Inspection on 01/02/07 for Heathside House

This inspection was carried out on 1st February 2007.

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

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

Other inspections for this house

Heathside House 17/02/09

Heathside House 12/08/08

Heathside House 25/06/07

Heathside House 21/06/06

Heathside House 09/01/06

Heathside House 16/08/05

Heathside House 30/03/05

Heathside House 30/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Heathside House Heathside Lane Goldenhill Stoke On Trent Staffordshire ST6 5QS Lead Inspector Mrs Wendy Grainger Key Unannounced Inspection 1 February 2007 09:00 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 House DS0000030493.V326949.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 House DS0000030493.V326949.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathside House Address Heathside Lane Goldenhill Stoke On Trent Staffordshire ST6 5QS 01782 234551 F/P 01782 234552 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) Stoke on Trent City Council Mr Karl Shepherd Care Home 44 Category(ies) of Dementia - over 65 years of age (44), Learning registration, with number disability over 65 years of age (2), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (44), Physical disability over 65 years of age (44) Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 Learning Disability over 65 years pf age (LD (E)) - Places for existing residents only To include 1 male service user under the age of 65 years. Date of last inspection 21st June 2006 Brief Description of the Service: Heathside House is registered to care for 44 older people. It provides long term and respite care and includes an eight-bed EMI unit. The home is situated in Goldenhill, on the outskirts of Stoke-on-Trent. The home was purpose-built approx 25 years ago and is managed by Stoke-on-Trent City Council. It is registered under the Care Standards Act 2000. The home is well placed for public transport, which gives frequent access to the main centres of Kidsgrove, Tunstall and Hanley that provide a wide range of facilities. There are good local community links including churches, pubs, shops and community centre. The home is situated in its own grounds surrounded by secure fencing. Limited car parking is provided although parking in the surrounding side roads is possible. The home is purpose built with accommodation provided on two floors. There is a shaft lift and also stairs access between floors. All bedrooms are single occupancy with a wash hand basin although none provide en-suite facilities. There is a range of assisted bathing facilities, including one providing a Parker bath and another a walk-in shower room. There are adequate assisted toilet facilities throughout the home. The home is divided into four areas, all of which have their own sitting rooms and dining areas. In addition, there is a small smokers lounge situated off the entrance hall. Three of the lounges offer a domestic style of environment with a kitchenette area for preparing breakfasts, snacks and drinks. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector completed this second inspection on the 1st February 2007. The home had not been provided with resident or relative comment cards, or a pre inspection questionnaire. The assistant managers assisted the inspector in the absence of the registered care manager. Records, reports and documents required to complete the inspection report were made available when located. A sample tour of the home was undertaken with the manager. Residents were spoken to within each lounge. At the time of the inspection there were 42 residents at the home. What the service does well: The staff were committed to the care of the residents making their life style a priority. Residents throughout the time at the home were relaxed with the staff and the support required to assist them. Residents spoken with were complimentary about the staff and their approach. One family who had their relative admitted as an emergency were very happy with his progress and the manner in which he was being cared for. The assistant manager made time to explain what the normal process of the stay would continue and he would be made a permanent resident. One family told the inspector “her dad looked 100 better” since he had been in the home The managers were knowledgeable about the residents and their needs. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There were a number of concerns identified to the managers during the tour of the home and from the records and documents provided. The home did not have sufficient collective risk assessments for a selection of the residents who choose to continue with their life style. The staff need to consider eliminating the possibility of cross contamination within the toilets and bathrooms. Un-covered toilet rolls were evidenced in toilets, personal toiletries were identified left in bathrooms. Within two of the bathrooms the bath mats were in an extremely poor hygienic condition (black mould on the underside) The key to the lift had been snapped off for a minimum of two weeks; this was evidenced as a problem for the residents that use the lift as the doors did n ot remain in the open position for any length of time. The staff had contacted the company but no key had been provided. The pipes in bedrooms and radiators identified in the main lounge were not protected; this is a health & safety requirement to protect the residents. A sample of the care plans evidenced at the time of the inspection they did not relate to the total care, support required, social and diverse needs, identification of an individual i.e. photograph and poor risk assessments were identified. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 7 The inspector had concerns in respect of the medication being administered. Eye medication was out of date and being administered. Creams left in the treatment room out of boxes and with no identification. Numerous gaps in the medication administration records. There was a requirement for the home to have a small medical fridge and not to use the one used that was from one of the units. The fridge in Golden view had a split seal and needed replacing. The Wedgwood unit was without a fridge, staff had to go into the home for milk or other provisions leaving vulnerable residents alone. There was a requirement to replace the fridge/freezer within the main kitchen. The home could not evidence that letters to confirm, that, following the assessment of an individuals needs confirmation had been forwarded to the prospective resident or their representative. The home provided very limited activities, the records of any activity were not current, and the last entry was August 2006. Staff records evidenced that they were incomplete; information to comply with the national Minimum Standards should be contained in the records. 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 House DS0000030493.V326949.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 House DS0000030493.V326949.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 adequate Standards 1,3,4 were reviewed This judgement has been made using available evidence including a visit to this service. Prospective residents were provided with the appropriate information prior to admission to the home. . EVIDENCE: The Statement of Purpose was located within the front entrance of the home. The document was current and complied with the homes facilities and staffing. The manager/senior stated no resident was admitted to the home without an assessment of his or her individual health and personal needs. Samples of Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 10 three plans were evidenced at the time of the inspection. The manager has failed to comply with of the National Minimum Standards by not confirming in writing that the placement would be suitable to meet their need. This report makes this a requirement. The staffs at the time of the inspection were unable to confirm that residents had been provided with the terms and conditions of the home. This has since been clarified by the service manager for the establishment. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is poor Standards 7,8,9,10 were reviewed This judgement has been made using available evidence including a visit to this service. The sample of plans evidenced that the quality of the information was incomplete, not current and would not provide sufficient detailed information to care. Arrangements were in place for the continued health care from other professional agencies. There were a number of concerns in respect of the medication system, storage and administration of medicines. The concerns identified had a potential to put residents at risk. Staffs observed at the time of the inspection were sensitive to individuals needs; they interacted and respected the residents, assisting when necessary. EVIDENCE: Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 12 Three plans were sampled during the visit; each resident had different needs. The content of the plans were poor in their content and detail. Risk assessments were not in place to protect the residents. Residents were evidenced to use the stairs and lifts independently. The inspector was told that a risk assessment had not been completed. While residents were encouraged to take calculated risks in their life style; every effort should be made to minimise the risk. Photographs were not in place on all the care plans, there was no evidence from dates that a review and risk assessment had been updated recognising any changes to routines. A concern held by the inspector that the staff appeared unaware that the resident that chose to administer medication required a risk assessment The document used for the reduction of a high risk of smoking had not been reviewed for some time. With the exception of one person, there was no written evidence that the residents had been consulted and involved in their care plan. The care plans would be more effective for the staff if they were streamlined and all the non-relevant documents removed and filed away. Dependency levels evidenced that for one person the levels had not been reviewed since August 2006. There was lack of evidence in the care plans relating to the social and the diverse needs of individuals. A review of an individuals Moving & Handling requirement had not been reviewed since July 2006, there was no evidence if any changes had occurred. Arrangements were in place for the continued health care for all the residents. The inspector witness the assistant care manager quickly arrange an appointment and transport for one resident that should have attended the local hospital. The inspector had concerns in respect of the administration, safekeeping and storage of medicines. Evidence identified that eye medication was being used and recorded, which was out of the safe date period. Creams were being used that had been removed from their original containers; no names were evidenced on the tubes in use. This is a poor practice. Medicine received into the home should remain Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 13 in their original boxes/containers, labelled with the prescribing details to reduce the risk of mistaken administration. The record for the administration of prescribed medicines evidenced identified numerous gaps in the system where staff had failed to sign. Any controlled medication prescribed must be signed for on the medication administration record and the controlled drugs record. Medication should not be stored in a domestic fridge, the provider is required to purchase a small medical fridge and maintain daily records of the temperatures. Staff were observed and heard to be respectful assisting residents where necessary. Resident’s privacy and dignity was observed not to be compromised by the staff. Staff greeted visitors in a friendly manner welcoming them to the home and providing them with information about their relative. Residents spoken with provided the inspector with positive comments about their care “the girls are good some are better than others” “the staff meet my needs and are good to me”(I enjoy my food” Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate Standards 12,13,14,15 were reviewed. This judgement has been made using available evidence including a visit to this service. No one person was responsible for activities; the home therefore provided limited stimulation for the residents. Visitors were welcomed to maintain contact with their relative. Menus were based on the cultural area, home cooking was provided. EVIDENCE: One of the residents was resident in Wedgwood unit, this unit catered for the more dependent individual. There were no records or evidence that any activities were provided for this group of residents. Within the other two units the records were not current the last entry was August 2006. The out of date records identified that TV DVD dominoes and Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 15 singing were provided. There was evidence of some external entertainment being provided; this again was somewhat limited. Residents spoken with were satisfied with the care they received; they were cheerful and interested in the inspection. Visitors spoken with felt that they were welcomed by the staff “ I feel that I can come at any time” “the staff are pleasant” Catering offered an alternative to the main meal; this was evidenced during the serving of the main meal. Menus were based on a cultural area/diet; special diets could be prepared when applicable. The menus evidence were balanced in their content, home cooking was the commitment of the cook. The required temperatures to be maintained by the catering staff were current. The upright fridge/freezer seal was in a poor hygienic condition the seal was split this unit needs replacing and cleaning. Other areas in the kitchen were satisfactory. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good, Standards 16,18 were reviewed. This judgement has been made using available evidence including a visit to this service. The home had a balanced complaints process, accessible to all visitors, staff and residents. Residents were protected from abuse by staff training to protect the vulnerable adult. EVIDENCE: The homes complaint process had been activated by two people, both complaints were on going and being investigated by the Social Services. The inspector was told that there was a possibility that the management may receive a further complaint. Staff confirmed that they had received training to protect the vulnerable adults in their care. This awareness was part of the homes induction programme for new staff. Five of the staff were at the time of the inspection on Vulnerable Adult training. Heathside House DS0000030493.V326949.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): Quality in this outcome area is poor. Standards 19 20 21 23 24 25 26 were reviewed. This judgement has been made using available evidence including a visit to this service, and a tour of the home. There were areas within the home that were a potential hazard for the residents. Cross infection was a possibility for the residents from lack of infection control practices. EVIDENCE: Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 18 Located in a busy through road, the home was purpose built to accommodate 44 older people; on two floors the first floor was accessed via the shaft lift or stairs. Residents were provided with single rooms, there were no en-suite facilities within the home. Bathing and toilet facilities were made available on each unit. Divided into four areas to accommodate residents with varied needs. The home has recently had a total upgrade of the system for fire protection. Remedial decoration work had been commenced to repair the home following the firework; there remained work to be finished. Within the Wedgwood unit the inspector was concerned as to the lack of infection control practices that may put residents health at risk. A number of loose toilet rolls had been left in the toilets with a quantity of incontinence pads left uncovered on the window. Other areas within the home displayed personal toiletries left in bathrooms; this was a potential hazard to residents who could inadvertently drink the liquid. Non-slip bath mats in two bathrooms were black with a mould on the underside. With the exception of one bathroom no thermometers were found. This issue was raised on the last inspection and made a recommendation. To ensure the safety of the residents this report will make it a requirement to place a thermometer in each bathroom for the staff to use before each bath. Wedgwood unit was without a fridge the inspector was lead to believe that the fridge had been put into the treatment room. This unit requires a fridge so that staff did not have to go to the kitchen each time a drink was prepared leaving the residents unsupervised. Bedrooms seen displayed many personal possessions, residents spoken with told the inspector “ I like where my room is, I have brought my things in” “ my room is nice and warm” At the time of the inspection the lift, which accessed the first floor had a fault; the doors would not remain open independently. Some residents accessed the first floor independently and this fault would be a hazard to the residents observed using the lift. The inspector was told that this fault had existed for two weeks the key to hold the door open had been broken off and the residue remained in the lift. During the inspection the manager contacted the firm responsible, for an update to rectifying the problem. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 19 The inspector had concerns in respect of the unguarded radiators in the large dining room and in bedrooms where pipes also need protection. The large radiator in the lounge was hot to the touch and while no resident sat near it, it was a potential hazard. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is poor, Standards 27 28 29 30 were reviewed This judgement has been made using available evidence including a visit to this service. Due to the staff shortages and the dependencies of the resident group residents could be at risk. Staff records for training could not be evidenced staff records were incomplete and could leave residents at risk. EVIDENCE: At the time of this inspection the staffing levels were of a concern to the inspector, especially within the Wedgwood unit where there was one person on duty. This person was assisting one resident in her room to have lunch. To protect the person dignity the door was shut. This practice left six residents unsupervised, some of who prefer to wander the corridors. This report makes it a requirement to review the staffing deployment to ensure that the residents were protected by appropriate staffing levels and stimulated by interaction of the staff. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 21 Four care assistants; one cook, kitchen assistant and one handyperson supported the management. The afternoon shift remained the same for the care staff. The night shift consisted of one management sleeping in the home with two waking night staff on duty. There were four vacancies for care staff totalling a minimum of 100 hrs. Despite the two vacancies for housekeeping staff the building was maintained to a good standard. The inspector was not able to confirm from the discussions with the managers on duty the training undertaken by the staff since the previous inspection; the registered care manager was off duty. Management staff had undertaken some training including potential aggression; one of the assistant managers first aid was not current. As the management are the only ones with a recognised certificate by the City Council. For the night shift completed by the assistant manager the home would be without a manager with the require qualification. The staff personal files were sampled. These were not current and did not contain all the relevant information; including a copy of birth certificates, current photograph, references were not always on file. This was evidenced from the sample of four files reviewed. The records would benefit from a more structured format to make accessing information easier. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate Standards 31,33,36,38 were reviewed. This judgement has been made using available evidence including a visit to this service. There were areas within the management and administration that were not available or current to ascertain if all precautions to protect the resident were in place. EVIDENCE: Staff confirmed verbally that they received formal supervision from the management. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 23 There was no evidence of the home obtaining formal feedback from the residents, and or stakeholders to the home. The water temperatures taken monthly by the handyperson were current. It was recommended that the handyperson record the date as well as the month. Fire records evidenced that only three of the weekly tests were undertaken in the month of September. Records identified that the staff had been part of fire drills, video viewing and questionnaires. It was recommended that staff taking part in a fire drill sign the records personally. The management had completed the risk assessment of the resident’s needs and contingency plan in the event of an emergency. Records evidenced that for three consecutive months an emergency light fitting had failed the test. No action had been taken to rectify this problem. The remit for this work was the City Works department. This report makes it a requirement that this is addressed. Heathside House DS0000030493.V326949.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 3 1 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 2 X 3 1 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 3 2 2 Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 01/03/07 2. OP7 15(2) Rationalise care planning to offer a meaningful assessment, plan, risk assessment and review of care. This is outstanding from the previous inspection report. 01/08/06 The registered person shall not provide accommodation unless the registered person has confirmed in writing to the service users and or their representative that the care home is suitable to meet the health and welfare needs of individuals. The registered person shall ensure that the home is conducted so as to promote and make proper provision for the health and welfare of the residents. The registered person shall make arrangements for the recording, handling, safekeeping and safe administration and disposal of medicines received into the care home. Applicable medication should be stored in a DS0000030493.V326949.R01.S.doc 3. OP4 14 (d) 01/03/07 4. OP9 12 (a)13(2) 01/03/07 Heathside House Version 5.2 Page 26 5. OP12 16(n) 6. OP19 OP25 23(b)(n)( p)13(4)a (c) 7 OP7 Schedule 3 medical fridge with daily temperatures recorded. the records for any controlled drugs should be signed for in the appropriate book and Medical records administration sheet. The registered person shall 01/03/07 consult residents about a programme of activities arranged by or on their behalf. A record of such activities should be maintained. all residents should be included in the activity programme including the residents in Wedgwood The registered person shall 01/03/07 having regard to the size of the home ensure that the premises of the home are of sound construction and kept in good state of repair. The problem of the lift should have been addressed. Remedial work to repair the décor shall be addressed more effectively to ensure the safety of the residents. Residents were at risk due to the non-compliance of Health & Safety with radiators and pipes not protected. Unnecessary risks to the health & safety of the residents are identified and so far as possible eliminated; thermometers should be purchased for each of the communal bathrooms. Equipment in the bathrooms should be audited on a monthly basis to ensure they were maintained in a clean and satisfactory manner Photographs were not in place 01/03/07 on all the care plans, there was no evidence from dates that a review and risk assessment had been updated recognising any changes to routines. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 27 8 OP29 OP30 19 & schedule 2 9 OP33 24 (1) 10 OP37 17 (3) 11 OP38 13 (3) 12 OP38 23 (4) 13 OP19 23 14 OP27 OP28 18(10(a) The registered person shall not employ a person to work at the care home unless the appropriate checks have been taken the records identified in Schedule 2 were incomplete, there was limited evidence on the staff records available No evidence was made available to identify any effective quality assurance process from relatives, residents or stakeholders. The registered person shall ensure that records referred to in Schedules 1,2,3,4, are kept up to date and available at all times for inspection The registered person shall make arrangements to prevent infection and the spread of infection at the care home. Incontinence pads and exposed toilet rolls should not be left in toilets. Personal toiletries should be returned to an individuals bedrooms or secured away within a lockable facility The registered person arrange for the maintenance of all the fire equipment including the emergency lighting system; and to ensure that the weekly test of the equipment is completed The registered person shall ensure that the equipment provided in the home is suitable for its intended purpose. One unit requires the purchase of a fridge, the fridge/ freezer in the kitchen was in need of replacement and the fridge in the unit on the first floor had a split seal and a possible harbinger of germs The registered person shall ensure that having regard to the size of the home, the statement DS0000030493.V326949.R01.S.doc 10/03/07 20/03/07 20/03/07 10/03/07 01/03/07 10/03/07 10/03/07 Heathside House Version 5.2 Page 28 of purpose, number and needs of the residents ensure that there were sufficient staff on duty at all times for the health & welfare of the residents. The home should have a minimum of 50 of staff with the appropriate National Vocational Qualification in Care 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 2 Refer to Standard OP38 OP26 Good Practice Recommendations To provide the means for staff to personally sign their attendance and involvement in a fire drill For the handyperson to record the date when the water temperatures were taken. Heathside House DS0000030493.V326949.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 House DS0000030493.V326949.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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