans Care Home 32 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (32) of places Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number (32), there can be up to 2 service users aged between 60 and 65 in the category of DE. The service should at all times employ a suitable qualified and experienced manager who is registered with the CSCI. Date of last inspection 24th February 2005 Brief Description of the Service: Heathside is a purpose built Local Authority residential care home, supporting thirty-two older people with dementia, who do not need nursing care. Two residents can be admitted between the ages of sixty and sixty five years. The home is situated near Leigh town centre, close to local shops and public transport. There are thirty-two bedrooms some have en-suite facilities. All rooms have an address and visual cues which are used throughout the home. Communal space within the home includes, a dining room, a dining room and lounge area, two lounge areas a garden room and a conservatory and a snoozelen room. The layout of the building allows residents to walk freely and securely around the home. Specific colours have been used in different parts of the home’s walking area, which helps to orientate the residents. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Heathside residential home took place on 30th January 2006, from 9.35am until 11.55am. The manager was present throughout the inspection. The inspector conversed with the manager, two members of staff and four residents. A member of staff said good things about the home and the residents appeared to be content and at ‘home’ in their environment. Policies and procedures were discussed and a sample of staff files and resident’s files were checked. The inspector checked the premises and maintenance files. What the service does well: What has improved since the last inspection? The service user guide has been updated and written in a user-friendly way and uses pictures and diagrams, this will assist the residents to understand the content of the guide. The activities hours have been increased to twelve hours a week and focus’ on both group and one to one activities. In addition to this, a project worker has put together a monthly activities programme, where a special activity takes place once a month. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 6 New furniture and curtains have been purchased for the garden lounge area. Care plans are being reviewed on a monthly basis and staff supervision is being carried out regularly ensuring staff receive supervision at least six times a year. The manager has introduced a formal ‘back up system’, a procedure, which is to be followed when staff are unable to cover a shift due to sickness. The system was introduced in November 2005, following the last inspection and is displayed in the main office. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 7 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 DS0000005739.V268682.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home provides a service user guide for prospective service users, which gives sufficient information to ensure that they are able to make an informed choice about where to live. EVIDENCE: The home provides two-service user guides; one guide is for prospective service users and their relatives and representatives. It is presented in a pack containing a number of leaflets and a brochure on Heathside. The brochure gives a brief summary of Heathside, and has photographs of different areas of the home. It informs the reader of the ‘person centred care’ provided at the home. There is information on activities, staffing structure and the purpose of each staff role. Prospective service users would also visit the home to look around and to spend time at the home before admission for respite or permanent care. The service user guide for residents living at the home has a ‘welcome to Heathside’ summary, which can be presented in large print, audiotape or CD or in a different language. The guide gives the same information as the Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 9 prospective service user guide, but also has information on dementia care mapping and dementia care and support. All the current residents have a copy of the service user guide in their rooms. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 The assessments, care plans, risk assessment and regular reviews, and ensures the residents health needs are fully met. Any resident who was able to administer their own medication, would be protected by the application by staff of the home’s policy and procedure on medication. EVIDENCE: The inspector checked three resident’s files, each file has a photograph of the resident and a key information sheet. The files also contain daily diary sheets, the initial assessment, care plan, risk assessment, continence assessment, challenging behaviour record and positive events record. The care plan includes physical health, communication, mobility and dexterity, personal safety and risk assessment, medication and medication history, mental health and cognition, diet and weight, food and meals, dental and foot care, daily living and social activity and a resident profile. All the files seen had an up to date review, for example, 6th January 2006 and 24th January 2006. The care plans demonstrated the resident’s needs are continuing to be met and are reviewed on a monthly basis. The assistant managers liaise regularly with health care professionals involved in the residents care. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 11 The home operates Wigan Social Services Departments medication policy and procedure, which instructs staff on the procedure to follow if a resident should wish to administer their own medication. None of the residents at Heathside have ever requested to administer their own medication. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 The recent increase in activity hours and monthly programme, better serves residents social, cultural, religious and recreational interests. Staff are trained in dementia care, which enables them to assist residents to exercise choice and control over their own lives. EVIDENCE: Since the last inspection the weekly activities hours has been increased to twelve hours. There is a designated member of staff who is responsible for providing the daily activities, these can be group activities, reminiscence, old movies, craft or trips out or one to one activities. A project worker has developed a yearly plan for the residents, where a significant activity takes place once a month, The inspector and manager discussed how staff engage residents in activities, for example, if staff and a number of residents play music in the lounge, other residents join them as they are drawn to the lounge by the music, residents come and go from activity sessions as they choose. To ensure residents are able to exercise as much choice and control of their own lives, staff try to assist them in doing so by helping them to maintain independence by accompanying residents shopping or on outings. The home Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 13 has a hairdressing salon to assist residents in maintaining a good appearance. Staff initiate sing a longs and time for a chat and reminiscence. The home has a snoozelen, where residents can relax, whilst board games are used to maintain concentration. Life skills are maintained by encouraging residents to dust and assist in the dining room and to improve co-ordination, residents are encouraged to dance and get involved in gardening. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 A compliments, complaints and concerns book is displayed in the reception area, encouraging visitors to write in the book anything that concerns them, the complaints policy and procedure is explained in the service user guide, which all residents have a copy. The staff at Heathside, adhere to Wigan Social Services Departments, Protection of Vulnerable Adults policy and procedure, to ensure residents are protected from abuse. EVIDENCE: The Inspector read the compliments, complaint and concerns book. Visitors are encouraged to write their opinions in this book, which they do. A recent concern was from a relative who was unhappy that the TV was out of order after a number of weeks; the manager addressed the concern and wrote in the book what was to be done about it. This is an informal way of communication, visitor raise issues and the manager addressing issues; the book is available to be read at anytime by everyone. The home has a formal complaints policy and procedure, which is explained to residents, prospective residents and their relatives and representatives in the service user guides. A resident or visitor with a formal complaint would be given a leaflet and directed to Wigan Social Services Departments Customer Relations team, who would investigate any complaints thoroughly within twenty-eight days. There have been no formal complaints since the last inspection Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 15 The home operates Wigan Social Services Protection of Vulnerable Adults policy and procedure, which has recently been revised and re-launched by the department. All staff receive training on the protection of vulnerable adults during the induction period. NVQ level 2 in care has a unit on adult abuse, twenty two staff have now achieved NVQ level 2; whilst six new staff have completed induction training and are part way through ‘skills for care’ training, after which they will enrol on NVQ level 2. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23, 26 The residents have their own bedrooms, which they personalise to suit their own needs. There are a number of carpets throughout the home, that have strong odours, which makes certain areas of the home unpleasant for residents, staff and visitors. EVIDENCE: The inspector viewed a number of bedrooms on a random basis. There are thirty bedrooms of which fifteen have en-suite facilities; all other rooms have a commode. The bedrooms were pleasantly decorated and furnished and had been personalised. However, a respite room, has a strong smell from the carpet, the carpet needs replacing as soon as possible. Four other bedrooms have carpets that smell. Relatives have asked the manager if the home will replace the bedroom carpets with vinyl floor covering. The inspector has requested that the manager carry out an assessment on the four residents and their rooms to determine if vinyl floor covering is necessary for all of them. On completion of the assessments, the manager should put Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 17 the matter in writing to the Commission for Social Care Inspection for consideration. The carpet at front of the home by the office has a strong smell, the residents like to sit and spend time by the office, on the day of the inspection, five residents congregated there drinking tea and coffee. The carpet should be replaced as soon as possible. There is a section of carpet by rooms 1 and 2 that may need to be re-placed. The fire extinguisher from the wall by room 8 needs to returned straight away. The handyman was to do this on the day of the inspection. Since the last inspection, the home has purchased new furniture, including three new sofas and new curtains for the garden lounge area, a number of residents were having a nap in this area on the day of the inspection. There are two enclosed garden areas, which are well maintained and accessible to the residents. These areas are utilised during the summer months. The inspector observed residents moving around the home freely and appearing comfortable in their surroundings. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 To ensure the residents are in safe hands at all times, staff receive mandatory and specialist training. The home operates Wigan Social Services Departments recruitment policy and procedure, ensuring the protection of the service users. EVIDENCE: The home’s staff team consists of a manager, four assistant managers, twentyeight care staff, ten domestic staff, three cooks and a handyman. Since the last inspection, the manager has introduced a formal back up system, which staff must follow if a member of staff does not turn in to work due to sickness. The procedure is displayed in the main office and was implemented in November 2005. Staff training and supervision; ensure residents are in safe hands at all time. Twenty-two staff have achieved NVQ level 2 in care. Six new staff have completed an induction programme and are now on foundation training, which will be followed by NVQ level 2. All staff receive mandatory training, for example moving and handling and food hygiene. Recent specialist training has included; essential lifestyle planning, mental health report writing, understanding schizophrenia, understanding dementia. The manager and assistant service manager are both qualified trainers for the Alzheimer’s Society and are intending to run the course, ‘Yesterday, Today, Tomorrow’ for staff at Heathside. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 19 A member of staff told the inspector that the training was good and relevant to the care provided to residents. The home operates Wigan Social Services Departments, recruitment policy and procedure, which ensures the protection of residents. All prospective staff complete an application, attend an interview, provide two satisfactory references and have CRB checks (Criminal Records Bureau), before commencing employment. The inspector was unable to check staff records as these are kept at Wigan Social Services Departments Human Resources section. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 26, 38 To ensure the home is run in the best interests of the residents, their needs are monitored and their relatives and representatives are consulted. Staff are supervised regularly to ensure they are equipped to provide a good service. A number of safety checks must be recorded, to demonstrate the safety and welfare of the residents is protected. EVIDENCE: Resident’s needs are monitored daily and through formal reviews, to ensure the service is run in their best interests. Relatives are invited to a carers meeting at the home every two months, the meetings are from 6.30pm until 8.30pm. An assistant manager is responsible for chairing the meetings. The Inspector read the minutes of recent meetings, the agenda included; CSCI inspection, key workers, staff rotas, continence pads, Freedom of Information Act, confidentiality, hairdressing, possible new developments at the home and Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 21 fundraising. This is followed by and open discussion and a questions and answers. The meetings are well attended by relatives. The inspector also checked two audit files, the audit of premises and the audit of care. Monthly audits are carried out, for example, medication was audited 12/01/06, quality assurance review 9/01/06. The audit of the premises file identified that Regulation 26 visits had not taken place in November and December 2005. The manager told the Inspector that a Regulation 26 visit had taken place for January 2006; however, the record of this visit was not on file. Regulation 26 visits must take place on a monthly basis by a senior manager. The inspector checked the maintenance file, where external inspectors carry out inspections, which demonstrated the electricity was inspected 8/01.04 and gas was inspected 1/03/05. The handyman is responsible for internal maintenance and recording checks, these include a health and safety checklist, identification of repairs, risks and hazards, including doors, furniture, electrical, carpets, boiler etc. The records demonstrate emergency lighting is checked weekly and a routine check of fire equipment was carried out 5/1/06. The Inspector checked the fire book and brought to the manager’s attention, that staff have not been signing the fire book. Staff must sign the fire book to state they have read and understand the procedure. The fire book recorded the last fire extinguisher inspections as being carried out in August 2004, however, when the extinguishers were checked they had been inspected in September 2005. Staff must remember to record all fire safety equipment checks in the fire book. Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 22 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 3 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x x x 3 x x 2 x STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 2 Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard OP26 OP26 OP26 OP26 Regulation 16 16 16 16 Timescale for action A section of carpet to the front of 30/03/06 the home, by the office needs replacing. A section of carpet in the 30/03/06 corridor by rooms 1 and 2 needs replacing due to odour. The carpet in room 30, a respite 28/02/06 room needs replacing due to odour. Four bedrooms need assessing 28/02/06 to determine if alternative floor covering is more suitable than carpeting. A senior manager must carry out 01/02/06 regulation 26 visits every month. Staff should sign the fire book 28/02/06 following fire training, to demonstrate that they understand the procedure. Following inspections of fire 28/02/06 extinguishers, the inspection date should be recorded in the fire book. The fire extinguisher by room 8 28/01/06 should be refitted back on the wall. Requirement 5. 6 OP38 OP38 26 23 7 OP38 23 8 OP38 23 Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. X Refer to Standard X Good Practice Recommendations x Heathside DS0000005739.V268682.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Heathside DS0000005739.V268682.R01.S.doc Version 5.1 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!