Inspection on 13/04/05 for Heron House

This inspection was carried out on 13th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heron House 20/11/08

Heron House 25/03/08

Heron House 01/05/07

Heron House 03/05/06

Heron House 23/11/05

Heron House 10/01/05

Heron House 26/08/04

Heron House 26/11/03

Heron House 26/09/03

Heron House 19/11/02

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

CARE HOMES FOR OLDER PEOPLE Heron House Coronation Close March Cambridgeshire PE15 9PS Lead Inspector Lesley Richardson Unannounced 13 April 2005 @ 10:00 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 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. Heron House Version 1.10 Page 3 SERVICE INFORMATION Name of service Heron House Address Coronation Close, March, Cambridgeshire, PE15 9PS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01354 661551 01354 657291 Four Seasons Homes No 4 Ltd Mrs Pauline Walker Care Home with Nursing 59 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (17), Old age, not falling within any other of places category (59), Physical disability over 65 years of age (59), Terminally ill over 65 years of age (59) Heron House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 30 beds Nursing Care 2. 1(one) named individual below 65 years of age for the duration of their residency (DE) Date of last inspection Brief Description of the Service: Heron House is a purpose built home situated off a main road in a residential area of the market town of March. It is owned by Four Seasons Homes No 4 Ltd and provides care and support for up to 59 service users over the age of 65 years, including up to 17 service users with dementia. The home has 53 single rooms and 3 double rooms, 53 of which have en suite facilities. Resident accommodation is on one level. There are a variety of communal areas available to service users and the home provides bathing and additional toilet facilities with aids and equipment to enable the needs of service users to be met. Service users have easy access to the gardens at the rear of the home, although this remains in poor condition due to building works. The home is situated approximately 1 mile away from the centre of March, where there is a range of shops, pubs and a post-office. Heron House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6½ hours and was carried out as an unannounced inspection on 13th April 2005. Half a day was spent talking to the manager and examining records and documents. The inspector looked around the building and spent time with service users and staff. Nine people who live at the home and three of the staff on duty were spoken to during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Assessments and care documents telling staff how to look after people need to be completed and written in more detail. This would mean staff members would have the information needed to care for service users. Criminal Records Bureau and Protection of Vulnerable Adult checks must be made for all staff members. The home has been asked to do this after the previous two inspections and there are still staff members without these checks. The recruitment and vetting of staff members before they start work needs to improve to make sure service users are not at risk from the people looking after them. Better records must be kept by the home to make sure staff members are trained properly and that concerns raised with the manager or staff members about service users are dealt with. Staff members giving out medication must become more aware of the correct way this should be done, to make sure service users rights are not infringed. Staffing rotas still do not show which staff members’ work in which areas of the home, making it difficult to see which staff members cared for particular service users. Heron House Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Heron House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Heron House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 The home does not have adequate systems in place to ensure that there is a proper assessment prior to people moving into the service. There is also no clear record of staff training and therefore there is no assurance that care needs will be met. EVIDENCE: The manager stated either she or the deputy manager completed preadmission assessments, although none of the three service user files seen contained a pre-admission assessment. Hospital discharge reports were seen in two service users files but these were not in enough detail to ensure new and existing service users were properly assessed and planned for, or that the home would be able to manager their needs. Mandatory training was given to all staff members during their induction period and the manager was updating a training matrix as there was no easy way for her to identify which staff members had training on which date. Heron House Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Systems were in place for referring service users to health care professionals, but poor care recording was such that it could not ensure personal, health and social care needs were met. EVIDENCE: Individual plans of care were seen in the service user files, but these did not ensure all aspects of personal and health care needs were identified and planned for. One service user admitted for nursing care had a written plan for only one aspect of personal care. Actions identified in another service users care plan had not been carried out and plans were not always reviewed on a monthly basis. Plans that had been reviewed on a monthly basis did not reflect changes in service users needs. Service users care records showed the access each service user had to health care professionals, but the results of these visits had not been recorded in the care plans to show changes or further action required to ensure care needs were met. One service user’s care record showed staff members had attempted to give medication covertly without exploring with all health care professionals the best ways of meeting that service users care needs. Heron House Version 1.10 Page 10 Service users stated care staff were good and polite, and one service user stated some staff members were “very nice, always happy”. Heron House Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Limited social activities provided some stimulation and interest for people living in the home. Visits from relatives and friends, ensured continued social contact. Meals offered a healthy, varied diet for service users. EVIDENCE: Some activities are organised by the home on a routine basis and service users stated they were also able to watch television and play board games. External activities were limited and while some service users were happy with this arrangement, others made their own arrangements to go out and access local community activities. Service users stated they were able to have visitors throughout the day. The home was not pro-active in ensuring service users were able to maintain mobility; service users in one of the lounge areas had their walking frames kept at the door, if they needed help with mobilising to reduce the risk of falls. A main meal took place during the inspection; food served contained a good variety of food groups and looked appetising, and there were a range of alternatives available. Service users stated they were happy with the choice available and that vegetables were already on plates prior to serving, although Heron House Version 1.10 Page 12 they had not been consulted about this. The dining room was very noisy as the door to the kitchen was kept open, which hampered spontaneous conversation. Heron House Version 1.10 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 The home had a satisfactory complaints system but little evidence that issues raised were treated as complaints or that there would not be repercussions. EVIDENCE: The home has a detailed complaints procedure that would assist and guide service users, visitors to the home and staff members in making and dealing with a complaint. The manager stated no complaints had been received at the home although service users families had discussed issues they were not happy with. Three complaints have been received by CSCI over the past year alleging poor care practice. One was not upheld, one was partially upheld and the third is still being investigated. Information received from complainants suggested complaints were not made at the time for fear of retaliation. Service users stated they had the opportunity to vote in the forthcoming election, although one service user said there were no posters around the home alerting all service users about the election. Heron House Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 26 The standard of the environment within this home is good, providing service users with an attractive and homely place to live. However, there is no evidence of improvement through maintenance or future planning for outdoor areas. EVIDENCE: The home was well decorated and maintained; most areas were accessible and safe for service users, with large open communal spaces. A door previously used as a fire exit in the dementia care unit, remained signed as a fire exit, which would present significant risk to service users. Service users were unable to access garden areas due to building works at the rear of the home. Safe access to the garden area for service users in the dementia care unit has not been possible for over a year and several requirements have been made. As no landscaping plan was available a further requirement has been made for this to be produced; legal action may be taken against the home if this requirement is not met. A courtyard area looked bleak and unattractive, one Heron House Version 1.10 Page 15 service user commented that it “could do with some flowers” as it was “looking a bit dull. The laundry area was placed away from kitchen and dining areas, infection control instructions were available in sluice areas and laundry staff members gave a good understanding of infection control measures within the laundry. Heron House Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There has been little improvement in the standard of vetting and recruitment practices since the last inspection, with appropriate checks not being carried out and potentially leaving service users at risk. The arrangements for ensuring staff training has been completed is not good, therefore leaving service users at risk of being cared for by staff without the knowledge to ensure their safety or meet care needs. EVIDENCE: The staff files of recently employed members of staff showed that the home had not undertaken all the necessary recruitment checks to ensure the protection of service users. Criminal Records Bureau (CRB) checks had been requested, but no PoVA check had been undertaken for the two most recent employees, and one of these staff members had started employment at the home before the CRB check had been returned. Staff members employed from overseas had neither PoVA or CRB checks completed, the manager stated she had no authorisation from the registered provider to complete these checks. Staffing rotas identified the staff members on duty but did not specify all of the staff working in each area, i.e. the dementia care unit. The manager was unable to show which staff members had attended training sessions and when further training was required. Heron House Version 1.10 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 33 The systems for service user consultation are limited with little evidence that service user views are sought and acted upon within the home rather than at organisational level. The management of the home is barely adequate but some record keeping and staffing records are not well managed, potentially placing service users at risk. EVIDENCE: The registered manager has been in post since November 2000 and has registered nurse and registered mental nurse qualifications, but it is not known if any management qualifications have been achieved. There is evidence from the inspection that the manager has not kept adequate records to ensure staff members are able to safely care for service users. A recent service user survey was undertaken and the manager stated responses were still being returned. These would then be collated and the results published by the registered provider. Heron House Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 2 x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 x 2 x 2 x x x x x Heron House Version 1.10 Page 19 YES 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 3 Regulation 14(1)(a) (b) Requirement The needs of potential service users must be assessed by a suitably qualified or suitably trained person. The home must obtain a copy of the assessment. Records of all training must be maintained. A written plan as to how each service users needs are to be met must be compiled. Arrangements for the safe administration of medicines must be made. Service users must be able to make decisions with respect to the care they receive and have their wishes and feelings taken into account. Premises must be of sound construction and in a good state of repair externally. External grounds for use by service users are provided and must be appropriately maintained. (31st March 2005 timescale from previous inspection not met.) The staff rota must show which staff members are on duty at any time and in what capacity. (31st March 2005 timescale from Version 1.10 Timescale for action 15th May 2005 2. 3. 4. 5. 4 and 30 7 9 14 17(2) 15(1), (2)(b) 13(2) 12(2), (3) 31st May 2005 18th April 2005 15th May 2005 15th May 2005 6. 7. 19 20 23(2)(b) 23(o) 15th May 2005 31st May 2005 8. 27 17(2) 15th May 2005 Heron House Page 20 previous inspection not met.) 9. 29 19(1)(b) (i) The registered person must ensure satisfactory enhanced CRB checks are obtained for all care staff. (28th February 2005 timescale from previous inspection not met.) 15th May 2005 10. 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 12 Good Practice Recommendations The provision of activities for service users should be explored to accommodate a wider range of tastes and include specific activities for people requiring dementia care. All concerns raised should be recorded and responded to. Service users or their representatives views should be obtained regularly by the home to ensure the home is run in the best interests of the service users, and to ensure a rapid response to concerns raised. 2. 3. 16 33 Heron House Version 1.10 Page 21 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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. 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