Inspection on 25/10/07 for Heaton Lodge

This inspection was carried out on 25th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heaton Lodge 03/10/06

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

CARE HOME ADULTS 18-65 Heaton Lodge 320 Wellington Road North Heaton Chapel Stockport Cheshire SK4 5BT Lead Inspector Steve Chick Unannounced Inspection 25th October 2007 12:30 Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 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 Lodge DS0000066591.V350877.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 Adults 18-65. 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 Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heaton Lodge Address 320 Wellington Road North Heaton Chapel Stockport Cheshire SK4 5BT 0161 432 8589 0161 432 8589 heatonlodge320@supanet.com www.carefirsthomes.co.uk Heaton Lodge Limited 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) ** Post Vacant *** Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 23 service users to include * up to 23 service users in the category of MD (Mental Disorder), excluding learning disability or dementia. * up to 4 service users in the category of MD(E) Mental Disorder - over 65 year of of age, excluding learning disability or dementia. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3rd October 2006 2. Date of last inspection Brief Description of the Service: Heaton Lodge is a Victorian property, which retains many of its original features. The home is registered to provide accommodation for up to 23 residents, between the ages of 18 and 65 years, with mental ill health. The home may accommodate up to four persons over 65 years. The home is owned by Mrs Mary Nawal, who purchased the home in April 2006. She also purchased another care home for males with mental health needs a few hundred yards from Heaton Lodge. Heaton Lodge is situated on the A6 in the Heaton Chapel area of Stockport and is approximately five minutes’ drive away from the town centre of Stockport. The care home is well placed to the local amenities with a health centre, shops and public houses in walking distance from the care home. The home has a statement of purpose and residents’ guide which were reported to be given to prospective residents or their families when they visit the home to look round. The fees for staying at the home (as at October 2007) were reported to be between £420 and £700 per week. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced site visit to the home. All key standards were assessed. This report also uses information gathered since the last key inspection. This includes an Annual Quality Assurance Assessment (AQAA) which is a self assessment of the service offered, completed by the manager and sent to us before the visit. The AQAA presented as giving a good initial assessment of the service’s strengths and areas which need improvement. At the same time that the AQAA was sent to Heaton Lodge, so were a number of questionnaires which the manager was asked to distribute to service users and relatives, or advocates of service users. At the time of writing this report six questionnaires had been received from service users and two from relatives. Since the last Key Inspection (October 2006) we have undertaken a Random Inspection (March 2007) to assess how well the service was addressing identified problems. . Everyone spoken to during both visits was positive about the care provided at Heaton Lodge. Since the last key inspection we have received no complaints about Heaton Lodge. For the purpose of this inspection three service users were interviewed in private and one was interviewed, at their request, in the presence of the manager. One visitor was also interviewed in private as were two members of staff.. Additionally discussions took place with the manager and the owner. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation including staff rotas, medication records and the complaints log. What the service does well: Staff undertake good assessments to ensure that prospective service users’ needs can be met. Service users are encouraged to take an active part in the care planning process and positive relationships are maintained between staff and service users. Service users comments included “staff are nice and very friendly” and Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 6 “they [staff] are there for you” One service user said the best thing about the home was “staff [being] understanding and compassionate”. Service users are encouraged to be independent, are enabled to take informed risks and are supported in maintaining relationships. Good links are maintained with appropriate health care professionals. An atmosphere is maintained where service users feel safe to raise concerns. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. Service users’ needs are appropriately assessed and they, or their representatives, are able to visit before a decision is made that the home is appropriate for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service user files was looked at. Those who had been admitted to the home since the last key inspection had documentary evidence of an assessment having been undertaken by an appropriate professional. The AQAA (a self assessment undertaken by the manager of the home) stated that “Each service user has an individual pre-admission assessment carried out prior referral to determine whether the service can meet their needs. This is carried out between the Manager of the home and the service users CPN or Social Worker.” Discussion with the manager indicated that this procedure was followed in practice. Four of the six service user questionnaires returned, confirmed that they had enough information to decide to move into the home. However, it is not possible to tell from the questionnaires how long ago each respondent moved to the home. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. Service users’ health, personal and social care needs are met by the consistent implementation of the home’s policies and procedures. Service users are involved in decision making about their lives, including taking informed risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service user files was looked at. All had a written plan of care and all but one had a recent review undertaken with appropriate community based professionals. There was documentary evidence that the manager had started to monitor the frequency of reviews and had identified those which were overdue. The deputy manager confirmed this and reported he was in the process of contacting social workers and CPNs so that these reviews could be done. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 10 There was good documentary evidence that service users, as well as professionals, were involved in their ‘care planning’. This was also confirmed by service users who were interviewed during the visit. All service users spoken to during the visit were positive about their care. One person specifically requested to speak to the inspector to make sure we knew how much Heaton Lodge had improved under the influence of the new owner and manager. This was also mentioned by another service user who had been living at Heaton Lodge for some time. Another service user said she had been told, by staff, “if you ever need anything just come to us” this person also reported that staff were responsive when approached and said “staff never turn their back on you”. Staff were able to cite positive improvements made by some service users in terms of their improved motivation and participation in community based activities. Daily records presented as being well maintained. Staff who were spoken to, believed that a combination of the written records and the verbal information exchanged at each shift handover, enabled them to be aware of the current care needs of each individual at the home. The AQAA reported that “We encourage all service users to be involved in changes in their plan of care and make informed decisions from advice given to them of how they would like to be supported. … All service users are deemed to have capacity unless otherwise stated in their documentation and are supported in taking risks as part of their independent lifestyle.” Observation and discussion with service users and staff confirmed that service users were free to leave and return to the home. All returned service user questionnaires stated that they made decisions about what to do each day, and could ‘do what they want to do’ at all times of the day. A visitor described as the best thing about Heaton Lodge “they look after [relative] well”. One service user said that one of the best things about the home was “[you have] your own facilities, and can come and go as you like.”. Another service user described the owner as “very decent”, and a person with whom he could “exchange ideas”. There was some evidence that written risk assessments should be completed in more detail, to demonstrate that predictable risks are minimised, without unduly infringing an individual’s right to take informed risks. For example, a risk assessment relating to a service user administering their own medication did not fully address the steps taken to protect other service users at Heaton Lodge from any potential risk of them accessing that medication. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. Service users have opportunities for personal development through engagement with appropriate activities in the local community, and are able to maintain appropriate personal relationships. Service users’ health and well being is enhanced by the provision of good quality food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was reported in the AQAA that … “We support residents in making informed choices about how they can develop themselves and utilise their time by enrolling at day centres or courses through the local college” Service users and staff spoken to were able to cite a range of activities in the community which people living at Heaton Lodge could, and did, participate in. These included computer courses with mind, ARC -- arts drama etc., and Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 12 various drop in centres. Participation in specific opportunities for personal development are not compulsory, but, if appropriate through the care planning process, are encouraged. One member of staff who was spoken to, described Heaton Lodge as a “relaxed community” where people were “not institutionalised.” This was also seen to be the case through observation of interactions between staff and service users. Visitors are allowed at all reasonable times. One visitor spoken to indicated that he felt welcome at the home, saying that one of the best things about Heaton Lodge was that “I don’t mind coming in”. Service users were able to confirm that they went on outings with other people living at the home. One service user cited outings and activities as amongst the best things about the home. Another talked about how much they had enjoyed eating chips on the Prom at Blackpool. Service users spoken to were generally positive about the provision of food. There is a menu, with a choice, and service users can state their preference up to an hour before the meal time. Service users spoken to confirmed the availability of a choice. At the time of the visit to the home the cook had prepared a buffet tea as it was one service user’s birthday. Included in the buffet, at the request of the service user, were venison sausages and quails eggs. Records of food consumed by individual service users was not routinely kept. This was discussed with the manger who reported that more detailed records would be kept if there was a specific identified problem for an individual service user, in connection with eating. The freedom for service users to consume food away from Heaton Lodge, without the need to report this to anyone at the home, did present as undermining the potential usefulness of maintaining records for all service users. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. Service users’ physical and emotional health needs are met in the way they prefer. The home’s procedures in connection with administration of medication are implemented to the benefit of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users spoken to were positive about their interactions with staff. Comments included “staff [are] understanding and compassionate”, “they are there for you”, “I can wind them up and have a laugh” and “they [new owner and manager] have taken much more interest in the residents”. As mentioned previously in this report, in the section on ‘Individual Needs and Choices’, there was good evidence of service users being involved in the way in which their care is planned and implemented. Interactions between service users and staff were observed to be relaxed and appropriate, whilst being respectful and maintaining individuals dignity. For Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 14 example, service users were asked if the inspector could look in their personal rooms. Evidence was also observed where incidents of incontinence were dealt with sensitively and discreetly . All service users spoken to expressed the view that appropriate access was maintained with health professionals. Many service users routinely received support from community and hospital based mental health workers. There was also documentary evidence that service users had appropriate access to the full range of medical and para medical services available in the community, including chiropodists, opticians and dentists. This did not always appear to be recorded in the service users individual file, which would be best practice, but was recorded in a diary specifically for appointments. One visitor spoken to was able to confirm that their relative had been supported to go to a doctor for a routine check up. The home uses a pre dispensed monitored dosage system to administer service users’ medication. Medication was seen to be appropriately and securely stored. Since the last key inspection the manager has amended the medication policy and procedure. This had been looked at by a Commission for Social Care Inspection Pharmacy Inspector at the time, and was not looked at again at this visit. The manager reported that prescribed medication was monitored and considered by staff. He was able to cite an example where he had questioned the amount of anti depressant being prescribed. This had resulted in an amendment to the prescription and an improvement in the behaviour of the service user. Not all service users had a photo on the medication administration records, which is considered best practice to avoid the possibility of mistaken identity. Given the relatively small size of the home and the capacity of the service users, mistaken identity is unlikely, but possible if, for example agency staff are needed to be used at any point. There was good documentary evidence that the medication administration records were routinely monitored by the manager, and that omissions or errors were quickly identified and appropriate action taken with staff. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. Service users are confident that any complaint they may have would be dealt with appropriately and are protected from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaints procedure which was found to be appropriate at the random inspection conducted in march 2007. This was not looked at again at this key inspection. All service users spoken to were confident that any complaint would be taken seriously by the staff and management at the home. Observation of the relaxed interactions between staff and service users would indicate that an atmosphere was maintained at the home where service users could raise concerns. This was also evidenced by service users comments which included, “[the manager] said if staff are not okay I should tell him”; “staff are nice and very friendly”; “[I have] been told, if you ever need anything just come to us” and one service user saying the best thing about the home was “staff [being] understanding and compassionate”. All respondents to the service user questionnaire said they knew who to talk to if they were not happy. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 16 The visitor spoken to was also confident that “they [staff] would try to put anything right if it was wrong.” Similarly staff spoken to were confident that they and their colleagues would respond appropriately to any complaint. The complaints log was looked at. This presented as only recording formal complaints and the value of also keeping a ‘central’ log of informal complaints was discussed with the manager. The training information supplied, indicated that staff were booked onto ‘Protection of Vulnerable Adults’ training in November and December 2007. This was confirmed by staff who were spoken to. These staff demonstrated an understanding of the need to be vigilant about the possibility of vulnerable service users being abused or exploited. They also expressed confidence that, if necessary, they would whistleblow. We had been informed of one incident since the last key inspection when a service user had alleged an assault had taken place in the community, outside of the home. Information provided to us by the manager indicated this was dealt with sensitively in supporting the service user to involve the police. One safeguarding investigation has also taken place, which was investigated by the local authority in co-operation with the manager and provider, and was not upheld. All service users spoken to indicated that they felt safe at Heaton Lodge, and those who were asked, believed that all other service users at the home were also safe. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, hygienic and predominantly safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this key inspection a tour of the building was undertaken. This included communal areas and a selection of service users’ bedrooms. There were several communal areas where service users could spend their time, or they could access their rooms when they chose. The improvements identified at the random inspection in March 2007 had been maintained and improvement to the building continued. There was a designated smoking area. Some broken tiles at the side of one bath needed replacing. The manager reported that he was aware of the damage and that interim safety precautions Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 18 had been implemented. The tour identified two areas of potential risk. Some windows were not fitted with anything to restrict how far they could be opened, and not all radiators were either covered or had guaranteed low temperature surfaces. Falls from windows and becoming trapped against radiators are known and predictable possible causes of death or injury in care homes. The manager was advised that all windows and unprotected radiators should have a written risk assessment to establish what risk, if any, they posed, and what strategies, if any, needed to be put in place to reasonably minimise those risks. Service users who were spoken to said they liked their accommodation. At this unannounced visit the home presented as clean and tidy, with no unpleasant odours. This was confirmed as the usual state of the home by service users, staff and the visitor spoken to. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. The numbers and skills mix of staff on duty promotes the independence and well being of service users. Recruitment and vetting procedures are not always effectively applied to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was able to provide a list of staff who had received training in specific issues and those who were booked on courses in the near future. A small selection of certificates was looked at to verify this information. Staff who were spoken to reported that the owner and manager were very supportive of staff taking up training opportunities. New staff who were spoken to, confirmed that they had undergone a period of induction to the home which had been appropriate and helpful. As mentioned Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 20 elsewhere in this report, all service users spoken to were complimentary about the staff team. Staff were described variously as “understanding and compassionate”, “nice and very friendly” “they [staff] have helped me a lot since Ive been here”, “new younger staff are all very caring”. A copy of the staff rota for the period 17th September to 14th October was looked at. This indicated that staffing levels were usually maintained at three carers on duty between 07:45 and 22:00 and two between 22:00 and 08:00. These numbers presented as being appropriate to meet the needs of the service users living at Heaton Lodge. One staff member mentioned that there is sometimes an extra member of staff on in the morning, which was reported to be very helpful as the morning was often the busiest shift due to appointments and meetings with other professionals. In addition to the care staff, service users benefit from ancillary staff who provide domestic and cooking support. A selection of staff files was looked at in connection with recent recruitment and vetting practices. All files seen had CRB (criminal record bureau) disclosures and Pova1st statements. However, examples were seen where these were not always obtained before the person started work. The manager reported that the interim period was only ever used as induction and training, with no unsupervised access to service users, but none the less this not allowed by regulations and is unlawful, even if only for a few days. Examples were seen where there was no second written reference. The manager reported that verbal references had been obtained, but not recorded. Examples were seen where an applicant’s employment history was in insufficient detail to enable any gaps to be identified and explanations sought. There was evidence that the employment records were being audited by the manager and these gaps and omissions were being highlighted for remedial action. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. The manager presents as qualified and competent to manage the service for the benefit of the service users, but has not been fully assed as suitable for this role by the Commission for Social Care Inspection. Service users are confident their views influence the way in which the service is run for their benefit. Most of the home’s health and safety procedures are implemented for the benefit of service users and staff. This judgement has been made using available evidence including a visit to this service. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager of Heaton Lodge and the owner, both reported that the delay in applying for the manager to be registered with the Commission for Social Care Inspection was due to his CRB (criminal record bureau) disclosure not yet having been received. They also reported that they had been making enquiries about what was causing the delay. All service users and staff who were spoken to were very positive about the manager’s approach and competency. The manager was reported as having appropriate qualifications for the role, including the Registered Managers Award. Proof of those qualifications was not sought at this key inspection. Three service users were spoken to who had been at Heaton Lodge since before the new owner and manager had taken over. They all drew to our attention the improvements which had been made to the home. These included not only improvements to the furnishing and décor, but also to the perceived approach to service users. One service user commented “they have taken much more interest in the residents”, and “when they say things will change they do”. The manager reported that a formal, structured, Quality Assurance system was still under development. This had not prevented the identification of areas in the service which needed improvement. There was clear evidence at this key inspection that action had been taken in this respect. In spite of the absence of a formal Quality Assurance, service users reported being involved in their care planning, and felt listened to. Occasional service user meetings were held. Minutes of the September meeting were seen. This would offer another forum where service users’ views could be aired. The manager reported in the AQAA that the home’s Health and Safety and Hygiene and Food Safety policy and procedures had been reviewed in June 2007. These documents were not looked at during this key inspection. A selection of records relating to fire detection and alarm systems was looked at and presented as being appropriately maintained. Other necessary routine maintenance and checks were reported as being ongoing. No obvious risks to health and safety were observed during this visit, other than the need to undertake the risk assessments relating to windows, radiators and self administration of medication, identified elsewhere in this report. Staff who were asked confirmed the availability of disposable gloves and aprons to minimise the risk of cross infection. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 24 No 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 YA34 Regulation 19 Requirement Timescale for action 01/12/07 2 YA42 13 In order to minimise the risk of exposing service users to inappropriate staff, all the vetting details set out in legislation must be thoroughly followed. Specifically this relates to obtaining a full employment history in sufficient detail to identify and explain any gaps in employment; not commencing the employment of anyone in the home without a CRB (criminal record bureau) disclosure, or in exceptional circumstances a POVA1st declaration. Records must be maintained to ensure the registered person can demonstrate these procedures have been followed. In order to protect the health 01/12/07 and safety of service users, the safety of all unrestricted windows and all unprotected radiators must be considered. These risk assessments must be in writing and in sufficient detail to demonstrate why any action taken, or not taken, to minimise any risk is reasonable. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA20 Good Practice Recommendations To minimise the risk of medication being given to the wrong person, the medication administration record should include a photograph of the service user. Service users who are administering their own medication should not be putting themselves or other people at unnecessary risk. To ensure that staff can demonstrate how decisions to enable informed ‘risk’ are made, a detailed record should be maintained of all issues taken into account. Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heaton Lodge DS0000066591.V350877.R01.S.doc Version 5.2 Page 27 - 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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