Inspection on 03/10/06 for Heaton Lodge

This inspection was carried out on 3rd October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heaton Lodge 25/10/07

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 Kath Oldham Unannounced Inspection 3rd October 2006 08:30 Heaton Lodge DS0000066591.V306977.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.V306977.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.V306977.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 8880 0161 432 8677 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) Heaton Lodge Limited 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.V306977.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 23 residents to include * up to 23 residents in the category of MD (Mental Disorder), excluding learning disability or dementia; * up to 4 residents in the category of MD(E) Mental Disorder - over 65 year 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. N/A 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 25 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 were reported to be between £350 and £420 per week. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place on 3rd and 9th October 2006. Time was spent with the senior carer and in conversation with staff and residents. Examination of documents was also undertaken. In addition, a range of records, including care plans, medication records and health and safety and fire records, were examined. The inspection was an opportunity to look at all the key standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home. Comment cards were left at the home for completion by residents, their relatives or visitors and staff, asking them what they thought about the care at Heaton Lodge. In addition, nine questionnaires were sent to health and social care professionals who have regular contact with the home or who have made placements at Heaton Lodge, seeking their views and opinions regarding the care of residents in the home and how they are received in the home. Five GP’s were also sent comment cards to ascertain their views of the care and support residents receive. Comments received in time for writing the report are included. Comment cards received after this time will be used to inform the next inspection. What the service does well: Staff were seen to have good relationships with the residents and appeared kind and sensitive in their approach. The owner continues to work hard at developing and maintaining the standards in the home and demonstrated a commitment to meeting the standards and positive outcomes for residents. Through discussion the provider was able to identify the individual needs of the residents. The staff in the home know the residents well and what the health needs of each person are. The home works closely with doctors, nurses and other people who help to look after health needs. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It would be good if the home carried out an audit of the service by using satisfaction questionnaires. It is important that the views of not only the residents but that of their relatives, GP’s and other visiting professionals are requested to see how they feel the service is being delivered and maintained by the home. The home must advise the CSCI of any event or incident that impacts on the health or well-being of residents, for example, accidents or incidents experienced by residents. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 8 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.V306977.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is adequate. Residents’ needs are assessed prior to them being accommodated at the home, this detail must be recorded. The lack of terms and conditions of residency being provided limits the information residents receive about the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: An assessment is undertaken prior to residents coming to the home. Staff visit the resident at their own home or where they are staying, which may be in hospital or at another setting. If the residents’ needs can be met by the home and they like the sound of what the home can provide, an introductory visit is arranged. When undertaking the assessment staff look at the residents’ needs and abilities, in addition to the current resident group and their needs and aspirations, and also the skills and experience of the staff group. The deputy said it is important to get the balance right to ensure that the home is able to meet the needs of the new resident. The care files for three of the most recently admitted residents were examined. Two of the care files did not confirm that a written assessment had been undertaken. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 10 Residents said they visited the home before making a decision to have a trial period. One resident said they were admitted from hospital and one resident said they visited the home to see if it was what they were looking for and whether they liked the feel of the home. They further stated that they had a meal and stayed for as long as they wanted. Another resident said once they had been to look round, they knew they liked it. One health and social care professional indicated in their comment card, “staff at Heaton Lodge worked effectively to organise the move in of my client”. A resident said, “I was just told it was a better place, and able to go out on my own”. Examination of a sample of residents’ files identified that there was a contract of residency in place by the placing local authority. An individual terms and conditions of residency with the home was not contained in the files examined. This would clearly identify to the individual the specifics of their residency and needs to be in place so residents have all the information they need about the home and its rules and regulations. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. Residents care plans were not sufficiently detailed. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of care files for three most recently admitted residents found that a care plan was not always in place. The deputy manager said that a new care plan format is to be introduced and staff have received guidance in its completion. The deputy said the format was easy to use. The details within this one care plan were limited. Information needs to be transferred from the initial assessment to ensure that all residents’ care needs are recorded and staff are aware of how to assist and manage residents’ mental health needs. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 12 Contact sheets are used to detail the daily support and interventions of staff and detail how residents have been. The contact sheets in some instances contained detailed information, which gave a picture of how residents spent their day and the support staff provided. Others contained minimal information and, on occasions, staff made judgements about how a resident was feeling. Incident sheets are also maintained which detail any behaviour which is inappropriate or which has had an impact on residents or others living or working in the home. As part of the initial assessment process, the home should undertake a comprehensive risk assessment that looks at specific areas, such as moving and handling needs, falls, personal care, communication and risks associated with the community and environment. Those areas that are identified as known or potential hazards may need to be assessed further by the relevant specialist and support/guidance in minimising those hazards and risks may then need to be developed. Examination of three recently admitted residents’ files did not include risk assessments. The strategies in place to minimise this risk were not indicated which has the potential to put residents at increased risk and does not enable staff to have information which may be necessary to keep residents and themselves safe. The home works with the residents to find out what the person likes and does not like in terms of diet, activities, environments and communication. Through this, they try to offer residents day-to-day choices and decisions that reflect their needs. Restrictions of choice are only made to safeguard the residents. Residents meetings are now regularly arranged and provide a further opportunity for them to comment on the service they receive. A health and social care professional indicated in a comment card “the overall care provided to residents is improving and will do so further I hope.” They also said, “if they give specialist advice this is not always incorporated into the resident’s care plan”. A further comment card indicated, “home has improved since new owner, client happy and feels supported”. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. The personal development of residents has improved and additional opportunities are being provided. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home offers and supports people to participate in activities within the home and in the community that they enjoy. Visitors are welcome and the routines of the home are based on people’s own preferences and activities. Meals are based on people’s needs and choices and appear nutritionally balanced. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 14 People have the opportunity to visit local cafes, restaurants, pubs and other amenities that they enjoy. People also have the opportunity to continue maintaining their own independence skills through undertaking domestic tasks within the home and shopping. The activities they take part in are based on their abilities, needs and goals. These are not recorded so it is difficult to see if the activities are meeting the identified goals. Additional opportunities are being provided to residents to go out in the evening, for example, to play bowls or go to the pictures. Residents said they had been out on day trips and had enjoyed trips to the country. The home has a minibus and this is routinely used. Residents said it was much better having somewhere to go and someone to go with in the evening. The cook said she had all the equipment she needed in the kitchen and she just needs to tell the owner what is needed and it is provided. Variations have been made to the menu and residents are aware that they must let the cook know what they want for their meals by 11:00am so she can make sure they get what they want. The ordering of foodstuffs has been changed and a regular weekly supply of fresh food is ordered each week. One resident said they now have red salmon regularly and they are really pleased with this. Other residents, who are vegetarian and diabetic, are aware of what they can have and ask the cook to make their favoured dish. Residents said they liked the Residents were aware that they heard making their requests. A improved since new manager”. better”. food and the cook made what they asked. could have what they wanted to eat and were comment card indicated, “Food seems to have A resident indicated, “the food has got much The cook said she enjoyed coming to work and it was a pleasure to prepare food for residents that they like which is nutritious. A record is not made of food served to residents and a menu is not routinely followed. A record of kitchen cleaning is to be introduced and is to be followed and completed by cooking staff in line with Environmental Health guidelines. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. Medication was not administered or recorded correctly and recordings relating to meeting other health care needs of residents was poor. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Community Psychiatric Nurses or social workers from the mental health service support residents to address their emotional and mental health needs. Appointments are also arranged and attended by residents with consultants in mental health when this is required. The residents’ doctor and dentist undertake health care. A number of residents attend chiropody appointments and other specialist health consultations. There was no record of this contained within the records maintained at the home. Staff at the home administer the majority of medication prescribed to residents. CPN’s also attend the home to administer injections. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 16 Examination of the medication records identified that the medication had not always been signed as having been administered. Written medication records were also within the records, these must be verified by a second staff member to ensure that no errors have been made in copying out the prescriber’s instructions. Not all staff who administer medication have received medication training. This compromises residents and staff’s safety. Staff who have attended training in medication administration commented that this has improved and developed their understanding of medication and the effects this can have on residents. Risk assessments were not in place for residents who self-administer medication. This compromises the safety of residents at the home. Both GP’s who responded in comment cards indicated that if they give specialist advice, this is incorporated into the resident’s care plan. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. Residents are not aware of the complaints procedure, however were protected from abuse through daily care practices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A complaints procedure is in place, however staff were not really aware of the procedure, only that they speak to the owner. They were unaware whether residents had received a copy of the complaints procedure but were confident that residents would let their feelings and views be known. Residents who completed comment cards indicated that they knew who to speak to if they were not happy. Two GP comment cards indicated that they had not received any complaints about the home. The home also has its own informal complaints process where residents and carers can contact the senior staff to discuss issues that they are not happy with or concerns they have. The home will try to resolve any concerns directly or may require the attention of the owner. There was no record of any complaints or comments within the complaints book since November 2005. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 18 The staff team on duty were asked about their awareness as to the protection of residents from abuse, including asking if they had received training. Some staff could confirm receiving training and others could not. All the staff team are required to receive training in this area of practice. All new staff recruited were required to undergo a Criminal Records Bureau check, including being checked against the POVA list, prior to commencing employment. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. The proposed replacement and upkeep of the home should promote the safety, security, comfort and respect of residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The new owner has undertaken an audit of the building to see what work needs to be carried out to make the home comfortable for residents. New carpeting is to be fitted and the decoration in the hall, stairs and landing is going to be completed. Staff said they understood it was the owner’s intention to complete this work by Christmas 2006. A number of bedrooms have been repainted and look a lot brighter and cleaner. Bedroom furniture is being repaired or replaced in readiness for new residents coming into the home. One of the care staff is repainting bedrooms and three were scheduled to be completed in the week of the inspection. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 20 A maintenance book is in place and staff routinely write in the book jobs that need to be attended to. These items are then picked up and attended to by the maintenance person as required. The lounge, which was previously non-smoking, has been altered so residents can play table tennis or pool in there. Further work is to be undertaken to split the room into two sections to provide a smoking room as well. New beds have been purchased and it was thought that all residents’ bedrooms had new beds in place. Work is to be undertaken in the cellar to provide additional space for residents to use. A health and social care professional indicated in their comment card, “the arrival of the new manager has meant my client has a new chair and table as required”. The former flat in the home has been converted into a double room, which two residents are now sharing. A bedroom has been changed into a relaxation room, where soft furnishings and beanbags have been introduced, which provides residents with an alternative space to relax. Fish had been purchased and one resident suggested asking other residents for ideas what to call the fish. The furnishings and furniture were all domestic in nature, giving a homely environment. Privacy locks on bathroom and toilet doors have been identified as being needed and these are again to be attended to. The kitchen is to have some attention to its layout and some new appliances are to be purchased to support cooking staff in their role. The kitchen is compact and investigations are to be made whether it can be extended into the dining room. A health and social care professional who has residents placed at the home indicated, “Hopefully the physical environment will be improved as it’s desperately needed”. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 35 Quality in this outcome area is adequate. The home’s recruitment practices and procedures ensure that staff are safe to work with vulnerable people. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home has an in-house induction programme. This needs to be reviewed to ensure it meets the new standards being introduced through the Skills for Care Induction modules that are a compulsory requirement for all care staff. The staff team were receiving some training that will give them the skills required to meet the residents’ needs. A challenging behaviour seminar was scheduled for staff in the week of the inspection and it is envisaged that additional training in mental health is also to be scheduled in forthcoming weeks. The deputy said that all staff are studying or have obtained NVQ qualifications. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 22 Three staff members were on duty up until 3:00pm, with two staff on duty until 10.00pm. Two night staff were on duty. The number of staff on in the afternoon needs to be increased to support residents. It was reported that a new member of staff had been appointed to take on this role. A comment card said, “Staff levels seem to have improved since the new management”. It was found that, overall, a thorough recruitment and selection procedure was in place. This included face-to-face interviews, two written references and CRB/POVA checks were completed before an appointment was confirmed. The home were not able to confirm that all staff members were provided with copies of the Code of Practice published by the General Social Care Council. This needs to be addressed to ensure staff are familiar with how they should perform and the rules governing care workers. Two health and social care professionals indicated that there was not always a senior member of staff to confer with. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. Safeguards are in place to protect residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home was purchased by Mrs Nawal in April 2006 and has been advertising for a manager. Interviews have been held to appoint a suitable manager to the home. It was reported it is hoped a manager has been found. In the interim, the registered person has appointed a deputy and has herself spent a number of months at the home to support and develop the service provided. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 24 Examination of records identified a number of incidents or accidents that had not been reported to CSCI, as required by regulation. Discussions took place with the deputy on what constitutes a reportable incident. The home confirmed that work on self-monitoring the service needs to be put in place, including setting up an annual survey. This survey is to be aimed at formally seeking the views of people who use the service and other stakeholders, like social and health professionals, about their opinions regarding the quality of service provided by the home. Once completed, the findings are to be published and copies provided to the residents and the Commission for Social Care Inspection. Examination of the fire safety records identified that all the necessary checks had been undertaken in line with the Fire Authority’s procedures. Examination of residents’ personal allowance records identified they were completed appropriately. Advice was given to the administrator to number receipts to correlate to the written record for ease of auditing. Residents sign on receipt of their monies and, to assist residents to budget, individual times during the week are arranged for collection of their monies. Residents meetings are arranged which provide them with an opportunity to comment on the service they receive. Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 25 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 2 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? New service 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 YA7 Regulation 12 Requirement The registered person must ensure that risk assessments are undertaken for residents where risk is defined. The registered person must ensure all staff who have the responsibility for administering medication receive training, that medication administration records are signed contemporaneously, and that risk assessments are undertaken for all residents who selfadminister medication. The registered person must further promote and develop the complaints procedure to include the routine of recording complaints and comments relating to service provision. Ensure that all residents have access to a copy of the complaints procedure. The registered person must arrange for all incidents as defined within the regulations to be notified to CSCi in writing. Timescale for action 03/11/06 2 YA20 13 03/01/07 3 YA22 22 03/11/06 4 YA37 26 03/10/06 Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 27 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 YA2 YA6 Good Practice Recommendations The registered person should ensure that a written assessment is undertaken by the home and a record of this is maintained in residents’ care files. The registered person should further develop care plans to include all specialist care/support provided to residents and review the care plans at the request of residents or at least every six months. The registered person should provide all residents with an individual terms and conditions of residency signed by them and available for inspection. The registered person should have a menu in place and maintain a record of meals served to residents to enable anyone viewing the records to assess whether the diet is sufficient in terms of nutrition or otherwise. The registered person should ensure that health care appointments and consultations are recorded within residents’ care files. The registered person should ensure that handwritten medication is signed and verified by a second staff member. The registered person should ensure that when symbols are used in the medication records that need defining, that this takes place on the medication records. The registered person should arrange for all staff to receive training in adult protection. The registered person should provide all staff with a copy of the General Social Care Council code of practice and ensure they are working within the confines of this code. 3 4 YA5 YA17 5 6 7 8 9 YA18 YA20 YA20 YA23 YA31 Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Heaton Lodge DS0000066591.V306977.R01.S.doc Version 5.2 Page 29 - 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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