Inspection on 09/01/06 for Heathside House

This inspection was carried out on 9th January 2006.

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

The inspector 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 01/02/07

Heathside House 21/06/06

Heathside House 16/08/05

Heathside House 30/03/05

Heathside House 30/09/04

Similar services:

Maple Lodge

Heathlands

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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 Wendy Snell Unannounced Inspection 9 January 2006 9:45 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.V277654.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heathside House Address Heathside Lane Goldenhill Stoke On Trent Staffordshire ST6 5QS 01782 234551 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.V277654.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 Learning Disability over 65 years of age (LD(E)) - Places for existing residents only 16th August 2005 Date of last inspection 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.V277654.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Monday morning from 9.45am to 1pm. Six service users, two staff members, the assistant manager, administrator, maintenance person and registered care manager were spoken with. Four staff files were examined to check recruitment practices and training. The communal environment was also inspected during this visit. What the service does well: What has improved since the last inspection? What they could do better: The Commission for Social Care Inspection is concerned that a service user has been admitted who is of an age for which the home is not registered. A letter Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 6 of serious concerns was issued and there remains ongoing communication between CSCI and Stoke-on-Trent City Council regarding this matter. The home also needs to improve the systems and storage of information relating to staff vetting to ensure that there is clear information about how the home safeguards service users. Appropriate systems and information also needs to be in place regarding staff training so that the home clearly demonstrates the competence of staff to meet the needs of the service users in the home. 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.V277654.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has clear assessments of service users’ needs, which enable staff to support them appropriately. EVIDENCE: Assessment documentation was inspected on the 16th August 2005. Comprehensive assessment documentation was found to be in place. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 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 the following standard(s): 10 Service users spoken with feel that staff at Heathside house respect their privacy and dignity. EVIDENCE: Six service users were spoken with about issues relating to privacy and dignity. All the service users said that they were well cared for by the staff team at Heathside House. They confirmed that when they are assisted to use the bathroom facilities that staff always close the door. They also said that staff always knock on the door before entering their bedrooms. Heathside House has a telephone located within a small room so that service users can make and take telephone calls in private. Two service users confirmed that they use the telephone on a regular basis. During a previous inspection it was noted that GP visits take place in service users’ bedrooms. Staff and management interactions with service users observed during the inspection were sensitive and respectful. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 10 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): 13 & 14 An increase in staffing has enabled service users to have more access to their local community. The service users spoken with felt that they are encouraged to express choice and that the staff listen to them. EVIDENCE: Community contact and activities within the home was examined at the previous inspection. The feedback from service users and relatives was that some service users would benefit from taking part in more activities and from spending some time in the community. It is pleasing to note that this has now been addressed and that extra staffing hours have been made available for this purpose. A diary outlining how some of this time has been used was available during the inspection. A variety of outings including walks to the local park, riding school and shops as well as indoor activities were recorded. A service user confirmed that she had enjoyed a trip out to the local park. A staff member who has been involved with these activities said that service users had ‘really benefited’ from the extra input. Service users confirmed that there are able to see their families and friends as they wish. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 11 Service user autonomy and choice was examined. Heathside House is divided into four lounge areas. The manager stated that service user representatives from each lounge attend regular meetings with staff where issues relating to choice are discussed. The minutes of these meetings outlined that 8 service users and 2 staff had attended. Six service users were spoken to. One service user stated that she had attended a recent meeting where ‘people can talk about what they want doing’. All service users acknowledged that there was a routine within the home but felt that they were offered choices on a daily basis regarding their own daily living. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 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 the following standard(s): 18 Staff training would enhance the adult protection system within this home. EVIDENCE: The home has an adult protection policy, which is in the process of being updated. The manager demonstrated an awareness of what to do to safeguard service users from abuse. Two staff were spoken with and a number of staff training records were inspected, which revealed that staff have not received up- to-date training in adult protection procedures. Training or refresher training in this area would further safeguard service users from abuse. Six service users were spoken with - all said that they felt that staff listen to their concerns and respond accordingly. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 13 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 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 are responding to. 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 are 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 smoker’s lounge situated off the entrance hall. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 14 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 discussions with CSCI regarding the outstanding environmental issues within this home. A recent fire officer inspection has also identified some structural changes which need to be made to the internal building. CSCI understands that Stoke-on-Trent have now evaluated the cost of the work which remains outstanding. In December 2005 Stoke-on-Trent City Council forwarded the framework of an overarching plan of action to CSCI. There are now ongoing discussions between Staffordshire Fire and Rescue Service and CSCI regarding the contents of the plan. The home is comfortable, warm and clean. However, it remains in need of redecoration and updating. It was pleasing to see that work had started on the redecoration of corridor areas. The maintenance person explained plans for further work to update the décor in the corridor areas. 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.V277654.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 Identification and recording of staff training is not satisfactory and does not adequately demonstrate the skills the staff have to meet the service users needs. The home’s recruitment and training records do not clearly identify the vetting processes of all staff. EVIDENCE: The manager was asked about the percentage of staff who had achieved NVQ2. A detailed record was not available. The manager said that the home had experienced difficulties with the assessment of NVQ candidates. The latest monthly monitoring record for this home indicated that seven staff have achieved NVQ2 and that three assistant managers are working towards NVQ3. Two care staff were spoken with both stated that they had not started NVQ2 training. As a detailed breakdown of this information was not available at the time of the inspection it should be forwarded the Commission for Social care inspection. The manager should ensure that 50 of the care staff employed within the home have or are working towards NVQ2. The National Minimum Standards timescale for this target was by 2005. There was a variety of information within the home relating to training. Four staff files were examined. The training information within these files was disordered and did not provide an accurate record of training attended. The manager stated the staff members keep some of the staff training certificates and therefore the home does not have a record on file. The home should have a record of all training attended by staff. The manager showed two examples Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 16 of where staff files had been updated. These files contained good, clear information relating to staff training. The manager must ensure that there is an accurate training record for all staff and that this information is also included in the home’s statement of purpose. The manager had a corporate induction pack for a new starter. The manager is reminded that all new staff members must receive induction training within six weeks of appointment. Two staff were spoken with and both confirmed that training is generally available. The home’s staff recruitment and vetting processes were examined and four staff files were looked at. The information within the staff files was disordered. There was no system or date order for the information stored. It is recommended that this system be reviewed as it prevents easy access to core information regarding the home’s vetting processes. The file of the latest recruit to the staff team contained information relating to safe recruitment practices. There was evidence of a CRB clearance and two references. There was also a completed application form and information which confirmed identification of the staff member. However, appropriate information relating to references and CRB clearance was not within the staff files of the other three staff members. This was discussed with the manager. It is acknowledged that the three staff members were employed at Heathside House prior to 2002 and therefore two references were not required to be on file. However, information relating to the CRB clearance must be available for all staff. The manager contacted the human resources department to clarify this matter and stated that he would forward this information to the Commission for Social Care inspection. This was not done. As a result of further communication between the CSCI and Heathside House this information was eventually clarified. The manager must ensure that information relating to CRB clearances must be available in respect of all staff. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 17 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 & 35 The manager has the appropriate skills and experience to manage the home. However, the Commission for Social care Inspection is concerned that a service user of an age for which the home is not registered was admitted to this home without CSCI notification or agreement. There are good systems in place to safeguard service users’ monies. EVIDENCE: The manager has the skills and experience to manage the home and was observed to interact well with his staff team and with the service users. Staff spoken with said that he was approachable and supportive. The service users spoken with were aware of who the manager is. The manager is in the process of completing NVQ4. The manager should provide information regarding the timescale for completion of this award. The Commission for Social Care Inspection is concerned that the manager had accepted the admission of a service user who was of an age for which the home is not registered. The Commission for Social Care Inspection were not Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 18 notified of this admission and agreement had not been sought to vary the conditions of the homes registration. There is on-going communication between the CSCI and Heathside House in relation to this issue. The home’s administrator was spoken with. The way in which the home handles service user’s monies was inspected and found to be satisfactory. There was evidence of good recording accompanied by receipts, which provided a clear audit trail of monies spent. All monies taken from a service user’s personal allowance was shown to have two staff signatures with service users also signing for their money if they are able to. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 x x x x x x x STAFFING Standard No Score 27 x 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 x x 3 x x x Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 and 30/11/05 not met) The outstanding recommendations made by Staffordshire Fire and Rescue to be addressed in timescales agreed with them or by. The manager must undertake medication training (Previous timescale of 01/07/05 and 30/11/05 not met) Satisfactory information relating to the vetting of all staff must be available within the home. The home must have a record of all staff training. The statement of purpose must be reviewed to include up-todate information about the qualifications and training of staff. Service users who do not meet the category or conditions of registration must not be admitted to this home. DS0000030493.V277654.R01.S.doc Timescale for action 06/02/06 2. OP19 23(4)(a) (b) 31/03/06 3. OP9 18(1)(i) 06/02/06 4. 5. 6. OP29 OP30 OP1 19(5)(d) 17(2) 4(1) 09/01/06 28/02/06 28/02/06 7. OP31 21(1) 09/01/06 Heathside House Version 5.1 Page 21 8. OP31 21(1) A variation and agreement with CSCI must be sought. 16/01/06 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 Refer to Standard OP28 OP28 OP29 OP29 OP18 Good Practice Recommendations A breakdown of the percentage of NVQ2 qualified staff should be sent to the Commission for Social care Inspection. 50 of staff should have NVQ2. The timescale within the National Minimum Standards was 2005. The manager should ensure that all staff have an ordered training record. The manager should ensure all staff have an ordered personnel file with clear information regarding recruitment and vetting checks. All staff should have adult protection training. Heathside House DS0000030493.V277654.R01.S.doc Version 5.1 Page 22 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.V277654.R01.S.doc Version 5.1 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. 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