Inspection on 21/06/06 for Heathside House

This inspection was carried out on 21st June 2006.

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 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 House 17/02/09

Heathside House 12/08/08

Heathside House 25/06/07

Heathside House 01/02/07

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 Mr Keith Jones Key Unannounced Inspection 21st June 2006 10:00 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.V299470.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.V299470.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.V299470.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 9th January 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.V299470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector, the care manager and senior staff, in a professional and cordial atmosphere. The Inspector acknowledged receipt of the prepared information questionnaire and 9 comment sheets, all complimentary. The last inspection report was discussed, and it was noted that most of the requirements and recommendations had been dealt with satisfactorily. On the day of inspection there were 39 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of residents, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. A review of the administrative arrangements confirmed solid practice. A full verbal report was offered at the end of the inspection to the care manager, who had been joined by the service manager and senior staff for the feedback. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: What has improved since the last inspection? Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 6 In addressing the recommendations made, the Home has demonstrated a meaningful commitment to the ethos of continuing improvement of standards, especially in bringing fire precautions up to standard. A tightening up of admission procedures has taken place to ensure that only appropriate categories of service user are admitted. Improvements in staff recruitment and administration procedures will have a beneficial effect in safeguarding residents. 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 House DS0000030493.V299470.R01.S.doc Version 5.2 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 House DS0000030493.V299470.R01.S.doc Version 5.2 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): 1,2,3,4,and 5 Quality in this outcome area is “adequate”. Heathside House ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are presented in a way to facilitate easy understanding of services and standards of care. Residents spoken with expressed their appreciation for the standard of attention offered to them on their assessment visit, usually arranged through Social Services direct. The Home ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. The Statement of Purpose has been reviewed, but the Provider has not yet addressed a firm Contract to individual service users. EVIDENCE: Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 9 The Statement of Purpose and service user’s guide represent a good description of the home’s aims and objectives, philosophy of care and terms and conditions, offering service users and their relatives the opportunity to make an informed choice about where to live. Requirements prescribed in Schedule 1 are addressed. The document needs to be kept under review to reflect changing circumstances. It is stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. The Inspector was impressed with the attention to detail in recognising the degree of anxiety prospective residents have on moving in to the Home. Diversity issues were discussed that need to be reflected in an effective Statement of Purpose. There is an awareness of the needs of a diverse population that will require a flexibility in policy and procedural arrangements. A pre-admission assessment is usually carried out by a Social Services assessor and occasionally by a senior member of staff. There is an appreciation of any special needs of the individual including cultural, social or personal needs, which are discussed and documented. This assessment initiates the process of care. The Home demonstrated, through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. Emergency admissions are taken in, as seen in case tracking, and were found to be competently assessed. The family is kept fully informed of the situation and events, offering service users and their relatives the opportunity to make an informed choice about where to live. The Provider has not yet addressed a firm Contract to individual service users, which will represent an area of serious concern for compliance. Heathside House DS0000030493.V299470.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is “adequate”. The service users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family, although the records process is in need of review and re-organisation. The home has a GP provision that visits the home frequently. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. There exists a straightforward, yet effective medicines administration system, which needs a review of administration and recoding. EVIDENCE: Four case records were examined and found to be in need of immediate review and organising. Some residents had very sketchy, and ill-disciplined care plans, some with inconsistent reviews. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 11 The Home is presently introducing a new system and thereby running two systems in tandem. This is presenting a confused situation that the Care Manager and senior staff need to resolve as a matter of some immediacy. The daily record is fragmented and inconsistent. However there are some records that identify a well-balanced, accurate appraisal of requirements. The system would also benefit with a clear record of date of assessment, and signature of the accountable person. The home has good links with specialist services – GPs, Social Services, physio, speech and occupational therapy. A tour of the premises evidenced that there was a range of mobility and pressure relieving equipment, and examination of service user plans found that residents are assessed in relation to pressure sore risk, falls risk and nutritional risk. The administration of medicines adheres to procedures to maximise protection to service users. The storage was secure with satisfactory added security for any potential controlled drug. However there were gaps in the administration record of when, and why drugs had not been given. The system would also benefit from an information sheet with a photograph and personal information of each resident, included in the MAR folder. Staff training and recognition has been established. There exists some confusion over the practice of retaining ‘homely remedy’ arrangements. Prevailing records need updating with clear Medical support. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. The spiritual needs of service users were recorded and observed by the staff with due respect. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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): 12,13,14 and 15 Quality in this outcome area is “good”. Heathside House’s main objective is to respect the individual, thus delivering care in a relaxed and easy environment, with routine flexible to accommodate needs, and not dictate daily life of service users. Personal choice and relative self-determination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. These policies are designed to match expectations and to achieve a harmonious relationship throughout. The Home offers a good standard of diet, to which all service users spoken to were highly complimentary of all aspects of quality. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. EVIDENCE: Four residents were identified for case tracking. Discussions with those service users and staff clearly identified a relaxed and informal atmosphere in which the service user’s needs were paramount. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 13 Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Those service users’ rooms inspected showed a strong influence of personalisation in the inclusion of belongings, some furniture and general décor. Activities were in evidence on the inspection day and a programme of in-house entertainment was available, including arrangements for special events. There were some instances of residents left in meaningless circles in large, institutionalised day areas, although not typical. Several residents demonstrated remarkable vigour and cheerfulness, clearly very happy with their situation, and complementary of the staff. Choices were available for many aspects of daily living, and menus provided a varied and good choice of food available on a three weekly programme. The good standards of catering at Heathside House offered an excellent service, to which all service users spoken to were highly complimentary of all aspects of quality. A menu on a three weekly cycle offered a wholesome, varied and excellent choice. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each resident, and some of the relatives. An excellent lunch was served during inspection, with choices available, served in well-furnished dining rooms. Staff were seen to offer discreet assistance to those who required it. The kitchen was inspected with the cook and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. COSHH signs and notices were in evidence. Training certificates in food handling and hygiene were evident. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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): 16,17 and 18 Quality in this outcome area is “good”. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. Service users’ legal rights are protected by the systems in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users. EVIDENCE: A complaints book is maintained which shows a responsible approach in handling complaints appropriately. Experience has proven the depth of sensitivity of senior staff to addressing complaints in an effective manner. This includes a ‘niggles’ book for minor concerns received in-house, and found to be resolved to complainant’s satisfaction. It is recognised that at the time of inspection there was an issue regarding an Adult Protection investigation concerning a resident’s behaviour. It was seen that appropriate action was in being taken. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. It was advised that training on abuse should be for all staff annually. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 15 There is an in-house code of conduct presented to staff on induction, which would be complemented with the provision of the General Social Care Council’s recognised code of conduct booklet, for the attention of all staff. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is “poor”. The facilities in the Home are domestic in style and afford the residents with a comfortable, homely environment. The home provides comfortable accommodation for the service users who live there. Outstanding issues in relation to the environment that have been raised by CSCI and the fire authorities, which Stoke-on-Trent senior management have responding to. The upgrading of fire safety facilities has been extensive and scheduled for compliance completion during July. EVIDENCE: 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. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 17 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 smoker’s 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. There is a small patio area situated at the side of the building. There are ongoing outstanding environmental issues within this home. A recent fire officer inspection report has been extensively addressed, including some structural changes, which need to be made to the internal building. This work is scheduled to be completed by August 2006. Some work was seen as sub-standard in fitting, an issue for address by the Care Manager. The home is comfortable, warm and clean. Arrangements for the disposal of clinical waste are satisfactory. There are some areas remaining in need of redecoration and updating. It was pleasing to see that work had started on the redecoration of corridor areas, although there was damage to handrails that had created sharp edges that represent a risk. The Care Manager was asked to submit a development plan for 2006/07. It was noted that the passenger lift was out of order, and would be for a total of two weeks. Staff and residents had been well prepared to accommodate the demands that this placed on them. There were no malodours noted, much to the credit of the housekeeping and care staff. Water temperatures were satisfactory, although the Home has no Bath thermometers, needed in each communal bathroom. Laundry arrangements are satisfactory, although consideration should be given in providing clear COSHH posters to accommodate the use of toxic de-stainer liquid in use. Service users confirmed that the home is well heated and that their bedrooms are warm. The service users spoken with said that they were ‘happy’ with the environment in which they live. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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): 27,28,29 and 30 Quality in this outcome area is “good”. Staffing levels were seen to be satisfactory, the daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a good standard of care. The improvements made in staff selection/appointment have had a significant effect upon the provision of cares to ensure protection of service users. Records show improved staff training had a broad spectrum of care and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: There were 39 service users in the home on the day of the inspection. Off-duties for week commencing 11/06/06 – 08/07/06 were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a satisfactory standard of care. The staffing establishments were examined and found to be satisfactory in meeting the staffing notice. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 19 An average coverage was seen to be: Early shift – 0800 - 1500 - 1 senior carer and 4 care staff. Late shift – 1500 - 2000 - 1 senior carer and 4 care staff. Night shift – 2000 - 0800 - 3 care staff (I sleeping). The issue of sleeping staff was discussed in light of recent events concerning a Vulnerable Adult situation and the fire safety report, which advises a review of the sleep-in policy. Agency and bank staff are extensively used to meet shortfalls in covering shifts. The care manager was recognised as supranumery. There are suitable levels of support staff for housekeeping, maintenance and catering. It was noted that the operations manager is to be re-sited. It is expected that the Care Manager will have to take up day-to-day responsibilities for support services, which would place an onerous burden on a stretched care management. The Home has extensively reviewed and established a satisfactory procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, 2 references taken and CRB (enhanced) checks gathered before a contract is offered to successful candidates. The improvement of staff selection has a significant effect upon the provision of cares to ensure protection of service users. Three staff files were tracked and confirmed the policies in action. Each of those members of staff were generally happy with their working situation, felt valued and received a good standard of training. All staff need to be offered the GSCC code of conduct to supplement internal policies. A checklist approach to the appointment of staff is established and secured a satisfactory process of staff administration. All new staff goes through an induction process that will ensure that they are going to be the right person for the Home. However there was no direct evidence that a formal process takes place. It is recommended that all staff have a formal, recorded induction programme, and a statement of terms and conditions of service through a comprehensive contract. Records show a regular supervision and a broad spectrum of care and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. There are 11 care staff with appropriate level of NVQ training (50 ), and the Care Manager will be completing Level IV and the Registered Manager’s Award this September. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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): 31 - 38 Quality in this outcome area is “adequate”. The manager has the appropriate skills and experience to manage the home. There is a confidence apparent in the interaction of residents, staff and the Home’s management, that demonstrated a positive relationship that pervades throughout the Home. EVIDENCE: The inspector observed at first hand the confident interrelationship that exist between staff, service users and relatives. The easy and relaxed atmosphere created by a responsive care staff enabled that confidence. Evidence was secured to confirm that a quality monitoring system has been established, based upon audit of standards, care plans, general audits and feed back from service users and relatives. Records of Residents’ Lounge Meetings were examined, and found to be meaningful. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 21 Local Authority presence was evident, although there were issues of communication, planning and contracts that need resolve. Changes in managerial arrangements are to take place this July. Care planning audit is recommended to enhance the resident’s daily living, and to ensure that individual requirements are maintained. Standards are discussed at staff meetings, daily handovers, direct observation and involvement and one to one staff meetings and supervision. Examination of staff records showed that employment policies are much improved and effective. All records and medical notes are kept confidential and secure. There is a willingness to create a training environment. A staff supervision policy and procedure is in place in the home, and will be maintained to form an established routine alongside a cascading training programmes. The accident books for staff and service users were checked and found to be accurate, up to date and Riddor sensitive. These issues and routines ensured the health, safety and welfare of service users and staff. The procedures manual was randomly examined and found to offer a very comprehensive reference. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions. A sample of administrative and maintenance records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. The administration and management of the home is uncomplicated and sensitive to the needs of service users. Relevant legislation, diversity and prevailing care issues were discussed and are fully appreciated by the management. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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 1 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 3 3 3 3 2 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 3 3 X X 3 2 2 Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1)(b)(c) Requirement Each Service User must have a written contract/statement of terms and conditions with the home (Previous timescale of 01/07/05, 30/11/05 and 06/02/06 not met) Rationalise care planning to offer a meaningful assessment, plan, risk assessment and review of care. The outstanding recommendations made by Staffordshire Fire and Rescue to be addressed in timescales agreed Maximise safety in ensuring early address to maintenance and repair to fabric and furnishings. That all instances of nonadministration of medicines be recorded to determine reason for non-administration. All staff records should evidence a structured induction programme. Timescale for action 01/09/06 2 OP7 15(2) 01/08/06 3. OP19 23(4)(a)( b) 30/08/06 4. OP21 23 (2) (b) 01/09/06 5 OP9 13.2 01/07/06 6 OP30 18 (c) (i) 01/07/06 Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 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. 1 2 3 4 5. 6 Refer to Standard OP19 .4 OP29 OP38 OP25 OP18 OP7 Good Practice Recommendations The management provide the CSCI a refurbishment/development plan for the Heathside House site for period 2006/07. That all staff are supplied with a copy of the General Social Care Council code of conduct and practice. That COSHH posters be secured in areas of chemical usage and storage. A bath thermometer be placed in each communal bathroom. All staff should have adult protection training. Ensure the daily report is kept up to date. Heathside House DS0000030493.V299470.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 House DS0000030493.V299470.R01.S.doc Version 5.2 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. 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