CARE HOMES FOR OLDER PEOPLE
Heaton Grange 425(a) Toller Lane Heaton Bradford West Yorkshire BD9 4NN Lead Inspector
Sue Dunn Key Unannounced Inspection 18th July 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 Heaton Grange DS0000064467.V300968.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. Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Heaton Grange Address 425(a) Toller Lane Heaton Bradford West Yorkshire BD9 4NN 01274 494439 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) Mr Deepak Patel Mrs Susan Miller Care Home 20 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (15), of places Physical disability over 65 years of age (3) Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Heaton Grange is a single storey detached residence situated in the Heaton area of Bradford approximately 3 miles from the city centre. There are carparking facilities to the front and the home is on a public transport route. A local shop is within walking distance. A patio and garden area has seating for the service users. The living accommodation consists of an open plan lounge and dining area with a conservatory to the front of the home. Bedrooms provide single and double occupancy with bathrooms and toilets all based on one level. Disabled access is via a ramp to the front door. Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. One inspector undertook the inspection, which was unannounced. The inspection started at 10 am and finished at 5.30pm A pre inspection questionnaire sent to the manager had been completed at the time of the inspection and was used to support judgements made during the inspection visit. Comment cards with pre paid envelopes were left in the home inviting people to express their views about the service. Several had been returned from residents, a health professional and the manager at the time of writing. The comments supported evidence gathered at the time of the visit. The report is based on information received from the home since the last inspection in January, observation and conversation with residents and staff, discussion with the manager, examination of 3 care files (which included case tracking two) and an inspection of the premises. This included an inspection of some bedrooms and all communal areas. There are some minor shortfalls against the standards but the home is judged to be managed in the interests of the residents most of whom had good social skills and were able to express their satisfaction with the service they received. Work has been undertaken to meet the requirements and recommendations made by the previous inspector. The scale of charges were said to range from £284.48 - £391.37 per week. There is a £15 supplement charged for a single room. Fees do not include personal toiletries, clothes, hairdressing or chiropody. What the service does well:
The home offers each person the opportunity to visit the home and stay for a short period before making the decision to move in permanently. This had worked well for the people spoken with who felt they had been able to make an informed choice. The home was comfortable and odour free. All rooms are on the ground floor and communal areas allow sufficient space for residents to move around freely. The overall standard of personal care was good. There was a relaxed and flexible approach to recreational activity. The activity programme, said to be used as a guide, did not do justice to the reality seen on the day of the inspection. The more mature staff were seen to converse well
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 6 with residents. It was good to see how residents enjoyed having a dog around the home. Meals were described as ‘good home cooking’ and the highlight of the day for all the people spoken with. The home has a written charter to remind staff, residents and relatives that people in the care home continue to have the rights enjoyed by the wider population. Residents were valued for their individuality and efforts made to accommodate each person’s preferences. What has improved since the last inspection? What they could do better:
The information for service users could be made easier for people to read by producing it in larger print and adding some visual interest in the form of colour and pictures. There must be evidence to show that residents and their families have seen the home’s terms and conditions of occupancy as the contract for agreed funding is between the funding authority and the home. It is acknowledged that the home had been advised not to use their own document. Pre admission assessments must be detailed enough for the home to show how they propose to meet the different needs of each person. There must be a photograph on file of every resident. All documentation must be dated and factual information complete.
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 7 There should be more background history in each person’s file in order to develop a care plan unique to each resident. The daily records must provide a record of how care is followed through between staff shifts. Staff should avoid recording ‘no change’ in residents daily records and make reference to the care plan to monitor its effectiveness and amend it if necessary. Personal information recorded in the desk diary could breach confidentiality. Drinks must be made more accessible and staff more proactive in encouraging people to increase their fluid intake during the day, particularly in hot weather to avoid dehydration. The written menu did not do justice to the personal approach to available choices. Napkins should be provided to protect clothing at mealtimes. Consideration must be given to improving the natural lighting and ventilation in the bedroom which opens into the designated smoking area, on health grounds and to improve the quality of the facilities for anyone occupying the room. There must be enough staff available to provide cover in the event of sickness and holidays. There must be evidence to show that Criminal Record Bureau (CRB) checks are periodically updated. It is recommended that the manager keep a master plan of all training and dates for ease of auditing each person’s training needs. Staff must have formal supervision at least 6 times a year. The registered manager must have an approved management qualification. There must be evidence to show regular Health and Safety checks are undertaken. It is recommended that the home have an emergency procedure policy in order to be prepared for any unforeseen situations which may require evacuation. It is recommended that the signs to the home be made more visible from the main road to make the home easier for ambulances, emergency vehicles and visitors to find. 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. Heaton Grange DS0000064467.V300968.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 Heaton Grange DS0000064467.V300968.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 The quality outcome in this area is adequate. This judgement is based on information from documentation, care files, speaking with residents and the manager. The home offers a good introductory service but the booklet should be in a format suitable for the people it is intended to inform. All service users are entitled to know what are the terms and conditions of occupancy. Pre admission assessments must be detailed enough to show how the home proposes to plan for overall care needs. EVIDENCE: The new proprietor has included an introductory page to the Statement of Purpose. This booklet includes a Service User Guide and a copy of an inspection report, though not the most recent. The Service user guide was informative but in small print with no visual interest. The aims of the home were included but it did not describe how the
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 10 aims were to be met. The information must be in a format suitable for the people it is intended for. The Manager was able to produce a copy of the terms and conditions of occupancy and there was evidence of a contract for people paying top up fees. The manager had been led to believe that the only contract people needed was the one from Social services. This however does not give the people using the service details of the terms and conditions of the home. A top up contract for one person included details of the room to be occupied. Pre admission assessments by social workers and the manager were seen in the files inspected. The assessment by the home focussed on basic physical care and did not describe what the home would do to meet overall needs. Another assessment by the manager only had information from the hospital on which to base her judgement that she could provide care. A letter in the file from the solicitor explained the terms of a supervised discharge. One resident described how she was able to visit the home and several others before making a decision about where she would live. Another person had a short stay in the home and settled well enough to become a permanent resident. Heaton Grange DS0000064467.V300968.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this area is adequate. This judgement is based on the available information including, inspection of a selection of care plans, discussion with residents, discussion with the manager, observation and comments received from a health professional who visits the home. The care plans did not include all the information required to meet overall needs, though observation showed that the manager did recognise each person’s individuality. Personal care was of a good standard. EVIDENCE: Care plans gave some guidance to staff and were evaluated each month by the manager. More could be done to improve the care plans however. Care files did not include a photograph as required. There was little background information recorded in the care files therefore no action plan specific to each persons differing social, intellectual, cultural and recreational needs. One person was happy to volunteer information about his past life but none of this was recorded in the care plan. One person’s care plan said she liked to discuss her past life but there was no information to provide
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 12 staff with conversational leads. The manager said she had asked families for relevant background history. It is suggested that she provides a pro forma with some leading prompts to help people with this task. Families are also asked to complete a factual information form. This should be checked and any omissions put right before the information is placed on file. The manager was advised to look at the back of the National Minimum Care Standards book for detailed guidance on what must be included in the records. The care plans seen included a Moving and Handling assessment, a weight monitoring chart and evidence of visits by health professionals. The recording of some information had not been followed through eg, outcome of a chiropody appointment though it had been recorded that foot care would be dependant on the chiropodist’s report. Staff should guard against recording ‘No change’ in residents’ care files as this does not give any useful information, but should try to record positive experiences and events in each resident’s day. Accident records were kept in each file. As the home is small and the manager provides hands on care she does not feel the need to use a separate auditing system for accidents. A desk diary is used for daily record keeping. Personal information about different people was recorded on the same page. This breaches confidentiality. The manager was advised about alternative ways of recording information to make it readily available but confidential. The weather on the day of the inspection visit was extremely hot. Umbrellas shaded outdoor tables and seating and sunhats and sun protection cream were available. There was no evidence seen of people being encouraged to have extra fluids during the day. A resident said a cup of tea was served during the morning and juice was seen to be served with the lunch. The manager said people can ask for drinks at any time but this was not seen to happen. The staff must be more proactive in encouraging people to increase the amount they drink each day. Residents were using all parts of the home and were observed to be appropriately dressed in well cared for clothing. Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 13 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 The quality outcome in this area is good. The judgement is based on the available information including inspection of care plans, discussion with residents and the manager and observation. There is a relaxed approach to activities, which suited the residents and everyone was complimentary about the food. More could be done to improve the documentary evidence of this. EVIDENCE: The Home’s activity programme does not do justice to the relaxed and flexible approach to activities. Several residents said how fond they were of the dog, which was talked to and patted. People were able to move freely around the home. A conservatory, smoke room, outside patio, dining room and lounge offered a range of seating. During the morning some residents were listening to music, which they clearly enjoyed as they commented when the tape finished. One was reading and went for frequent walks around a circuit created between lounge and dining area. The manager said the activities for each day are directed by the residents, who will soon say if they don’t want to participate. The programme is only used as a guide. There was good verbal interaction between residents and more
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 14 mature staff but this did not seem to come naturally to a younger member of staff. One person who said he liked gardening was occupied sweeping the patio area. The chef and care staff organised a quiz during the afternoon. One of the people whose care was being tracked took an active part in the activity and appeared to enjoy displaying her knowledge. The manager said the chef takes several people to the local pub periodically. This was said to be particularly beneficial when one person becomes agitated, as it is a familiar place. Two people go into town periodically with the manager and several have been enrolled to attend the local bingo. The menu sheet is displayed each day on the hatch into the kitchen but people were not aware of what was on the menu. The chef adopts a personal approach, speaking to each person individually and was familiar with likes and dislikes. The menu did not indicate the flexible range of choices. All the residents spoke highly of the food. ‘Its just like mother used to make’ said one person. Another said the food was what she liked most about the home and another said ‘it’s marvellous here, the food is good and you can have second helpings. One lady said she had really enjoyed the salad for tea and confirmed she had supper of her choice each evening before going to bed at ‘10ish,’ which bore out what the chef had said. The food sampled was hot, of good quality and flavoursome. Two people required full assistance with their meal staff were sitting down with them and assisting at each residents own pace. It is recommended that jugs of juice/water be placed on the tables to allow people to help themselves. Napkins should be provided to protect clothing at mealtimes. Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 15 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. This judgement has been made from speaking to the manager and residents, examining training records and other documentation. The manager should keep a log of all complaints and carry through her ideas for making residents and relatives aware of their rights. EVIDENCE: All the people spoken with were satisfied with the service. The manager gave an example of how she had worked with a relative to deal with concerns they brought to her attention. The relative was satisfied. A complaints log should be available for recording such information. The home has charter of rights for residents’, which the manager plans to place in each bedroom and in the home’s information pack. The complaints procedure is on display. The manager is considering placing a complaints and comments box close to the entrance to the home. All residents were on the electoral register and have a postal vote. Eight staff had completed the adult protection training and a letter inviting another member to attend the course was on the office wall. Heaton Grange DS0000064467.V300968.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, 23, 24, 25 and 26 The quality in this area is good. This judgement is based on a tour of the building, discussion with the manager, the chef and some residents. The home meets the needs of older people who do not need a secure environment. The new proprietor is making progress in carrying out work outstanding from the previous owner to improve standards and safety in the home. One of the bedrooms does not provide a satisfactory level of natural light or ventilation as the window opens onto an enclosed area, which is used as a smoking area. The home offers a clean, comfortable environment with good odour control. EVIDENCE: The home is difficult to find as it is hidden behind a nursing home and there is no notice on the main road to identify its whereabouts. The approach to the front door is across a well-kept patio area surrounded by a low fence. The outdoor area would not be secure for people who wander.
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 17 There was good odour control throughout the building. Communal areas within the home allow space to circulate and had recently been equipped with new chairs. The small size of some bedrooms limits the scope of personal possessions such as furniture but the contents in some rooms reflected the interests of the occupant. One lady said she had been able to choose her own bedspread and curtains after her room was redecorated. Hard floor covering had replaced carpets in some rooms as an odour control measure. All bedrooms were lockable for privacy and security of personal possessions, but the locks were not of an ideal design for older people. The proprietor has spoken to the fire safety officer for advice on more suitable handles. Some rooms were locked and residents gave permission or opened the door for the inspector to look at the room. The manager had tried to make one room look more ‘lived in’ by putting pictures and an artificial plant in room. The window of one of the bedrooms opens into a glass- roofed area designated as the smoking area, therefore there is no direct light or natural ventilation. The room was registered under the old legislation but is most unsatisfactory by present standards. The fire officer has requested that the glass in the window of the room be replaced with toughened fire resistant glass making this an even less attractive proposition for anyone occupying the room. All the fire safety work apart from this and the replacement of a push bar fire door has been carried out. Fire safety notices had been ordered and the chef will provide in house fire safety training when he has completed the fire trainer’s course run by WYFS. The proprietor has plans to redesign room 16 and the adjoining large bathroom to make two single rooms with en suite and make a new fire exit. Plans have not yet been submitted to the CSCI. Heaton Grange DS0000064467.V300968.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 The quality in this area is adequate. This judgement is based on examination of the rota, and training records, discussion with the manager and residents and observation of care practices. The staff are versatile and cover all aspects of care and domestic tasks, which they appear to do well. However, the home’s manager must ensure there are sufficient staff in the team to draw upon in the event of sickness and holidays. There had been an improvement in the training records and there was evidence of the training carried out since the last inspection. The rota must be a permanent record to show any staff changes. EVIDENCE: The rota was written in pencil and showed 2 care staff the manager and cook on duty for 15 residents. There have been no staff changes since the last inspection. The manager explained that one of the carer workers was her sister who had previously worked in the home and was covering for a member of staff who had phoned in sick that morning. She had been unable to maintain staffing levels any other way. It was clear that the person in question knew the home and the residents and was competent. The rota had not been amended to show the changes but was done so before the end of the day. The manager was advised that rotas are a legal document therefore must be written in ink and be accurate. There must be evidence to show that everyone who is employed, including ‘bank’ staff must have gone through the Protection of vulnerable adults (POVA) process, which is periodically updated and must have covered a basic induction training. Each member of staff had a file with details of their training. The manager had done this at the request of the previous inspector and had found it a useful
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 19 way of identifying shortfalls in training. It was suggested that she keep a master plan of all training courses, who did what, and when for ease of audit and to organise a yearly training plan. The regular member of staff on duty said she had completed her NVQ2 and was starting NVQ3 The manager had arranged to make adjustments to the rota to enable staff to attend NVQ support days. All the staff were doing food hygiene training with Park Lane College. The college also provided the manager with a questionnaire to do infection control training with the staff, which has been done in house. It was apparent from observation and discussion that residents are valued for their individuality and the home tries to accommodate each person’s preferences. It was agreed that if the manager does a moving and handling trainers’ course and keeps up to date with practice she can provide in house training and updates for staff. It is the manager’s responsibility to ensure staff are competent to carry out the tasks required and decide when staff need training updates There is a system of supervision in place. In the file examined this had not taken place recently. The care staff are responsible for general cleaning and the laundry, as the home does not employ domestic staff. One resident said there were ‘ample staff’. The chef was helping with recreational activities during the afternoon whilst a care worker spent 1:1 time with a resident who was agitated. The home’s policy on escort duties was discussed and the impact this can have on staffing costs. It is suggested that the arrangements for this be detailed in the service user guide. Heaton Grange DS0000064467.V300968.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, 32, 35, 36, 37 and 38 The quality in this area is adequate. The judgment is based on discussion with the manager, inspection of records and discussion with residents. The manager has a good relationship with residents, recognises each person’s individuality and takes pride in providing a good standard of care. She has not yet achieved an approved management qualification. Some of the homes records let down the care provided. EVIDENCE: The manager had enrolled on an NVQ4 in management programme with a new provider. She felt confident that the new provider would give the support she needed to achieve the award. The manager had a ‘hands on’ style of management and her commitment to the care of the residents was apparent. It is recommended that some of her management tasks be delegated to one of the senior carers whilst she is undertaking the NVQ course and to provide a staff development opportunity.
Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 21 The new proprietor was said to visit the home 2-3 times weekly and has indicated a commitment to make improvements to the home. The proprietor and Chef (manager’s husband) go round the home to identify any repairs or renewals needed, but this is not recorded. A copy of a health and safety check list pro forma is to be forwarded to be adapted for the home’s use. Action has been taken to improve fire safety and fire safety training and to provide infection control and food hygiene training. The home does not have an emergency procedure policy. The manager is advised to contact the city’s disaster unit for information and develop a procedure for the home. A resident said she gets a personal allowance each week, which she uses for personal clothing and other items. The home does not handle finances for residents. The manager said she has received positive comments from other professionals about the home’s reputation for giving good personalised care. Heaton Grange DS0000064467.V300968.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 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 x 3 3 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 3 2 2 3 Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 23 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 OP2 Standard Regulation Reg 5 Requirement There must be evidence to show that every resident or their representative is familiar with the homes terms and conditions of occupancy The home’s pre admission assessments must be sufficiently detailed to show how each persons care needs are to be met before they are admitted to the home. Care plans must contain all the information set out in the schedule of records to be kept and provide sufficient detail to give guidance to staff about the different approach to care for each person Consideration must be given to improving the natural lighting and ventilation in the bedroom adjoining the smoking area. There must be sufficient staff in the team to provide cover in the event of sickness and holidays Staff CRB checks must be periodically updated The manager must complete NVQ level 4.
DS0000064467.V300968.R01.S.doc Timescale for action 31/10/06 2 OP4 Reg 14 31/10/06 3 OP7 Reg 15 30/11/06 4 OP25 5 6 7 OP27 OP18 OP29 OP31 Reg 23(2)p Reg 18 Reg 18 Reg 9(2) 31/12/06 31/12/06 30/11/06 31/12/07 Heaton Grange Version 5.2 Page 24 8 OP36 Reg 17, Reg 22 9 10 OP36 OP38 Reg 18 Reg 23(4)(d) The home must keep a log of all complaints, the rota must be a true indelible record of each shift, care files must include a photograph, there must be documentary evidence to show regular health and safety checks are undertaken. There must be evidence that formal staff supervision takes place at least 6 times a year Fire safety training for staff must be provided twice a year and a record of attendance kept. 30/09/06 31/03/07 31/12/06 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 OP7 3 4 5 OP31 6 OP30 OP37 OP15 OP19 Refer to Standard OP1 Good Practice Recommendations The Statement of purpose and Service User Guide should be in a format, which takes account of the group of people it is intended to inform. There should be more background information in care files to assist staff to develop a care plan for each person which meets cultural, intellectual, recreational and spiritual needs Napkins should be provided at mealtimes and residents given the opportunity to pour their own drinks subject to a satisfactory risk assessment Steps should be taken to make the home more visible from the road The home should make arrangements for the manager to delegate some of her management responsibilities whilst she is working towards the NVQ award The manager should have a system to allow for easy auditing of staff training. Heaton Grange DS0000064467.V300968.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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