Inspection on 21/12/05 for Heathside Rest Home

This inspection was carried out on 21st December 2005.

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 Rest Home 13/08/07

Heathside Rest Home 24/05/06

Heathside Rest Home 29/06/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Heathside Rest Home 74 Barrington Road Altrincham Cheshire WA14 1JB Lead Inspector Val Bell Unannounced Inspection 21st December 2005 14:00 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 Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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 Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Heathside Rest Home Address 74 Barrington Road Altrincham Cheshire WA14 1JB 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) 0161 941 3622 Miss Alicia McDonnell Miss Frances Anne McDonell Miss Alicia McDonnell Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users requiring personal care shall be sixteen (16) over the age of 65. Care staffing levels will not fall below the minimum levels set out in the Residential Forum Guidance `Care Staffing in Care Homes for Older People`. The registered persons must undertake training in the protection of vulnerable adults from abuse by 31 July 2005. 29th June 2005 Date of last inspection Brief Description of the Service: Heathside provides residential accommodation and personal care for up to sixteen residents within the category of old age. However, any of the residents could additionally have a physical disability. Heathside is a large property, which is set in pleasant grounds. The home is situated on Barrington Road in Altrincham, close to the town centre. Service users bedrooms were personalised with furniture, photographs and possessions from home. Fourteen single bedrooms and one double bedroom are located on two floors. All rooms are fitted with washbasins and vanity mirrors. A small car parking area is available at the front of the building. There are gardens to the rear of the property. This area includes a patio/barbecue area, with garden furniture, where residents can sit in the summer months. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during daytime hours on 21 December 2005. The registered manager was not present at this inspection. Various records were examined, including care plans and conversations were held with residents and care staff. Seven of the nine outstanding requirements had been met and a further six requirements were made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: There was little evidence to demonstrate that the appropriate level of management leadership, direction and guidance was being consistently provided. This had resulted in residents and a visiting professional being Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 6 unclear about who owned and managed the home. Additionally, because the manager was not present on the day of inspection it was not possible to assess her progress on undertaking the appropriate management training. Although there had been significant progress in developing care plans, several shortfalls in reviewing and updating some of the care plans were found. This gave cause for concern that some residents were not having their changing needs identified and met. Lastly, the homes accident book and the local authority procedure on the protection of vulnerable adults from abuse could not be located on the day of inspection. 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 Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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 Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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 New residents appeared to be given the appropriate information to help them settle into the home and to decide if the home would be able to meet their needs. EVIDENCE: Standard 1 was not fully assessed on this occasion. However, it was observed that a new resident was being admitted to the home during the inspection. Staff spent time with the resident introducing her to the other residents and staff. Appropriate information on routines, such as mealtimes was also shared with the resident. Staff took every opportunity to ensure that the new resident settled in well. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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): 7 and 9 Although significant progress had been made in developing care plans, several shortfalls placed some residents at risk of not having their assessed needs met. Robust systems in the administration of medication ensured that residents received the correct medication at appropriate intervals. EVIDENCE: Five care plans were assessed during this inspection. It was noted that significant progress had been made to the structure and relevance of care plans since the last inspection. Resident’s likes and dislikes had been recorded and timely referrals had been made to healthcare professionals if a resident’s health needs were a cause for concern. Residents who suffered from diabetes were receiving regular chiropody and eye tests. This provided evidence that residents had access to the full range of community healthcare services available. Several shortfalls were identified, however. It appeared that the monthly weighing of residents had ceased in September 2005. The inspector was told Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 10 that the homes scales were broken and had not been replaced. This was a cause for concern as one of the care plans stated that the resident had suffered weight loss in the period up to September although this had not been monitored in the previous three months. A requirement was made accordingly. Furthermore, another care plan stated that the resident was on a weight-reducing diet. The care plan should have detailed how that persons target weight was to be achieved and the outcome could not be monitored due to weighing scales not being available. A further requirement was made. A third shortfall was noted in the care plan of a resident who had suffered two successive falls. The appropriate action had been taken in referring this resident for medical advice following each fall. However, the care plan and falls risk assessment should have been reviewed and updated following the first fall and this had not been done. A third requirement was made. A resident who had been admitted to the home two months prior to this inspection did not have her photograph included in the care plan. A fourth requirement was made. The home was assessed as operating a safe system of the administration of medication and the requirement made at the previous inspection had been addressed. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the Standards in this section were assessed on this occasion. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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): 16 and 18 Lack of access to the appropriate procedures for the protection of vulnerable adults from abuse placed the safety and welfare of residents at risk. EVIDENCE: No complaints had been received by the home since the previous inspection. The inspector was told that staff had received training in the protection of vulnerable adults (POVA) from abuse. However, a copy of Trafford Metropolitan Borough Council’s procedure on POVA could not be located during the inspection. It was required that this procedure is held in the home and made available to all care staff. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 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 homes attention to environmental health and safety issues protected the safety and welfare of the people living in the home. EVIDENCE: Since the previous inspection window restrictors had been fitted to all first floor windows and hot water temperatures had been risk assessed and monitored on a regular basis. Additionally, a loose bath panel had been secured. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 14 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 Provision of training opportunities for care staff will ensure that they develop the skills and knowledge to meet the assessed needs of residents. EVIDENCE: The registered manager was not available during this inspection. In conversation with staff it was confirmed that an NVQ programme was available to care staff. Progress on care staff achieving NVQ 2 will be fully assessed at the next inspection. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 15 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 and 38 The home could not provide evidence that the home was being appropriately managed, by the registered person on a daily basis. This places the care staff at risk of having insufficient leadership and guidance in adequately meeting the assessed needs of residents. EVIDENCE: Due to the registered manager not being present at this inspection it was not possible to assess progress on her willingness to study for a management qualification. Consequently, the requirement made at the previous inspection is re-iterated in this report. The record of a resident’s social services review made reference to Mr and Mrs McDonnell being the home’s proprietors. This suggests that health and social care professionals visiting the home consider that the home is owned and managed by the registered person’s parents. In conversation with some Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 16 residents it was apparent that they were unclear as to who the registered providers and registered manager were. This is a cause for concern as it calls into question the level of involvement of the registered manager of the home on a day-to-day basis. The registered manager must provide evidence of her management of the home by including her management hours that on the staff rota. A message was left for the manager to contact the inspector to discuss this issue. Residents confirmed that they had access to money held on their behalf by the home for safekeeping. The homes accident book could not be located on the day of inspection. A requirement was made accordingly. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 2 Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 17(1)(a) Requirement The registered person must ensure that information is held on each resident as required by Schedule 3 of the Care Homes Regulations 2001. The registered person must ensure that the weight of residents prone to weight loss is monitored at appropriate intervals. Care plans must contain sufficient detail to ensure that the desired outcomes based on residents’ individual needs can be met. Care plans and risk assessments must be reviewed and updated at least monthly and more regularly as residents’ needs change. The registered manager must obtain a copy of Trafford Metropolitan Borough Councils policy on the Protection of Vulnerable Adults from Abuse (POVA) Previous timescale of 29/10/05 not met. Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 19 Timescale for action 21/03/06 2. OP8 12(1)(a) 21/03/06 3. OP8 14 (2) 21/03/06 4. OP8 14 (2) 21/03/06 5. OP18 13 (6) 21/03/06 6. OP31 9 (2b) (i) The registered manager must be qualified to NVQ level 4 in management (or equivalent) by 2005. 21/03/06 7. OP31 17 (2) Sch 4 (7) 8. OP38 17 (2) Sch 4 (12) Previous timescale of 31/12/05 not met. The registered person must 21/03/06 provide a copy of the duty roster of all persons working in the care home and a record of whether the roster was actually worked. The registered person must 21/03/06 ensure that the homes accident book is available for inspection at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heathside Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Rest Home DS0000063746.V270406.R01.S.doc Version 5.0 Page 21 - 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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