Inspection on 10/10/06 for Herondale

This inspection was carried out on 10th October 2006.

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

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

Other inspections for this house

Herondale 19/11/08

Herondale 21/02/08

Herondale 28/11/05

Herondale 07/07/05

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

CARE HOMES FOR OLDER PEOPLE Herondale 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU Lead Inspector Ann Farrell Unannounced Inspection 10th October 2006 08.30 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 Herondale DS0000063695.V313936.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. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herondale Address 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU 0121 7531653 0121 7714188 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) home.fxg@mha.org.uk Methodist Homes for the Aged Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (36) Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accommodate up to 36 older people over the age of 65 years with dementia or who have a mental illness and may also be infirm. (DE(E)) and (MD(E)) That the home can accommodate one named service user under 65 years of age with dementia. 28th November 2005 2. Date of last inspection Brief Description of the Service: Herondale is a purpose built; two storey home that is registered to provide care to 36 residents for reason of mental health problems, but predominantly specialise in dementia care. It is situated in a residential area within the boundary of Heartlands Hospital; it is close to shops, local amenities and is accessible to public transport systems. There is adequate parking to the front of the building with a large enclosed garden to the rear, which has a patio and seating for use by residents when weather permits. The home is divided into four wings or house groups spread over the ground and first floors. The first floor is accessible by the stairs or a passenger lift. Each house group has its own lounge, dining area, kitchenette, a bathroom, a communal toilet plus nine en-suite bedrooms. The en-suite facilities consist of a toilet and shower facility and are of sufficient size fore residents with mobility problems. There is a range of equipment for moving and handling residents plus pressure relief equipment for residents at risk of developing pressure sores. A passenger lift gives access to all areas in the home and there is wheelchair access to the front and rear of the building. The main kitchen and laundry area are situated on the ground floor, which are staffed separately. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork inspection was conducted over two days commencing at 8.30 am on 10th October 2006. This was the first statutory inspection for 2005/2006. Senior nurses were present for the first day. The manager and deputy manager were present for the second day of the inspection when feedback was given. During the inspection process the inspector undertook a tour of the home, sampled residents files and other documentation. Case tracking was used in respect of a number of resident’s files to determine care from the time of admission to the home plus direct and indirect observation were used to determine practice. During the fieldwork the manager, deputy manager, six members of staff, one resident and three relatives were spoken. A large number of residents were unable to communicate verbally and their views could not be obtained. What the service does well: The home provides specialist care for residents with advanced dementia. There is a relaxed atmosphere with flexible routines in the home. The building is purpose built and provides adequate space for residents to wander around as they wish and for those with mobility problems Visiting is flexible and relatives are supported in becoming involved with the care of relatives. The home holds meetings with relatives/carers regularly. Residents live in a safe, warm, comfortable and well-maintained environment. All bedrooms are single en-suite rooms with shower and toilet facilities. The home is divided into small groups for nine residents providing a more homely atmosphere. There is a choice of meals at all mealtimes and the feedback was positive about the quality and quantity of food. There is a good range of pressure relieving equipment for use with residents who are a risk of developing pressure sores and manual handling equipment for residents who require assistance with moving. The nurses have a good knowledge of residents and work with care staff to ensure needs are met. All staff were professional and treated residents with dignity and respect. Relatives stated they were happy with the standard of care. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 6 One relative stated,” The staff are wonderful, they look after my wife marvellous”. Another stated, “ The staff seem caring and are concerned about what she wears and how she is”. There is a group of volunteers who go into the home to provide activities or support residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 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 Herondale DS0000063695.V313936.R01.S.doc Version 5.2 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): 1,2,3,4 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents and their relative’s to enable them to make an informed choice about the home, but they require some further development and updating. The admission documents were lacking in detail and need further development to ensure all residents’ needs are identified. EVIDENCE: The home generally admits residents for long-term care who suffer with dementia or mental health problems. There is a brochure and service user guide available for prospective residents providing them with information about the facilities and services, but this document needs updating. The statement of purpose also needs developing and the manager states that she hopes to undertake this over the next month. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 9 The company has a contract of residence and copies were available n the sample of files examined. This will need to be reviewed in light of the change in regulations that came into force in September 2006. A small selection of resident’s files were inspected and it was found that a preadmission assessment is undertaken, but it was not signed, dated and lacked information. This process needs to be formalised and the home will need to write to prospective residents or their representatives confirming if the home is able to meet their needs. The manager stated the organisation has been reviewing documentation and this is to be introduced in November and training will be provided to staff. The home has been through considerable change over the past year and has employed a number of new staff, who do not have experience of caring for people with dementia. A training package relating to dementia care has been introduced and is to be cascaded to all staff in the near future. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to meet resident’s health and personal care. Medication is generally of a good standard. The care planning records and documents need to be developed further to demonstrate a personalised and holistic approach to meeting resident’s needs. Residents are treated with respect and in a dignified manner. EVIDENCE: Following admission to the home staff complete documentation and risk assessments. These were lacking in detail, some documents had not been signed and dated plus and in some cases there were no risk assessments in respect of bed rails where appropriate. Staff draw up a care plan for residents following admission to the home outlining how the resident’s needs are to be met by staff. On inspection of a sample of records they were of varying detail and there was no evidence that relatives or representatives had been involved with the process. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 11 Some were of a good standard, whilst others lacked detail or gave vague instructions and in some cases they had not been updated when changes were noted in residents condition. However, it was apparent that staff had taken action when issues or concerns were identified. On discussion with staff they were aware of residents needs and nurses had a good knowledge of residents. The manager stated they are to introduce some new documentation for care planning in the near future and this will include monitoring of ill being/well being and dementia mapping to assess residents progress and current status. During the inspection it was noted that one resident who was sitting in a chair in the lounge had a lap belt across their abdomen, which could be seen as a form of restraint. On discussion with the deputy manager it was stated that this had been discussed with other professionals and it was part of the care plan. Although the details were in the care plan they were rather vague and there was no evidence that the issue had been discussed with other professionals. It was also noted that medication was being crushed for a resident who had recently been admitted to the home. This was not recorded in the care plan and there was no evidence that this had been discussed with the G.P. and the pharmacist. Where possible liquid medication should be provided and if this is not possible the G.P. and pharmacist should be consulted. Whilst touring the home there was a number of pressure relieving devices in use to reduce the risk of pressure sores plus moving and handling equipment etc. to assist residents with mobility problems. Residents were well presented, appeared relaxed, content and were free to do as they wised within their capabilities. Staff were noted to treat residents with respect and it was stated residents privacy was respected. All residents are registered with a local G.P. who visits the home on a regular basis and it was stated that the specialist also visits the home on a regular basis also. Records indicated that there are regular visits from health professionals such as chiropodist and optician. Nurses liaise with other health care professionals as required such as physiotherapist etc. The home uses a monitored dosage system of medication, which is stored appropriately. The temperature of the room and fridge are recorded, but the minimum and maximum temperature if the fridge should be recorded regularly. On inspection of the medication it was found to be of a generally good standard. There were occasional gaps in the recording, some audits were not accurate and they had run out of medication on one occasion. On discussion with one resident he stated that staff were good and they looked after him well. Relatives stated they were happy with the standard of care and found the staff were concerned about residents. “ They seem very caring and are concerned about what she wears and how she is”. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 12 One relative stated “ They have got a special cushion and bed for her; she has a lovely room”. A portable telephone is situated on the ground floor and rooms have telephone sockets enabling telephone calls to be made in private. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Meals provided are of a good standard offering both choice and variety as well as catering for special dietary needs. There are some activities/occupation of residents, but this area needs to be further developed. EVIDENCE: Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 14 The home has flexible routines allowing natural wakening and residents are supported by staff in making choices about various aspects of life. Residents are free to wander around the home if wish and there are no rigid rules. Snoozlam equipment is available for use in resident’s bedrooms where appropriate. The home has an open visiting policy and on discussion with relatives they stated they could visit at any time and were made welcome by staff. They are able to have meals with their relatives and make drinks in the kitchenettes if they wish. The home has a volunteer organiser who has a group of volunteers who visit the home regularly and activities include a spirituality group, pat a pet and an entertainer visits the home. Staff spend time with residents and there was noted to be some interaction between staff and residents. Televisions and radios are available in each lounge and during the inspection the radio was playing most of the time. On discussion with one resident it was stated they did get bored at times and this area will need to be developed further to provide appropriate occupation of the residents. The manager stated that they were currently interviewing someone to provide alternative therapies and were hoping to employ and activities co-ordinator or a locksmith, who would be responsible for this area. The garden provides a potting shed, raised flowerbeds and garden furniture for use when the weather permits. The home employs separate catering staff who provide three full meals per day. Currently there is a three-week rotating menu with choices each day, which is reflective of the majority of the current resident group culture. It was stated cultural options have been provided in the past, but have not proved popular with the residents and alternatives to the menu can be provided where residents do not like the choices available. There was no record of food taken by residents, which is required by the regulations to demonstrate a varied nutritious diet. On discussion with relatives they stated the food was of a good standard as they assisted with feeding and also took some meals themselves. Meal times were observed and residents had a choice of meal. Meals were served from heated trolleys on each unit. Residents could take their meals where they wished and appropriate crockery and cutlery were provided to meet residents needs. Staff gave assistance where required and interacted with residents. The process was relaxed and unhurried. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The arrangements for dealing with complaints and the protection of residents are satisfactory. Policies and procedures are in place and staff have adequate knowledge. EVIDENCE: There is a complaints procedure and a record of complaints received by the home. The record indicated that no complaints had been received over the past year, but it was stated that one had been received directly by the service manager. There was no record of this complaint in the home. On discussion with relatives they stated they were not aware of the procedure, but if there were any concerns they would speak to a senior member of staff and they felt confident they would be addressed appropriately. The Commission has not received any complaints about the home. The home has a policy/procedure in respect of abuse and it refers to the local multi-agency guidance. On discussion with staff they were aware of the action to take in the event of any allegation of abuse. However, staff were not aware of the content of the whistle blowing policy and it is recommended that this be addressed. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents live in a safe, warm, comfortable and well-maintained environment. EVIDENCE: Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 17 The home is purpose built and is divided into four units/house groups. Each house group has nine en-suite rooms with an assisted bathroom, communal toilet, lounge, dining area and small kitchenette. The home was clean, odour free and generally well maintained. It was noted that re-decoration had been undertaken and was ongoing also some new furniture had been purchased, which was domestic in nature providing a pleasant environment for residents to live. There is a large enclosed garden to the rear of the building with a patio; garden furniture and a potting shed to be used when weather permits. The garden can be accessed by the ground floor lounges and provides an enclosed wandering space with a telephone box, sewing machine and beach area for residents to explore. Baffle locks were fitted to all doors and rooms that may be hazardous to residents had coded keypads to ensure residents safety. All bedroom doors have a lock and rooms have lockable facilities. En-suite facilities consist of a toilet, wash hand basin and shower providing easy access for residents with mobility problems. A call bell system is fitted to all areas so that assistance can be summoned where required and pressure mats are provided in a number of rooms to alert staff if residents get out of bed. A small sample of rooms were inspected and they were found to be of a good standard, had been personalised by residents or their families and on discussion with residents and relatives they were happy with their bedroom. Each of the four house groups has an assisted bath facility, accessible from both sides and there are communal toilets. During the tour it was noted that the assisted bath on Rose house group was not working properly and this will need to be reviewed. All areas are individually and naturally ventilated and windows are provided with restrainers. All areas are centrally heated with low surface temperature radiators to reduce the risk of scalding. Laundry facilities were sited on the ground floor, which were adequate. It was noted that bar soap was in use in the laundry, emollient was in a bathroom plus brushes and toiletries were on staff trolley’s suggesting they may be for communal use. These areas will need to be reviewed in light of the risk of cross infection. The chef is currently off sick and remaining staff or relief staff are currently managing the kitchen. Since the last inspection a dishwasher has been fitted. Fridge and freezer temperatures are recorded regularly, but hot food temperatures are only recorded intermittently. Other areas that require attention in respect of hygiene in the kitchen include; • All foods in the fridge must be dated. • Decanted foods must have a use by date. • Opened foods must be re-sealed or decanted into a sealed container. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 18 • • • Food items must not be stored on the floor A new blender is required. The paper towel dispenser needs to be replaced by the wash hand basin. It was noted that the fridge temperatures in kitchenettes were not recorded, food in fridges had not been dated, the units required more thorough cleaning and the top of one of the microwaves was rusting and will need replacement. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Staffing levels are maintained at satisfactory levels to meet resident’s needs. Recruitment procedures are robust and on going training is provided to staff. EVIDENCE: Duty rotas indicated that there are two nurses and seven carers on duty during the day with one nurse and four carers overnight, which was adequate to meet resident’s needs at the time of inspection. Staff members are divided into teams who tend to work together. Ancillary staff is also employed to support the care staff. On discussion with relatives they stated, “The staff are marvellous”. A small sample of staff files were inspected and demonstrated a robust recruitment procedure. However, it was noted that there was no evidence of a work permit for two members of staff who had recently been employed on discussion with the manager she was aware of the relevant details and stated she would follow it up. There is ongoing training in the home with 50 of care staff having completed NVQ level 2. Recently a number of new care staff have been employed and they are undertaking the induction programme and have been allocated to nurses, who are responsible for ensuring the training is completed. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 20 There were no records to demonstrate this and it will be followed up at the next inspection. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 21 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): 31,32,33,35,36,37,38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home is well managed in the interests of residents. Maintenance and servicing are up to date and in line with health and safety regulations. EVIDENCE: The manager is a registered nurse and has a number of years experience. Currently she is not registered with the Commission and is due to go on maternity leave in one months time. The organisation will need to forward details to the Commission about the arrangements for the management of the home during her absence. Staff were relaxed and friendly. They stated they enjoyed working in the home and found the nurses approachable. They stated that staff meetings and supervision had not occurred regularly recently and some did not feel well Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 22 supported. On discussion with the deputy manager she acknowledged that this area needs to be developed and it had been discussed at a nurses meeting that was held on one of the days of the inspection. A relative’s forum is also held and it was stated that this was over due, but it would be addressed in the near future when the arrangements for the managers absence had been finalised. The manager stated that there is a central team who undertake assessment of standards and values as part of the quality assurance process plus an annual survey of residents and relatives is undertaken and feedback goes to head office. This process has not been undertaken yet. When it does occur feedback should be obtained from other stakeholders and a development plan drawn up indicating outcomes for residents. As part of the process regular monthly visits by a manger is undertaken and a copy of the report sent to the Commission to comply with the regulations, but reports have not been forwarded to the Commission. The home holds some monies on behalf of residents in a secure facility and records/receipts were available. However, there was only one signature for some transactions. The company hold money on behalf of residents in an account at head office, and the home request money when required. However, they have no knowledge of the account and the amounts of money held on behalf of residents in the home. The Regulations require that the bank account should be in the resident’s name/names and records must indicate the details of money deposited and withdrawn on behalf of the residents. This area will need to be reviewed. The home has undertake servicing and maintenance in respect of equipment and are in the process of securing a contract for the serving of pressure relieving mattresses and cushions in order to comply with health and safety. Areas that were outstanding are in house testing of the emergency lighting system and hot water temperatures. A fire officer has recently undertaken an inspection, which was satisfactory and the manager is in the process of addressing some minor recommendations. The manager provided a training matrix and updated basic training is on going in respect of moving and handling, food hygiene, health and safety and fire but areas that need to be addressed include infection control and first aid. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 2 X 2 Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 2 Standard OP1 OP1 Regulation 4 5 Requirement The Registered Person must review and update the Statement of Purpose. The Registered Person must review the Service User Guide and ensure it is up to date with a copy of the contract and a copy given to all residents. The Registered Person must review and update the contract of residence in line with updated regulations. The Registered person must ensure all assessments of residents needs are comprehensive upon admission to the home and include full risk assessments. Timescale of 30/8/05 not met. The Registered person must ensure: • A comprehensive care plan is drawn up for all residents in the home outlining in detail the action to be taken by staff to meet their needs in consultation with DS0000063695.V313936.R01.S.doc Timescale for action 30/12/06 30/12/06 3 OP2 5b 30/12/06 4. OP3 14 30/11/06 5. OP7 15 30/12/06 Herondale Version 5.2 Page 25 residents or their representatives. • The care plan must be updated when any changes are noted. Timescale of 30/8/05 not met. 6. OP7 13(8) The Registered Person must ensure that records clearly indicate that reasons for use of the lap belt, who was consulted and the arrangements in place. The registered person must ensure: • The correct administration and recording of all medication. • Systems are put in place to ensure they do not run out of prescribed medication. • A Record the minimum and maximum temperature of the drug fridge is recorded. • Where there is a need to crush medication the G.P. and pharmacist are consulted and details are recorded in residents care plans. The registered person must review the arrangements for occupation/ stimulation of residents and ensure a suitable range of activities is implemented and records are retained in the home. Timescale of 30/12/05 not met. The Registered Person must ensure: • A record of all complaints is retained in the home. • All relatives are informed of the complaints procedure. The registered person must: • Herondale 30/10/06 7. OP9 13(2) 30/10/06 8. OP12 12(1) 30/12/06 9 OP16 22 30/10/06 10 OP19 16(2)(j) 30/10/06 Ensure food items are not stored on the floor. Version 5.2 Page 26 DS0000063695.V313936.R01.S.doc 11 OP26 13(3) Fridge, freezer and hot food temperatures are recorded regularly. • All foods in the fridge are dated. • Foods are re-sealed after opening or decanted into sealed containers, which are dated. • Provide new blender. • Ensure paper towels are placed within the vicinity of the wash hand basin. • Ensure all units on kitchenettes are thoroughly cleaned. • Replace the rusting microwave. The registered person must 30/10/06 review the arrangements in respect of infection control to include the use of bar soap toiletries, hairbrushes etc. The responsible person must forward details about the management of the home during the manager’s absence. The registered person must introduce a quality assurance system seeking feedback from stakeholders and draw up a development plan indicating outcomes for residents. Timescale of 30/3/06 not met. The responsible individual must ensure a copy of the monthly report is forwarded to the Commission. The Registered Person must ensure: • That where money is deposited in a bank on behalf of a resident the account is in the residents name and they must retain details of all monies held Version 5.2 Page 27 • 12. OP31 8(1) 30/10/06 13. OP33 24(1) 30/01/07 14. OP33 26 30/10/06 15. OP35 20 30/12/06 Herondale DS0000063695.V313936.R01.S.doc on behalf of the residents. Two people must sign all transactions. In the home. Timescale of 30/3/06 not met. • 16. OP36 18(2) The Registered Person must there are systems in place for staff to receive supervision at least six times a year. The registered person must ensure a record of food taken by residents in sufficient detail for those inspecting the record to determine whether the diet is satisfactory. Timescale of 30/12/05 not met. The registered person must ensure all staff receive updated training in respect of infection control, first aid and health and safety. The registered person must ensure the emergency lighting and hot water temperatures are tested regularly in house and records are retained in the home. 30/12/06 17. OP37 17(2)Sch 4 30/10/06 18. OP38 18(1) 30/03/07 19. OP38 13(4) 30/10/06 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 OP7 OP18 Good Practice Recommendations It is recommended that the format for carers notes be reviewed It is recommended that the whistle blowing policy be reviewed and all staff made aware of the contents. DS0000063695.V313936.R01.S.doc Version 5.2 Page 28 Herondale 3. OP32 It is recommended that the arrangements for staff meetings and relative’s forum be reviewed with a view to increasing the frequency. Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Herondale DS0000063695.V313936.R01.S.doc Version 5.2 Page 30 - 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. 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