Inspection on 21/02/08 for Herondale

This inspection was carried out on 21st February 2008.

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

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

Other inspections for this house

Herondale 19/11/08

Herondale 10/10/06

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 Richard Eaves Unannounced Inspection 21st February 2008 10:00 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.V356493.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.V356493.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 753 1653 0121 771 4188 home.her@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged 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) vacant post 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.V356493.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. 10th October 2006 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. The weekly fees range from £584 to £677, the fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the agency. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: reports from the organisation relating to the conduct of the home, records maintained at the home, the annual quality assurance self assessment and meeting and speaking with service users and staff. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with most of the service users. What the service does well: What has improved since the last inspection? The information for service users and relatives has been reviewed and reissued since the last inspection. New assessments and care plan documentation has been introduced and staff training has been provided. Arrangements for the management of medications has been improved. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 6 The range of and delivery of appropriate recreational activities has increased under the new management but there remain a need to appoint a skilled individual to lead this. The management of the kitchens has improved and since the previous inspection received an excellent grading from Environmental Health. The excellent quality assurance system has been implanted over the past year. Staff supervisions have improved and now the minimum six a year is demonstrated and staff mandatory training up-dates in areas such as infection control, first aid and health and safety can be seen to be up to date. Monitoring of health and safety records are up to date and available. The home has addressed previous requirements proactively. 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. The summary of this inspection report can be made available in other formats on request. Herondale DS0000063695.V356493.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.V356493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 Quality in this outcome area is excellent. The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before commitment to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide have been subject to a recent in depth review during December 2007 and reissued, they are good sources of information for current and prospective service users and their families. A copy of the contract/terms and conditions was seen for each service user included in case tracking, while the room number is extensively Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 9 entered within the case file it should also be included within the contract. Since the previous inspection a letter confirming that the home can meet assessed needs has been introduced. Five service users were selected for inclusion in case tracking and the case files of two others also inspected, these included all four areas of the home. The assessment process for each of the files inspected was thoroughly completed and informative and consisted of a activities of daily living model and a range of risk assessments for nutrition, pressure areas manual handling and service user specific risks. Each file included a social care and health care plan from the community. The files evidence the involvement of service users and their relatives in the assessment process. The home has a well-developed person centred approach to meeting needs. Each service user has a key worker and a senior nurse is identified as in charge of each of the four units. The nursing staff are largely mental health nurses while there are also general nurses with specific training and experience in dementia care. 60 of care staff hold an NVQ in care with all others currently enrolled, eleven are undertaking a level three qualification. The contract provides for a trial period. The service does not offer intermediate care. Herondale DS0000063695.V356493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 Quality in this outcome area is excellent. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of five service users were selected for case tracking including one from each unit, other case files were also examined to confirm consistency of completion and detail. Care planning documentation is well organised, current, clearly written and comprehensively encompasses a range of ‘care areas’ necessary to ensure the Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 11 delivery of care appropriate to the general and dementia needs of each service user. Residents were well dressed, appeared relaxed, content and were free to do as they wished within their capabilities. Staff were noted to treat residents with respect and it was observed that residents privacy was respected in such tasks as changing pads always done in the bathrooms or service users own room behind closed doors, all bedrooms being single en-suite. All residents are registered with a local G.P. who visits the home twice weekly, it was stated that the specialist also visits the home on a quarterly basis and is available to advise by telephone. Records indicated that there are regular visits from health professionals such as chiropodist, dentist and optician. Nurses liaise with other health care professionals as required such as physio’ and other therapies. The files indicate and the manager confirmed that there are no pressure sores currently and the effectiveness of preventative measures are audited frequently. The home uses the Boots monitored dosage system for most medications and the Boots Pharmacist undertakes quarterly audits. In addition the home maintains its own audits and the Primary Care Trust also regularly audits by their Pharmacist. A clinical waste contract is in place with PHS. An inspection of pharmacy arrangements showed there to be an air conditioned secure room, with monitoring of the room and refrigerator temperatures and checks that the electronic scales and suction machine were maintained charged. The home medication policy was available along with the Royal Pharmaceutical Society Guidelines. The GP’s records are also stored securely in this room. Other good practice seen was a guide to patch placements for such treatments as analgesia. The controlled drugs (CD’s) are checked at every handover and an examination of the CD book and handover book show these to be properly maintained and up to date. The medication administration record (MAR) charts were fronted by a photograph of the service user and essential information, such as allergies completed. The MAR charts were completed thoroughly and appropriate omissions fully documented. There was evidence that all medications are subject to review by the Consultant and GP on a regular basis. The ‘Gold Standards Framework has been adopted but has yet to be followed through in practice there being a very low rate of dying at the home currently. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. The home provides a varied social and recreational activity programme that provides interest and pleasure for service users. The involvement of family and friends is encouraged in agreement with the service users wishes. Service users are supported and encouraged to exercise choice in their lives. Meals at the home are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is actively trying to recruit an activities co-ordinator and while recruitment is underway care staff undertake the role during the afternoon and maintain the weekly group and individual programmes. Case files included for case tracking included a social profile, life story, interests and hobbies and an assessment of likes for entertainment and recreation drawn from these. Important events in the lives of individuals are noted and celebrated. Emphasis is given to supporting and maintaining the individuals expression of their faith and spirituality. The home has a dedicated Chaplain from the local chapel and also has good links with other faiths. Services, bible readings and Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 13 hymn sessions are held regularly and well supported by the service users. A programme of physical exercise assists in keeping fit and mobile and a range of sensory stimulating activities are also provided. Open visiting and a proactive approach to involving families in activities at the home including welcoming them to take a meal with their partner and joining in church services or attending them outside together, joining in special supper evenings and entertainments. The home does not have responsibility for individual finances, this being with external advocates such as family or social services. Rooms visited during the tour of the building showed that individuals have personal possessions with them at the home. The home has an ‘Access to Records’ policy which is promoted within the service user guide. The organisation provides clear standards for their homes to achieve in ensuring service users receive nutritious and satisfying meals. Each service user is assessed and monitored at least monthly or more frequently if problems are identified. Problems such as difficulty in maintaining weight are addressed preferably with a high calorie diet rather than supplements but these are also available. Menu’s were seen to include choices for mains and deserts for lunch and tea and these meals were used for the pureed meals. Supper is served and a cooked breakfast is increasingly being taken up, it is recommended that these be promoted by inclusion in the menus. The lunch served during the day looked appetising and those able expressed their satisfaction and all appeared to eat well many requiring assistance which was provided in an unhurried individual way. The home states that they are able to provide diets for all life-style, cultural, medical and preference reasons. They also have the stated aim of making the dining experience for residents enjoyable and relaxing. Drinks and snacks are available to residents at any time of day and night. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 - 18. Quality in this outcome area is good. The home has a satisfactory complaints policy and service users and their supporters can be confident that their views will be listened to and acted upon. Service users rights to participate in the political process are upheld and advocacy services promoted. Staff undertake adult protection training preparing them to uphold the welfare of the service users and to protect their rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is included in the service user guide and promoted in a range of ways including notices and by use of other formats such as pictures and other languages. There is a positive attitude to receiving concerns that is ‘invaluable in improving services’. The policy provides for timed responses, investigation and recording of outcomes. All concerns are externally audited and monitored by the organisations board. The electoral roll has been completed for this year and previously one service user is known to have registered a postal vote. The organisation promotes advocacy services to families, such as ‘Care Aware’ and the ‘Alzheimer’s Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 15 Society’, as well as individual service users. Advocacy is also promoted through the regular relatives meetings. The organisation has a clear prevention of abuse policy and procedure for dealing with any allegations or suspicions, including a whistle-blowing policy which has 2 free-phone confidential 24 hour lines (one for staff, and one for residents) both run by external agencies. The policies are compliant with the local multi agency arrangements. Staff are trained in The Protection of Vulnerable Adult awareness and receive annual refresher/updates. Policies are available that promote safeguarding such as recruitment checks and staff involvement in any financial transactions. See further details under staffing. Herondale DS0000063695.V356493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 – 26 Quality in this outcome area is excellent The Home provides a comfortable, attractive, safe and ‘homely’ place to live. The home is clean, hygienic and free from odours. Residents live in a comfortable home that offers them a life style suited to their age and condition. Specialist equipment, consistent with the needs of the Residents and the demands of tasks carried out by care staff, is available to facilitate the provision of care This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building was undertaken with no major issues identified the home was clean and no offensive odours were present. A selection of bedrooms were inspected on each of the four units, they are all single en-suite rooms including a shower. Assisted baths are available on each floor. All areas are individually and naturally ventilated and windows are provided with restricters, heating is with low surface temperature radiators. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 17 Each unit has its own communal areas and these were seen to be domestic in appearance and comfortable. Access to the secure garden is available from the ground floor lounges. The home is designed and decorated to enhance person centred support and promote the maximisation of independence. A sluice disinfector is available on each floor. The well equipped laundry is on the ground floor. It was noted that staff hand-wash facilities in these areas and the kitchen have uncontrolled supplies of hot water making thorough hand washing difficult due to the high water temperature. Records show that maintenance is up to date and monitoring of the environment is undertaken. It was seen that the homes recording of hot water temperatures at service user accessible outlets are maintained very close to the standard of 43°c consistently. The home has an annual repairs and renewals plan and a budget controlled by the manager. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 - 30. Quality in this outcome area is excellent. Staff are clear as to their individual roles and responsibilities and are enthusiastic, sufficient in numbers, well trained, supportive and committed to maximising the service users quality of life. The recruitment practices and staff training contribute to ensuring service users benefit from the skills and knowledge of the staff. This judgement has been made using available evidence including a visit to this service. 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. The rotas also indicate that these minimum numbers are frequently exceeded during the morning staff members are divided into teams who tend to work together. Ancillary staff are also employed to support the care staff. The rotas are 3 week repeating and staff full time hours are 34 a week. The current NVQ 2 qualification exceeds the standard and is at 60 . Those without this qualification are enrolled and will shortly bring the numbers up to 80 . Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 19 A sample of three staff files including the most recently employed staff and an overseas employee, show these to be completed to a very good standard with all appropriate pre-employment checks being undertaken such as Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (PoVA) first and work permit for student hours. One file had required a risk assessment on the CRB and Human Resources undertook this. The outcome of their considerations should be formally notified to the manager by letter and kept on file. The induction programme is to skills for care standard. The staff files also include a copy of the contract of employment, the job description, the completed induction document, receipts for issue of staff information/policies and procedures and General Social Care Council code of practice. Also on file are the records of supervision and training certificates. Staff training shows that all mandatory training is provided and certificates held on file. Other training undertaken by staff over the past 12 months include; E – Learning covering such areas as Infection Control, POVA, First Aid Dementia and advanced dementia training, mental capacity and food hygiene. Nurses also follow professional development and management training. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38 Quality in this outcome area is excellent Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. The managers approach is open and positive and develops positive relationships amongst service users and with staff. The home regularly reviews its performance, which includes seeking the views of service users, families and other stakeholders. Service users financial interests are safeguarded. Staff receive up to date and relevant formal supervisions. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 21 The manager has taken on this role since the last inspection and has yet to complete the registration process. She has wide experience in the field of mental health care and has undertaken management development training. Care staff were relaxed and friendly and said they enjoyed working in the home and good working relationships with the nurses. The few visitors seen said they were always made welcome and that the staff are marvellous. Staff meetings are held monthly in each unit led by the senior nurse for that area. Staff spoken with said they were kept well informed. The organisation has an excellent Quality Assurance programme, including an annual self-assessment and quality audits carried out be senior advisers a 6 monthly internal audit involving residents and junior staff, annual resident satisfaction survey, and internal Management review including a clear business plan and action plans from internal and external audits. Residents receive high standards of service confirmed by feedback from them, their families and other stakeholders. The local PCT also undertake their own audits and feedback to the home. Financial records are kept in accordance with best practice and procedures. Insurance certificates are displayed and meet requirements. The Finance procedures cover safeguarding of residents money and personal belongings. The home does not generally handle service users money or finances, preferring they remain independent or a family member. Detailed systems are in place to control and record any transactions. The home has a safe for residents use and all rooms have a lockable facility. The home complies with the organisations comprehensive staff supervision and senior managers of MHA monitor training policy and adherence. All staff are supervised at least 6 times a year, based on an annual appraisal. The sample of staff files inspected confirmed that supervisions are up to date Foundation inductions which meet the requirement of Skills for Care are implemented. Volunteers provide additional support for residents are fully checked, trained and supervised. The Health and Safety Policy clearly sets out the Managers responsibilities, and those of the wider organisation. MHAs Health and Safety Adviser ensures polices are up-to-date and monitors compliance. Senior managers carry out quarterly compliance checks at this home. Generic risk assessments are carried out for all potentially hazardous activities/equipment and individual assessments to safeguard residents and staff. The organisation has a comprehensive accident reporting system and regularly reviews how accidents can be reduced or prevented with an emphasis on falls. A sample of monitoring/checking records were inspected and were found to be fully completed and up to date. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 22 Herondale DS0000063695.V356493.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 4 3 4 4 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 4 3 4 4 4 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 4 3 4 Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. 6. Refer to Standard OP2 OP12 OP15 OP26 OP29 OP31 Good Practice Recommendations The home should ensure that the room to be occupied is included in any contract or terms and conditions. The appointment of an activities co-ordinator should be a priority. The availability of choices at breakfast and supper should be included in the menu. All staff hand-wash points such as sluices, laundry and kitchen should have hot water supplies controlled to promote good hand washing practice. Criminal Records Bureaux results letters from HR should include the outcome of any risk assessment that has been undertaken. The manager should complete the registration process. Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Herondale DS0000063695.V356493.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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