Inspection on 30/06/05 for Heathside

This inspection was carried out on 30th June 2005.

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 26/07/07

Heathside 22/06/06

Heathside 28/12/05

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 Coley Avenue Woking Surrey GU22 7BT Lead Inspector John Chivers Announced 30 June 2005 @ 10:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heathside Address Coley Avenue Woking Surrey GU22 7BT 01483 765046 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Ms Michelle Saville CRH - Care Home 51 Category(ies) of DE(E) - Demential - over 65 (12) registration, with number OP - Old Age (31) of places PD(E) - Physical Disability - over 65 (8) Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of persons to be accommodated will be over 65 years of age. Date of last inspection 3 November 2004 Brief Description of the Service: The home is registered to Anchor Trust Limited and is one of many Residential Care Homes administered by the company. Heathside is registered to accommodate a maximum of fifty one residents of either gender aged sixty five years and over. The home is a large purpose built property and is situated in a residential area close to the town centre. The homes grounds are spacious and well maintained. The home provides a homely and comfortable environment and offers a wide range of activities to the residents. The home provides a very good standard of care to the residents. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and commenced at 10 am on 30th June 05. The duration of the inspection was 4.5 hours. As part of the inspection process discussion was held with eight service users and two staff were formally interviewed. Discussion was also held with the home’s management. The inspection further included examination of the home’s policies, procedures, resident’s individual files, staff personnel files, statutory and none - statutory records and information supplied by the home via the pre-inspection questionnaire. The inspection was positive with evidence of continued good management and care practice. Written needs assessments and care plans were available with evidence of reviewing and updating as appropriate. Resident’s health care is monitored and recorded. The home’s recruitment and vetting procedures are satisfactory and the home’s staffing arrangements enable the service to meet its aims and objectives. The home’s records are kept to a good standard and evidence consistency in recording. The premises are maintained in good order with an on-going programme of redecoration and maintenance. Residents stated in discussion that they were satisfied with the standard of care provided at the home and that they had no complaints or concerns about the way staff treat them. There are no requirements or recommendations as a result of this inspection. What the service does well: The home continues to provide a good all round service to the residents. Residents confirmed that their needs are well catered for by staff and this is evidenced by the findings of this inspection. The home had a body mass index calculator and recording format, which shows individual residents weight/body fat ratio. This area is the specific responsibility of the deputy manager who has received training in this area. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 6 The home has regard for the vetting of staff and is committed to increasing the number of NVQ level 2 & 3 qualification holders within its staff team. The home provides a homely and comfortable living environment and encourages residents to participate in a wide range of activities if they wish to do so. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 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 standard(s) 3 and 6. The home ensures that written needs assessments are in place prior to admission and reviews these as appropriate. EVIDENCE: Written needs assessments were available in the sample of residents files inspected. The assessments were comprehensive and covered thirty six headings. There was recorded evidence of assessments being reviewed and updated. The home does not provide intermediate care, though it does offer four respite care places. Respite care is usually for one to three weeks. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8 and 10. The home has a clear regard for ensuring that written care plans and health care plans are in place and are monitored. The home has further regard for treating residents with dignity and respect. EVIDENCE: Written care plans were held in the sample of residents files inspected. The care plans were detailed and covered many areas. There was recorded and dated evidence of care plans being reviewed on a monthly basis and amended/updated as appropriate. Some residents stated in discussion that they were aware of the care plans, others were not too sure of the term ‘care plan’ but stated/indicated that they were satisfied with the standard of care provided. Written feedback from relatives evidenced that they felt the care practice at the home to be of a very good standard. Health care details are included in the initial assessments and care plans. Health care needs are monitored and recorded. There were clear records of visits by the GP, district nurse and other health care professionals. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 10 The home has recently introduced a ‘nutrition profile’ for each resident. This is undertaken in liaison with a nutritionist and includes the calculation of a body mass index which works out the height, weight and body fat content of residents. The home has a policy and procedure regarding privacy and dignity. Residents were observed to be treated with dignity and respect by staff and residents stated in discussion that staff respect them and treat them well. Written feedback from resident’s relatives conveyed the same opinion. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 and 14. The home provides a range of activities and enables community contact for the residents. Residents are encouraged to make choices and have autonomy. EVIDENCE: The home has an activity file, which demonstrates that a wide range of activities is available to the residents. These include activities within the home and at venues in the community. A number of activities were in progress at the time of the inspection and these were well attended by residents. Residents stated in discussion that they have the opportunity to participate in activities if they wish to do so. Residents also engage in pastimes and have contact with the local community and community groups. There are no restrictions on visiting times for family, relatives and friends. Residents were observed to have sufficient autonomy and confirmed in discussion that they had choice regarding aspects of their daily lives. Consultation and choice is usually conveyed via key workers or at residents meetings. The manager intends to increase the frequency of resident’s meetings and also invite relatives to attend and make a contribution if they wish to do so. This is planned to be implemented in August 05. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 and 18. The home takes complaints seriously and ensures investigation in such areas. The home has regard for protecting its residents and training staff in this area. EVIDENCE: The home has a written complaint procedure. Residents stated in discussion that they were aware of the complaint procedure, though they were clear they had no complaints about the service they receive. A minority of resident’s feedback forms stated that they were not aware of the home’s complaint procedure. Relatives were complementary about the home and stated that they had no complaints about the service provided. The home’s complaint book was available. The book evidenced that two complaints had been received since the last inspection. The complaints were of a minor nature and records evidenced action taken and outcomes. The home has an internal policy and procedure regarding the protection of Vulnerable Adults. In addition the home holds the Surrey County Council MultiAgency Adult Protection procedures. The manager stated that all senior staff attended the Surrey County Council Multi-Agency training in the protection of Vulnerable Adults in May 05 and all staff receive video training followed by a written test on the topic. Details regarding such training are held in the staff’s individual training profiles. Vulnerable Adult protection is also included in staff induction. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 13 Residents stated in discussion that they had no complaints about the way staff treat them. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The home is designed and located in a position consistent with its stated aims and objectives and is maintained in good order. Communal and private space areas are decorated and furnished to a good standard and afford the resident’s a comfortable and homely environment. EVIDENCE: The home is a large purpose built detached property situated in a quiet residential area close to the town’s facilities and amenities. The exterior of the building presents in good order and the grounds are well maintained. A sample of the home’s communal and private accommodation areas were inspected. The areas were decorated and furnished to a good standard and resident’s individual bedrooms were personalised. There was adequate space for the residents and they were observed to be settled and relaxed in their environment. Residents stated in discussion that they were satisfied with the standard of accommodation and facilities provided. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 15 The home has an on-going programme of maintenance and redecoration. It was evidenced that a new carpet is scheduled to be fitted in one of the home’s units and a bathroom is due to be redecorated. As this is in progress a requirement will not be made. The home has an infection control policy. Standards of cleanliness and hygiene were satisfactory throughout the home. No safety hazards were evident at the time of the inspection. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The home’s staffing arrangements are satisfactory and the service has regard for the required staff recruitment and vetting procedures. EVIDENCE: The home’s staff duty roster was available and evidenced clear and detailed recording. Currently the home uses a number of agency and bank staff that cover staff vacancies. At the time of the inspection the home had nine vacancies; however most of these posts had been filled and the appointees were awaiting the outcome of the home’s recruitment and vetting procedure prior to commencing duties. The home has an experienced and competent management team and have evidenced progress and consistency in the administration of the service over recent years. Currently 38 of the home’s staff hold either NVQ level 2 or NVQ level 3 qualifications and it is their aim to have 92 qualified to this level over the next few years. The core staff team have substantial experience in caring for elderly people and less experienced staff are supervised by their more experienced colleagues. The home has a recruitment policy and procedure. The policy was reviewed in May 05 and includes a ‘recruitment plan’, which identifies strengths, weaknesses, opportunities and threats in the recruitment system. A sample of six staff files were inspected. The files were in respect to staff appointed fairly recently. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 17 The files held an abundance of information and in the main included: contracts, certificated and photographic identification, application forms, two references, interview notes, health questionnaires, ‘POVA’ checks and Criminal Record Bureau checks. Based on the sample of files inspected, the home’s recruitment and vetting procedures are evidenced as satisfactory. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38. The home has regard for keeping clear transactions of resident’s personal cash. The home has a clear regard for health and safety matters concerning the home, residents and staff. EVIDENCE: A sample of the resident’s personal finances were inspected. Detailed records of transactions are held and the balance of cash held was consistent with written records. The home has a Health & Safety policy and procedure. The home’s Health & Safety ‘Law’ poster was prominently displayed. The home has a range of written risk assessments. The home’s fire risk assessment was available. The assessment was dated June 05. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 19 Fire evacuation drills were evidenced as quarterly and fire alarm tests occur on a weekly basis. Fire equipment tests were completed on 28th June 05 and the fire officer last visited the home on 7th January 05. The fire officer’s report evidenced the home’s current fire precautionary arrangements as satisfactory. The home’s electric systems test was dated 5th September 02 and will be retested again prior to its expiry date in September 07. A gas test certificate dated 29th June 05 was held and a Legionella test was evidenced on 20th September 04. The test also included a ‘dip’ test of the home’s water systems. Hot water temperature tests are taken on a regular basis and evidence temperature recordings of between 39 degrees centigrade and 43 degrees centigrade. There was recorded evidence of internal health and safety audits. Environmental Health Officer reports for health and safety and food hygiene were available and evidenced these areas to be satisfactory. The home’s accident report book was also available. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 21 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. Standard Regulation Requirement There are no requirements as a result of this inspection. Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations There are no recommendations as a result of this inspection. Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heathside H58 H09 S13671 Heathside V224042 300605 Stage 4.doc Version 1.40 Page 23 - 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. 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