Inspection on 06/02/06 for Heron Lea

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Heron Lea 13/11/08

Heron Lea 12/09/07

Heron Lea 04/10/06

Heron Lea 16/06/05

Heron Lea 21/02/05

Heron Lea 11/08/04

Heron Lea 12/03/04

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

CARE HOMES FOR OLDER PEOPLE Heron Lea Mill Lane Witton Norwich Norfolk NR13 5DS Lead Inspector Linda Wells Unannounced Inspection 6th February 2006 10:30 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 Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heron Lea Address Mill Lane Witton Norwich Norfolk NR13 5DS 01603 713314 NO FAX # 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) Miss Valerie Etheridge Miss Beverley Howkins Care Home 13 Category(ies) of Dementia (13), Old age, not falling within any registration, with number other category (13) of places Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Heron Lea is a care home providing personal care and accommodation for 13 older people who have dementia. The registered providers are Valerie Etheridge and Beverley Howkins who took over the home in April 2001. Both are actively involved in the home on a daily basis. The home is situated in the village of Witton, near to Brundall and approximately 7 miles from the city of Norwich. The building is a converted hotel and is set in large grounds. The home has 7 single bedrooms, 4 with en suite, and 3 double rooms including 2 with en suite. The ground floor accommodation is spacious and there is a safe garden area to the side of the building that service users are able to access in the summer months. The home has a lift to the first and second floors. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 06th February 2006 over four hours and was carried out as part of a routine inspection plan. On the day of inspection thirteen residents were living at the home and were seen to be having a meal, sitting in the lounges or in their bedroom. The inspection took the form of a tour of the premises, individual discussion with four residents, two staff members and the proprietor, group discussion with two residents, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The home cares for residents who have dementia and although the basic care needs of residents were met the specific environmental, record keeping and staff training on the needs of those with dementia had not been developed. To ensure that the health and social care, emotional needs and safety of all residents is assured the following ten requirements and seven recommendations were made to further improve the experience of living at the home for residents. • All plans of care must be written in a person centred format, using a Dementia mapping model to ensure the needs of residents are met. DS0000027320.V282244.R01.S.doc Version 5.1 Page 6 Heron Lea • • • • • • • • • • • • • • • • The procedure and arrangements of administering medication must be reviewed with staff members to ensure safe practise is carried out and residents protected. The window frames that are rotten must be replaced to make the home more attractive for residents. The radiators that are not guarded must be covered or low surface radiators fitted to ensure residents are protected. The exposed pipes in bathrooms, bedrooms and en-suites must be covered to ensure residents are protected. Staff members must receive training in person centred care; dementia care mapping, validation and how to create an appropriate environment and activities for people with dementia to ensure the needs of residents are fully met. All new staff must undertake training in moving and handling to ensure that they are fully trained to meet the needs of residents. All new staff must undertake food hygiene training to ensure they are trained and that the health and safety of residents is protected when food is prepared, cooked and served. All staff must receive supervision at least six times a year to review their work practise, clarify the aims and objectives of the home, the care provided to each resident and to identify, plan and review their training needs. A photograph of the staff member must be held in their staff file to support proof of identity. It is recommended that the name of a resident, photograph or picture be placed on their bedroom door to aid residents in identifying their own room. Repeated recommendation. It is recommended that a sensor system be used in the home to alert staff at night to the fact that residents are at risk of falls in their bedroom. Repeated recommendation. It is recommended that improvements are made to the environment, that are suitable and specific to those with Dementia to ensure the needs of residents are met. Repeated recommendation. It is recommended that any damaged bedroom furniture be maintained in good repair to make the bedrooms more attractive for residents. It is recommended that an easy chair be put in the bedrooms of those residents who like to sit in their bedrooms. It is recommended that any staff member working over 37 hours a week have their hours on the rota reduced in line with the working time directive to ensure that staff members are fit to work at the home. It is recommended that all senior care staff undertake NVQ3 training to ensure they are fully trained and equipped to run the home in the absence of the proprietors. 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. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 4, 5, 6 The admission procedure and written information available is adequate and enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The proprietor said that prior to admission as much information as possible was collected about a prospective resident from their family and other professionals. She said residents, their family or friends sometimes visited the home, that she or the joint proprietor often visited residents in their own home or in hospital and that residents were admitted on a one-month trial basis. One resident spoken to who had lived at the home for a few days said that she had visited the home prior to admission, her family had received information about the home and that staff had made her feel welcome and assisted her to settle in. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10, 11 The health and personal care needs of residents were met, however records were not all fully up to date and the safety of residents was not assured by the medication administration procedures. EVIDENCE: Residents had communication restrictions but indicated and looked to be well cared for. Four individual plans of care were examined and found to contain some relevant health, social and personal care information, daily records, resident profile, risk assessment, photograph, funeral arrangements, continence needs, reviews and visiting professionals details. However, they were not all complete and the proprietor said that the plans of care were about to be changed to include dementia mapping. A requirement was made that the plans of care must be written in a person centred format, using a Dementia mapping model to ensure the needs of residents are met. Residents were protected by the medication policies but not fully by the procedures seen carried out. A staff member was observed to have left the open tray of medication wallets and boxed tablets on the dining room table when she administered medication to residents in the lounges creating a risk of residents in the dining room having access to them. The proprietor said that Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 10 consideration was being given to the purchase of a lockable medication trolley and a requirement was made that the procedure and arrangements of administering medication be reviewed with staff members to ensure safe practise is carried out and residents protected. Records showed that staff had undertaken training and that medication was recorded and stored correctly. Staff members spoken to said that they treated residents with respect and gave examples of how their privacy was upheld. The records held on the arrangements at death for residents demonstrated that they or their family had been consulted and that their wishes were known. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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 the following standard(s): 12, 14, 15 The social and creative activities and meals provide some daily variation and interest for those living at the home. EVIDENCE: Staff members said that activities did take place occasionally in the afternoon such as musical instruments, videos or games. They said that residents enjoyed being in the garden in the summer, went on outings in the minibus and that they gave residents every chance to make a choice in their daily lives. Residents said that that their relatives and friends came to visit them in the home and that they enjoyed the meals. Observation of the main meal, menus and records revealed that they were balanced, wholesome and varied and that records were kept of any alternatives provided to aid in the monitoring of the nutritional health of each resident. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home has improved the procedure on the protection of vulnerable adults and it protects residents and supports the investigation of any cause for concern. EVIDENCE: No complaints have been received by the home and the proprietor said that any complaints or problems highlighted would be resolved quickly and to the satisfaction of all involved. The legal rights of residents are protected and records demonstrated that most residents had support from their families and that some residents had an advocate. Residents are protected from abuse, neglect and self-harm by the improved objectives, policies and procedures of the home and records showed that staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The standard of the environment within this home is reasonable providing residents with a safe and homely place to live, however it has not been adapted for the specialist needs of those with dementia. EVIDENCE: A tour of the building revealed that residents benefit from a home that is decorated and furnished to a reasonable standard but there is still work to be carried out to ensure that residents are fully protected and the specialist needs of those with dementia fully met. Three requirements were made to make the home more attractive and completely safe for residents. The window frames, that are rotten, must be replaced, the radiators that are not guarded must be covered or low surface radiators fitted and the exposed pipes in bathrooms, bedrooms and en-suites must be covered to ensure residents are protected. Four recommendations were made of which two were repeated that a sensor system be used in the home to alert staff at night to the fact that residents are at risk of falls in their bedroom, that improvements are made to the environment, that are suitable Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 14 and specific to those with Dementia to ensure the needs of residents are met, that any damaged bedroom furniture be maintained in good repair to make the bedrooms more attractive for residents and that an easy chair be put in the bedrooms of those residents who like to sit in their bedrooms. Residents were seen to have personalised their bedrooms however, a recommendation was repeated that the name of the resident, photograph or picture be put on the door of each resident to assist them in identifying their own bedroom. The home was observed to be clean and tidy, and to contain some specialist equipment such as a hoist and bath hoist. Some residents had the use of en-suite facilities and all had the use of a communal bathroom and toilet on each floor that could be adapted by the use of equipment to suit the needs of the residents. Infection control measures were seen to be in place and a service sluice/washing machine was provided. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The needs of residents are met, staff members are competent and the procedure for the recruitment and training of staff provides safeguards to offer protection for the people living in the home. EVIDENCE: Residents looked well cared for and the staff spoken to said that there were enough staff on duty to meet the needs of each resident. The proprietor said that she or the joint proprietor covered any shifts in the home if existing staff were not available. Observation of the rota revealed that some staff were working over 65 hours a week and a recommendation was made that any staff member working over 37 hours a week have their hours on the rota reduced in line with the working time directive to ensure that staff members are fit to work at the home Records demonstrated that staff members had a mix of experience and skills and those spoken to had completed or were about to commence NVQ2 training however, the senior on duty had not completed NVQ3 and there were times when she was left in charge of the home. A recommendation was made that all senior care staff complete NVQ3 training to ensure they are fully trained and equipped to run the home in the absence of the proprietors. Certificates held showed that an induction, foundation and updated training programs were undertaken by most staff but a member of staff who had been in post since September 05 had not completed training in moving and handling or food hygiene and assisted residents with their moving and handling and Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 16 prepared, cooked and served breakfast and tea meals. Some staff had undertaken Dementia training and the joint proprietor had completed training in Dementia Mapping but staff had not benefited from this training and had little knowledge of person centred care or the specialist needs of those with dementia. Two requirements and a recommendation were made to enable staff to gain the knowledge necessary for the range of needs of residents living at the home. Records have improved and showed that residents were protected by the staff recruitment checks that had been carried out. CRB checks, references, personal details and proof of identity were held in the file of each staff member however, a requirement was made that a photograph of the staff member be held to support proof of identity. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37, 38 Senior staff, support the proprietors in providing leadership, guidance and direction to staff however, planned supervision of staff members is infrequent. EVIDENCE: The proprietor and joint proprietor have managed the home for five years, have past experience of working in the care setting and have both completed the NVQ4 Registered Managers award. Staff members said that the home was well run and that the joint proprietors were approachable. Records demonstrated that the management, accounting and financial administration procedures carried out in the home offer safeguards and protect residents. The staff members spoken to said that they were supported by the senior staff and joint proprietors, handover and staff meetings and were aware of their role and responsibilities. Records held showed that staff members did not receive Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 18 regular supervision and a requirement was made that all staff receive supervision a minimum of six times a year to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs are identified, clarified and reviewed. A Quality Assurance system is in place that takes into account the views of everyone living, visiting and working in the home. It is carried out yearly in March and demonstrated that everyone is consulted and an action plan produced. Policies and procedures have been produced and were seen on all aspects of the home and service provided. The records held were found to promote and protect the rights and best interests of each service user. The proprietors successfully monitored identified financial budgets for the home and the proprietor said that there was no reason to doubt that the financial security of the home was not sound. The servicing and testing of all equipment had been carried out and relevant and timely certificates were held to ensure that the health and safety of residents is protected. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 2 3 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 3 3 Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12.1 Requirement Timescale for action 30/06/06 2. OP9 3. 4. OP19 OP25 5. OP25 6. OP29 7. OP30 The Registered person must ensure that all plans of care are written in a person centred format, using a Dementia mapping model. 13.4.b The registered person must ensure that the procedure and arrangements of administering medication is reviewed with staff members and that safe practise is carried out. 23.2 The registered person must ensure that the window frames that are rotten are replaced. 13.4 The registered person must ensure that the radiators that are not guarded are covered or low surface radiators fitted. 13.4 The registered person must ensure that the exposed pipes in bathrooms, bedrooms and ensuites are covered. 19.1 sch 2 The registered person must ensure that a photograph of the staff member is held in their staff file. 18.1.c The registered person must ensure that staff members receive training in person DS0000027320.V282244.R01.S.doc 30/04/06 31/08/06 30/06/06 30/06/06 01/06/06 30/06/06 Heron Lea Version 5.1 Page 21 8. OP30 18.1 9. OP30 18.1 10. OP36 18.2 centred care, care mapping, validation and how to create an appropriate environment for people with dementia. The registered person must ensure that all new staff members complete training in moving and handling. The registered person must ensure that all new staff members complete training in food hygiene. The registered person must ensure that all staff members receive supervision at least six times a year. 30/04/06 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP22 Good Practice Recommendations It is recommended that any damaged bedroom furniture be maintained in good repair to make the bedrooms more attractive for residents. It is recommended that the providers continue to explore ways in which the environment can be adapted to meet the needs of residents with dementia, including the use of colour and visual clues to aide orientation. (Repeated recommendation) It is recommended that the name of a resident, photograph or picture be placed on their bedroom door to aid residents in identifying their own room. (Repeated recommendation.) It is recommended that an easy chair be put in the bedrooms of those residents who like to sit in their bedrooms. It is recommended that a sensor system be used in the home to alert staff at night to the fact that residents are at risk of falls in their bedroom. (Repeated recommendation.) It is recommended that any staff member working over 37 DS0000027320.V282244.R01.S.doc Version 5.1 Page 22 3. OP23 4. 5. OP23 OP25 6. Heron Lea OP27 7. OP30 hours a week have their hours on the rota reduced in line with the working time directive. It is recommended that all senior care staff undertake NVQ3 training to ensure they are fully trained and equipped to run the home in the absence of the proprietors. Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Heron Lea DS0000027320.V282244.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!