Inspection on 25/06/08 for The Heights Care Centre

This inspection was carried out on 25th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Heights Care Centre 27/06/07

The Heights Care Centre 19/05/06

The Heights Care Centre 23/06/05

The Heights Care Centre 28/02/05

The Heights Care Centre 17/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Heights, The Care Centre Ankerbold Road Tupton Chesterfield Derbyshire S42 6BX Lead Inspector Rob Cooper Unannounced Inspection 25th June 2008 09:50 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 Heights, The Care Centre DS0000002085.V368186.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. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heights, The Care Centre Address Ankerbold Road Tupton Chesterfield Derbyshire S42 6BX 01246 250345 01246 250520 theheights@schealthcare.co.uk 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) Southern Cross Care Homes Limited Mrs Julia Marianne Williams Care Home 36 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (30) of places Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2007 Brief Description of the Service: The Heights Care Centre is a purpose built care home within the village of Tupton, approximately 5 miles to the south east of Chesterfield town centre. The home provides nursing and personal care and support for up to 36 older persons, including up to six older persons with dementia, who are accommodated within a dedicated ground floor area of the home. This area consists of six bedrooms, a lounge/dining room and a bathroom and toilet facilities, although people accommodated there mix freely with others who live at the home. The home also provides one bed for the purposes of rolling respite care and accommodates day care, although at the time of this inspection there were no persons receiving day care. The main home is purpose built over two floors. There is a choice of lounge and dining space on each floor and all bedrooms are currently used a single occupancy, some having en suite facilities. There are a range of aids and equipment and also environmental adaptations to assist those with disabilities, including level access, suitable bathing and toilet facilities, a shaft lift, emergency call system, handrails and grab rails and moving and handling equipment/hoists. The front door of the home is secured by way of a key-pad type lock. Kitchen and laundry facilities are centralised. There is level access to outside garden areas to the rear of the home, which provide seating and are well maintained with lawn and patio areas and planting. People are provided with twenty-four hour care and support from a team of nursing, care and hotel services staff, currently led by an acting manager. An activities co-ordinator is also employed. People who might want to live at this care home can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. In addition information about The Heights and the services it provides can be found at the following web site: www.ashbournesl.co.uk. The range of fees per week as at June 2008 is as follows: Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 5 £345.52 to £521.36 Fees are dependant upon individual’s assessed needs and their individually agreed terms and conditions, as agreed via local authority or primary care team contracting arrangements; or written contracts as agreed between the home and individual for those who are privately funded. All are also dependent as to whether people receive nursing care or personal care only. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of the key inspection process – so that no one at The Heights knew that the inspection visit was going to take place. The visit took approximately six hours over two days, with one inspector present, and a regulation manager present for part of the visit. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at the Heights. The methods used during this key inspection and visit were to visit The Heights, where a method called case tracking was used; this involved identifying four people who live at the care home and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of The Heights, looking at the activities on offer, and talking to three people who live at the home, two relatives and four members of staff about the quality of the service, and their experiences of living and working at The Heights. During 2007 the Commission for Social care inspection introduced an Annual Quality Assurance Assessment (known as an AQAA) as part of the inspection methodology, this allows care homes like The Heights to self assess their service. Information provided by the care home helped to form the judgements in this report. We also sent out ten surveys asking for views and information to people who live at the home, five to relatives and five to staff. Of these we have so far not received any back. The registered manager Julia Williams was on leave during this inspection visit, so other senior staff at the home provided much of the information during this key inspection visit. On the day of this inspection there were thirty-three people living at The Heights. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Two statutory requirements have been made as a result of this inspection visit. These relate to repairing or replacing the faulty hinges on a number of external doors and ensuring that all members of staff have a Criminal Records Bureau check, and by doing so making sure that people living at the home are not subject to unnecessary risk. In addition good practice recommendations would see the service user guide and statement of purpose available in other formats, such as large print and on an audiotape or compact disk (CD). Some of the information in these documents was found to not be accurate, and so a review would ensure people living at the home, or those who might want to in the future had the latest information available. Identifying the wishes of people living at the home at the time of the death will make this difficult time easier for all concerned, while regular meetings for people will allow them to formally comment on the quality of the service they are receiving. Regular formal staff supervision will allow mean the staff team are properly supported and effectively managed. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 8 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. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 9 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 Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 123&6 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People, who currently live at the care home, and those who would want to in the future, have access to detailed information about the services on offer. People have contracts or a service agreement and they receive a comprehensive assessment of their needs, which allows the people to make an informed decision about whether the home can meet their needs. EVIDENCE: Both the statement of purpose and the service user guide were seen during the inspection visit, and they are currently under review. These documents contained a great deal of useful information about the care home, however some inaccuracies were found and both documents are not available in other formats, no copies were available during this inspection visit. The basic information available would allow people living at the care home, and those Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 11 who might wish to in the future, to make an informed choice about living at this care home. Discussions with three people who live at the Heights showed that they had been given copies of the service user guide, and copies were seen in the people’s bedrooms. The foyer of the home also has copies of the last inspection report on display. In addition anyone who is interested can visit Southern Cross’s web site at: www.ashbournesl.co.uk., which also gives details of the services on offer, and has a link to the Height’s latest inspection report. The care files of four people who live at the care home were seen, and each one contained an agreement from Social Services to fund their placement, and a copy of the terms and conditions of residence. Two private contracts and one Social Services agreement were seen. Each of the four files contained a formal assessment of need. The assessments had all been completed in-house, although there were also examples of assessments completed by social workers and health care professionals in the files too. The evidence showed that the information provided by these assessments had been used to draw up the care plans. In their AQAA the Heights said: “We have a comprehensive pre admission questionnaire which covers personal care and physical well being, communication, mobility, continence, medication, social interests, religious and cultural needs, and family involvement, this is completed by the Home Manager or Deputy, the Home Manager then makes the final decision as to whether the home are able to meet the needs of each individual. We always receive a care management assessment and copy of a social services care plan before an individual is admitted to he home, but we also do our own assessments.” The Heights do not offer intermediate care, and therefore this National Minimum Standard was not assessed. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 & 11 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People have their personal care given in a professional and caring manner by the staff, which means that their personal and healthcare needs are being met. EVIDENCE: Each of the files that were seen contained a plan of care; this identified personal goals and people’s needs and how to meet them. Care plans were being reviewed regularly, and there were daily entries by care staff, to record progress and any issues relating to individual’s care. In addition a range of risk assessments relating to people’s individual care, and their health needs were also seen. All of the files that were seen contained health care plans. The plans included information relating to health care professionals such as visits to the doctor, or by the nurse, and any hospital visits, which were recorded on a professional visitors record. Vision Call a mobile optician provides a service to people living at the home. In addition a chiropodist visits people living at the home on a Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 13 regular basis, and their details, including a photograph were on display in the foyer. Three people were asked about seeing the doctor, and they all said that the staff would get them a doctor if they were unwell, and if they needed one. Representatives from Saga – the organisation for the over 50’s also visit the home to talk to residents and offer advice, on a range of different subjects including health care. Boots the chemist provides the Heights with their medication. Medication is provided in blister packs (a monitored dosage system – that gives all of the tablets needed at a certain time, for an individual in a sealed pack. This type of system does help to cut down on errors, and makes monitoring of the system easier.) An inspection of the medication systems showed that medication is handled safely. Administration records were seen and found to be complete. No one living at the Heights currently self-medicates. All aspects of the medication procedures that were seen showed a clear audit trail for medication, and indicated that people living at the care home were safe. Discussions with three people who live at this care home, and observation of the staff working with people showed that the staff treated them with respect and dignity. This included observing staff knocking on people’s doors before entering, and speaking in a respectful manner. In their AQAA the Heights said: “Staff monitor and record all changes in a service users health/condition and call for medical advice when needed. Staff are given training about privacy and dignity. Health professionals always see Service users in the privacy of their own rooms. Staff are aware of which name the individual likes to be known by this is also recorded on their own care plan. Service users have the use of a telephone to use in private when needed.” None of the files that were seen had an end of life care plan, or identified the individual’s wishes at the end of their life, or showed any input or discussions with relatives. This information needs to be recorded, as it will ensure that people’s wishes are followed, and will make what will be a stressful time, less so. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People have a lifestyle that reflects their cultural, social and religious interests, and needs, which means that their social care needs are being met. EVIDENCE: Discussions with three people who live at the home identified that they thought there were plenty of activities arranged. Comments received included: “I’m quite satisfied, there’s usually something going on.” “I like to play boules (the French game similar to bowls) I’m very good at it you know” and “I don’t join in much, I like to sit and watch.” The activities on offer ranged from Boules – they have a ‘boules pit’ in the garden to play the game, and bingo and table topped activities (games and puzzles), sometimes, outside entertainers come in – singers and musicians usually. Recently the care home hosted a day focussed on Elder Abuse, with different activities and information available, and relatives invited into the home to take part. Two relatives were spoken with during this inspection visit, both were very positive in their comments, and said that they were always made to feel welcome, and that the staff were friendly. Both relatives said the building was Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 15 very comfortable, and they always found it clean. Three people were spoken with and they said that their relatives were able to visit when they wished, and that staff always made them welcome, with comments: “The staff always make my sister a cup of tea, they are very kind.” “It’s no bother, people can come and see me when they want” and “There are always visitors here, people can come when they want.” During the inspection visit staff were observed to see how they were with the people living at the care home, and how they interacted with people on an individual basis. Observations were positive, and there was a good respectful atmosphere. Choices were also being offered, particularly around drinks and activities, with staff observed asking people and not just making assumptions. Staff in the kitchen showed how choices were offered and recorded at meal times. Discussions with three people showed that they both thought they had control over different things in their lives, and they were quite happy. There was a good choice of meal on offer including a vegetarian option if required. Information related to individual’s likes and dislikes was also seen in the kitchen. The food was well presented, and the dining areas were attractively laid out for people with flowers and menus on the tables. All of the people spoken with spoke positively about the food with comments such as: “The food is really nice” “there’s always a good choice,” and “I’m very happy with the food.” Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. People are safe, as a result of the policies, procedures and systems that are in place, and those people and their relatives are confident that their complaints will be taken seriously and dealt with. EVIDENCE: The Heights have received no complaints since the last key inspection in June 2007. The Commission have not received any complaints or concerns in that period either. The home’s complaints procedure, is on display in the foyer, and also forms part of the service user guide. Discussions with three people who live at the home showed that they knew who to complain to, and how to complain, although they each said that they had never needed to. Discussions with two relatives about the complaints procedure showed that they would both speak to the manager, if they were not happy with the staff ‘on the floors’ response, and they felt confident that she would deal with the complaint, although so far, this had not been necessary. In their AQAA the Heights said: “All service users and their relatives have access to advocacy. The contact details for this service is displayed in the foyer. All complaints are taken seriously and investigated recorded and responded to within 48 hours and resolved within 28 days. POVA, CSCI and whistle blowing policy displayed in the foyer. Home Managers Surgery’s displayed in the foyer.” Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 17 A review of the staff training records in relation to safeguarding adults, and a review of the statistics showed that twenty-four out of thirty-one staff had undertaken this training in the last twelve months. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. Three members of staff were asked about safeguarding adults training and all said they were aware of the issues, and had undertaken this training. The Heights have not had made any safeguarding adults referrals since the last key inspection. The recent action day on elder abuse held at the care home showed that the care home is committed to raising awareness of these issues. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate; this judgement has been made using available evidence including a visit to this service. People living at the care home are potentially at risk due to ongoing maintenance problems with the external doors. This means that they do not live in a safe, well maintained and comfortable home, although they do have their personal possessions around them, which means that they are living in ‘homely’ surroundings that meet their needs. EVIDENCE: A partial tour of the Heights showed that it was comfortable with good quality fixtures and fittings. Although a number of hinges to external doors were faulty which meant certain external doors were not being used, and posed a risk to people living at the home. Discussions with staff members and faded warning notices on the doors indicated the problems had existed for some time without being resolved. Outside the gardens are very attractively landscaped, giving a good choice of different seating areas, with a water feature, and Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 19 pleasant sitting areas, plus the boules pit. Internally the decoration is looking a little tired in certain communal areas, and is getting ready for redecoration. A number of bedrooms were seen, and these were well personalised, and homely, all of the people who were spoken with said they thought they had everything they needed, and that their bedrooms were comfortable and well equipped. During the inspection visit staff were seen cleaning in different parts of the building, and discussions with staff showed that there were cleaning systems in place, and the home had a good supply of cleaning materials. The building was found to be clean, and smelt fresh. In relation to cleaning the Heights said in their AQAA: “Validation audit carried out by the Operations Manager to check the cleaning schedule and cleaning records.” Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Staff have been recruited professionally, and are competent and trained to do their jobs, which means that the people who live at the care home are safe, and their needs are being met. However procedures for obtaining Criminal Records Bureau checks are not rigorously followed, which potentially puts people at risk. EVIDENCE: The Heights staffing rota was reviewed and this showed that there was enough staff currently employed to meet people’s needs. Two people living at the care home were asked about staffing levels, and they said that they thought there was enough staff on duty. Three members of staff were asked about staffing levels, two said they though they were sufficient, and the third, that sometimes they were a little bit short. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records showed that currently there are twenty-two care staff at the Heights, of whom six are nurses. There are ten staff with NVQ level II qualifications. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 21 The files of four members of staff were seen, to check that they contained all of the information that would show that staff at the Heights had been recruited in a safe manner – namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that the Height’s recruitment policy and procedure had worked to protect the people living there. However it appears the gardener has not had a Criminal Records Bureau check, which he should have. Discussions with three members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those checks had been completed. The staff training records showed that the Heights does have a training plan for its staff. Southern Cross, regularly audit the training records, and these showed that staff were receiving the training to help them to do their jobs. Discussions with three staff members provided evidence of the training courses staff had attended, including training in fire safety, nutrition and moving & handling etc. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 & 38 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. The Heights is a safe, well-managed care home with good systems for ensuring it’s quality in place, which means that people living at the home have their needs met. EVIDENCE: Julia Williams is the Registered Manager, having held the post since April 2008. She is suitably qualified and experienced and she has been judged by the Commission for Social Care Inspection to be a fit person to run a care home. The Height’s quality assurance system relies on questionnaires being filled in by service users, relatives and visitors. Copies of these questionnaires were seen together with evaluation of the results. The Heights do hold meetings for Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 23 the people who live there, although the records showed that these are not held regularly. Regulation 26 visits (these are monthly audits by a representative of the owners’ management team) are taking place, with copies of reports seen; these are part of the home’s quality assurance system. The Heights has a system for holding people’s personal monies. This is operated on their behalf by the staff (dependent on individual choice and their ability to manage the money, or relative’s involvement). Four people’s finances were checked at random. All of the cash tallied with the records, and receipts were seen, which enabled a clear audit trail of the individual’s financial expenditure to be followed. The Heights has a formal staff supervision system in place, in which staff receive supervision, either with the manager or with one of the other senior members of staff. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. The records showed that formal supervision is not currently happening on a regular basis, and this was also shown in discussions with three members of staff. A variety different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date, which shows that people are living and working in a safe environment. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 24 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation Requirement Timescale for action 31/08/08 2. OP29 Regulation The faulty hinges on the external 23 (2) b doors must be replaced as soon as possible, to allow people living at the home free access into the garden, and to make sure they are not at risk of injury by the faulty doors. Regulation All members of staff working at 31/08/08 19 the care home must have a Criminal Records Bureau check. This applies equally to ancillary staff as well as care staff. The gardener, who is a recognised member of the staff team, must have a valid CRB check, to ensure that people living at the home are protected. 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. Refer to Standard OP1 Good Practice Recommendations During the review and update of the statement of purpose DS0000002085.V368186.R01.S.doc Version 5.2 Page 26 Heights, The Care Centre 2. OP1 3. OP11 4. OP33 5. OP36 and service user guide, every effort should be made to ensure that the information contained in them is accurate and up-to-date. Key information provided for people about the home should be available in alternative formats to promote equal opportunity of access for those people who may have sight difficulties; this would include large print versions and audio – either on tape or compact disk (CD). The wishes of individuals at the time of their death should be recorded, ideally in a care plan, and consultation with people living at the care home and their relatives should also be identified. Regular meetings for the people who live at the care home should be held, with minutes of the meetings kept, and available for inspection. This will give people the opportunity to comment on the service they are receiving. Members of staff working at the Heights should receive formal supervision at least six times a year, with a record kept of the sessions, and made available for inspection. Heights, The Care Centre DS0000002085.V368186.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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. 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