Inspection on 12/09/07 for Heronswood

This inspection was carried out on 12th September 2007.

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 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

Heronswood 07/08/09

Heronswood 30/09/08

Heronswood 10/07/06

Heronswood 05/12/05

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Heronswood Heronswood 51 Harestone Hill Caterham Surrey CR3 6DX Lead Inspector Christine Bowman Unannounced Inspection 12th September 2007 11:00 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 Heronswood DS0000064646.V344025.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. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heronswood Address Heronswood 51 Harestone Hill Caterham Surrey CR3 6DX 01883 344645 01883 341232 valeriesrch@aol.com 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) S.E.S Care Homes Ltd Ms Susan Jane Bodle Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (21) Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2006 Brief Description of the Service: Heronswood is a converted and developed detached house providing accommodation for older people. The home is provided over three floors and the upstairs accommodation is accessed by a passenger lift. The home has two lounges and a conservatory, which leads from one of the lounges to the rear of the house. The home has a separate dining room. Fifteen of the eighteen rooms have en-suite facilities. There is a well-maintained and accessible garden to the rear of the house and parking facilities are available at the front. The weekly fees range from £514-£595. Extra charges are made for hairdressing – shampoo and set is charged at £8.30 – Cut, shampoo and set is charged at £14.50 Chiropody is charged at £10.50 per person. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 11.00 am and ending at 17.00 pm and was undertaken by Ms Christine Bowman, regulation inspector. The acting manager was not on duty when the site visit commenced but kindly changed her schedule and made herself available throughout the day to assist with the inspection process. At the previous site visit, the provider was required to appoint a manager for the home and make an application to the Commission for Social Care Inspection for registration. The home still requires a registered manager, and the current acting manager, who had been in post since February 2007, stated she had spent three months of that time managing a nursing home, owned by the same provider, leaving Heronsfield without a manager. The files of four people, who live at the home, were inspected including their assessments and care plans, risk assessments, medical information, activity schedules and menus. The recruitment process of two staff members was inspected and their training and development logs viewed. Staff rotas and the overview of staff training, health and safety certificates and records and the complaints and compliments logs were sampled. A tour of the premises was undertaken and most the people, who live at the home, were spoken with. Care staff were observed carrying out their duties and several were spoken with throughout the day. The atmosphere within the home was peaceful and relaxing and the staff were cheerful, friendly and helpful. Some visiting relatives stated they were pleased with the home and thought their relative was happy and more sociable since they had settled in and got to know the other residents. Two surveys completed by relatives or representatives of residents were returned and residents completed four surveys. Comments from these sources have been included in the report. The Annual Quality Assurance Assessment had not been returned to the Commission for Social Care Inspection by the required date and a reminder letter had been sent to the registered person. However, this information has not been received. Other information received and recorded on the inspection record since the previous site visit was also used in compiling this report. Thanks are offered to the management, the staff and the residents of Heronswood for their assistance and hospitality on the day of the site visit and to all those who completed comment cards for their contribution to this report. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? An application had been submitted to the Commission for Social Care Inspection for a variation to the conditions of registration because the home had accepted a resident whose needs were not within their conditions of registration at the time of the site visit. A risk assessment had been completed for one resident, who had been missing from the home at the previous site visit. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 7 The re-decoration of several resident bedrooms had been carried out when the rooms became vacant and they were clean, fresh and tastefully prepared for prospective residents. Infection control training had been accessed by the staff to inform them of ways of ensuring the prevention of the spread of infection within the home to protect the residents. Since the previous site visit, radiator covers had been provided to ensure the residents were protected from burning themselves on the hot radiators and the doors leading to communal areas and to resident’s bedrooms had been fitted with devices to enable the doors to remain open when residents wished but would safely close in response to the fire alarm. What they could do better: The Statement of Purpose and the Service User Guide should be reviewed to make prospective and current residents aware of essential current information with respect to the home, the provider and the staff so they are able to make an informed decision about the suitability of the home to meet or to continue to meet their needs under new ownership and management. The resident’s care plans must be reviewed regularly at least once monthly to ensure their changing health and welfare needs are assessed and arrangements are put in place to meet those needs. A full complaints procedure with a timescale for responding to complaints and the full details of the Commission for Social Care Inspection and the details of the responsible individual must be made available to residents and their relatives to enable them to make a complaint should they wish to do so. The manager must attend the local authority safeguarding adult training to ensure local multi-agency protocols are understood and followed to protect the residents. A local safeguarding adult policy that makes reference to the local authority multi-agency safeguarding adult procedures must be produced to inform the staff and all the staff should receive safeguarding adults training to ensure they are aware and up-to-date with current practise. At the previous site visit a requirement had been made that the external security arrangements must be reviewed to ensure the safety of the residents. The situation remains the same and the result is that the residents are unable to access the garden should they wish to do so without staff supervision and the conservatory doors are secured to prevent residents from accessing the garden. Newly recruited staff must not take up employment until all the recruitment checks in place to protect the residents have been processed. All the staff must receive mandatory training in a timely manner to ensure suitably trained staff support the residents and the responsible individual is advised to check with Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 8 the Home Office, the rules with respect to the number of hours students from abroad attending further education colleges, are allowed to work in order to ensure the law has not been broken. The home has been without a suitably qualified and experienced registered manager to provide stability and leadership for some time and it is the responsibility of the registered person to ensure a suitable manager is appointed for the home and that an application is made to the Commission for Social Care Inspection for registration. The Annual Quality Assurance Assessment requested by the Commission for Social Care Inspection must be returned in a timely manner to ensure sufficient current information with respect to the service is available to enable informed judgements to be made about how the service is providing and improving the services to the residents. 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. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Up-to-date information about the home was not available to enable prospective residents to make an informed choice about the suitability of the home to meet their needs. The needs of prospective residents had been assessed in a person-centred way showing how they would like their needs to be met. The home does not offer intermediate care. EVIDENCE: The Statement of Purpose and the Service User Guide had not been reviewed to make prospective residents aware of essential information with respect to the home such as the experience and qualifications of the current responsible individual and the staff. Information available to clients and prospective clients could be misleading because the brochure, which contained colourful photographs of the home, also gave the name of the previous proprietor and stated that Surrey County Council registered the home. A copy of the Service User Guide was requested but not currently available, therefore unlikely to be available to prospective residents on request. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 11 The acting manager had produced a ‘Welcome to your New Home’ booklet, which appeared to be a pleasant way of presenting the Service User Guide, however, much of the information required of the service to make available to residents and prospective residents was not included in this document. Fees and extra costs, a standard form of contract, terms and conditions, a full complaints procedure giving timescales and including the contact details of the Commission for Social Care Inspection and stating that complaints may be referred at any time, had not been recorded to inform them. The booklet did, however give an introduction to how the home is run, including daily activities, health and personal hygiene, and a brief mention of finances, bedrooms, information and advice and the complaints procedure. Of the four residents who completed surveys, two confirmed they had received a contract and two stated they hadn’t. All stated they had received sufficient information about the home before they moved in to decide if it was the right place for them. The two relatives who completed surveys also confirmed they always get enough information about the care home to help them make decisions. Three resident’s files were sampled and all contained assessments, which were person-centred, including a brief life history of the resident, their likes, dislikes and personal preferences, hobbies interests and involvement with family and friends. The home’s assessments provided social and personal information, which would inform the staff and help them to deliver person-centred care if transferred to the resident’s care plan. Health care assessments were not sufficiently detailed and one resident with mental health needs did not have a community psychiatric assessment. Another resident, who was underweight, had no evidence of a full medical check-up to ascertain a cause. No care management assessments were viewed on resident’s files. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s personal, social and healthcare needs are set out in care plans, which are not always regularly reviewed to ensure the resident’s current needs are being addressed. Healthcare professionals are accessed as required and medication is administered, handled and stored safely. Residents are treated with respect and their right to privacy is promoted and protected. EVIDENCE: The care plans of three residents were viewed. Assessments provided information with respect to the resident’s personal and social care needs, which had not all been transferred to the care plans. Care plans had been created where there was a problem/need to be actioned. The care plans had been reviewed on a monthly basis mostly, but there were some gaps, where reviews had not taken place over a two/three-month period. Three of the four residents who completed surveys confirmed they always received the care and support they needed and one stated that they usually did. Care plans had been signed by the residents to confirm their involvement and acceptance. A relative stated in the survey they returned, ‘They always seem to have Mum’s clothes Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 13 washed very regularly and she has a good supply of clean things in her wardrobe an drawers when I look.’ There was evidence of involvement of appropriate healthcare professionals including a General Practitioner, district nurse, community psychiatric nurse, chiropodist, occupational therapist, dentist and optician. The ‘Welcome to your New Home’ booklet informs new residents they can choose to remain with their own General Practitioner or transfer to the GP used by the home. Risk assessments were in place for those residents at risk of falling showing the identified risk, consequences and strategy to minimise the risk. A risk assessment had been put in place for a resident, who had been missing from the home at the previous site visit. The home had a medication policy and the staff, who administered medication had received training from a suitably qualified trainer. A list of signatures was kept for completing the Medication Administration Records and records were kept of the receipt and disposal of medication. Photograph of residents on their medication administration charts confirmed their identity when receiving medication to prevent drug errors. Three of the four residents who returned surveys thought they always received the medical support they needed and one thought they usually did. Staff members were observed knocking on resident’s bedroom doors and waiting to be invited in and giving encouragement to those using mobility aids. Two residents received visitors throughout the day. Of the two relative surveys returned, one relative thought it was not applicable for their relative to keep in touch with them and another commented, ‘ My mother is unable to contact me independently now, but the care home staff telephone or speak to me when I visit, if necessary.’ One staff member addressed a resident with a term of endearment instead of their name, but their care plan had not been sampled and this may have been their chosen form of address. Assessment viewed all recorded the resident’s preferred form of address to inform the carers. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle preferences, social, cultural, religious and recreational interests and needs are recorded and the home offers a range of activities to satisfy them. Contact with relatives, friends and the community is encouraged and residents are offered a well-balanced and appealing diet. EVIDENCE: The resident’s assessments included all the information necessary to ensure each resident’s preferences with respect to lifestyle, social, cultural, religious and recreational needs were known. The two relatives, who returned surveys, thought the service always met the different needs of the residents with respect to equality and diversity, and one commented, ‘As far as I know when I visit they seem to, they seem to understand age-related problems and difficulties with mobility and are very patient and re-assuring’. Resident meetings had also taken place and the minutes of the most recent meetings were viewed. Discussions had taken place about what kind of a trip the residents would like to take as a group and the result was that a theatre trip would be arranged. Feedback from residents was that the food was very nice and the staff friendly and helpful and that they would like to go out in the garden a little more often. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 15 Activities arranged for September included, ball exercises, hand and nail care, sing-a-long, knitting, quiz, bingo with prizes and film and wine with relatives on a Sunday. Once a month a local church group arrange a service and one resident goes to church with their relatives. Three of the four residents who completed surveys thought activities were usually arranged by the home for them to take part in and one thought they sometimes were. One relative commented, ‘ They try to make a homely atmosphere and encourage the residents to join in discussions, singing old songs etc. together, which isn’t always easy.’ Throughout the day relatives visited two residents. A relative commented, ‘Overall I am happy with the care my mother receives – she always seems relaxed and likes the food. She has her hair done most weekends and is kept clean and properly dressed.’ Lunch provided on the day of the site visit was roast with fresh vegetables (cabbage and carrots) roast potatoes and gravy and rice pudding or flan and was nicely presented. Residents observed eating lunch appeared to be enjoying the experience and confirmed this was so. The dining room was set out in tables for four with table cloths and the room was pleasantly decorated with framed pictures on the walls. There was a nice view of the garden and the room was bright and cheerful. A new resident stated they thought, ‘the food was very good.’ Of the four residents who completed surveys two always like the meals provided by the home, one usually did and one sometimes did. The menu was viewed and offered a good choice of well-balanced meals, however the menu on the notice board for the day was not the same as the meal provided. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident about raising concerns and making complaints but more information is required to inform them of the process. Safeguarding referrals are made appropriately but a shortfall in the timely access to safeguarding training leaves some staff ill-informed. EVIDENCE: Two of the four residents who completed surveys stated they always knew who to speak to if they were not happy, one usually knew and one sometimes did. 100 of residents and relatives, who returned surveys, confirmed they knew how to make a complaint. One relative stated the care service had always responded appropriately if they or the person using the service had raised concern about their care, and another relative thought they usually did. One relative commented that they had requested an item of specialist equipment to enable their mother to retain her independence, but so far this had not been supplied, although the person spoken to seemed to think it would be possible to order one. The relative stated they are going to ask about it again. A full complaints procedure with timescales and referral details for the Commission for Social Care Inspection was not included in the information given to new residents. The Commission for Social Care Inspection had not received any complaints on behalf of the home. Since the previous site visit, the acting manager was no longer in the role, and a new acting manager had been in post for the past seven months. A requirement had been made that they attend the local authority safeguarding Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 17 adult training. The present acting manager stated she had received the local authority training in Hampshire, where she had worked previously, however, protocols do differ so the requirement will be carried forward to ensure local procedures for safeguarding the residents are followed. The local authority safeguarding policy and procedure was available in the home for reference. A card with essential referral information and contact number was on the staff notice board and the staff handbook contained a short version of the policy and a whistle blowing policy. The acting manager was in the process of completing the home’s safeguarding policy, making reference to the local authority safeguarding policy and procedure. Two of the four staff, whose training logs were viewed, had no record of accessing this training and one had received this training in 2000. The acting manager stated that the Prevention of Abuse training was planned for October. A referral had been appropriately made by the home since the previous site visit and the matter had been handed over to the provider to investigate. A follow-up meeting is planned with the social services to reach a conclusion on the issue. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements had been made to the environment but more input is required to ensure the home is well maintained and that the safety of the residents is promoted. The home was clean, pleasant and hygienic. EVIDENCE: A tour of the premises was undertaken including all the communal spaces, the garden, the offices, the laundry room and some of the bedrooms were sampled. There were two sitting rooms and most of the residents were sitting in the larger of the two rooms with the door to the conservatory and the garden open and one resident stated they were ‘enjoying some fresh air’. The residents answered cheerfully and positively when asked if they liked living at the home. It was a warm day and the garden was pleasant, planted with shrubs and with a well-maintained, but sloping lawn and only a very small area suitable for access to those with mobility needs. The requirement made at the previous site visit to review this area with respect to the unsecured openings to the side of the house leading to the front of the house had not resulted in the Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 19 area being secured for the safety of the residents. The acting manager stated that the maintenance person had assessed the situation for the possibility of fencing but there was a problem with how to secure the fence to the house because there was a window where the fence would naturally be attached. The home was also situated on a steep road, which was not enabling to older people with mobility needs, should they wish to access their local community independently. There were large steps up to the front door and the car park was also sloping. A relative commented on how the home could improve access for those with mobility needs, ‘the only easy assess with a wheelchair is via the door to the garden in the dining room. Perhaps a small ramp would help in getting the residents in the wheelchair over the threshold. It could be a fold-up or otherwise removable ramp’. The re-decoration of several resident bedrooms had been carried out when the rooms became vacant and they were clean, fresh and tastefully prepared for prospective residents. Residents, whose rooms were viewed, had personalised them with photographs, pictures and small personal items. The ceiling of the smaller sitting room and the corridor leading to the dining room were in need of attention. The acting manager stated there had been an incident of flooding recently when a resident left a flannel in a sink and the water over-flowed damaging the ceiling. The electrical meters and fuse boxes situated near the ceiling in the corridor were quite untidy and would benefit from a review and some action to remove them from view. The laundry room was in the cellar and the environment was not conducive to acceptable working conditions. There was a wooden staircase with a handrail leading to a storage area with no natural light. The washing machines and dryers were situated in one corner of this space. The walls were white-washed and the floor was stone. The acting manager stated there was a sluicing facility on the washing machine. Hand washing facilities were not viewed in this area. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some good care practise was observed and access to induction and some specialised training promotes this, however, shortfalls in the recruitment process and in ensuring the timely access to essential training does not promote the safety of the residents and means they are not always in safe hands. EVIDENCE: The Annual Quality Assurance Assessment, which includes much of the data required to reach a judgement in this section had not been returned, leaving observations made during the site visit, staff personnel records sampled and the acting manager’s statements as the evidence accumulated. On the morning of the site visit, there were two staff on duty to support the ten residents currently living at the home and a chef cooking the lunch. Most of the residents were in the larger of the two sitting rooms, were smiling and appeared to be content and comfortable in their environment. However, later in the day a staff member stated there was a resident, who had returned from hospital and required nursing care, which she felt was too much for the staff. The acting manager confirmed that extra support and specialist equipment had been put in place to support this resident, who would not have survived a move to a nursing home due to their great age and vulnerable state. The acting manager should not have been on duty, but came in to support the inspection process. A relative commented, ‘ they still do not appear to have a Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 21 weekend cook, which I would think would be a good idea. The carers would then be able to concentrate on caring rather than cooking.’ The acting manager stated this situation had been rectified and the care staff were no longer required to spend time in the kitchen at weekends. The home was maintained in a state of cleanliness and was free from unpleasant odours. Of the four staff, whose training logs were viewed, two had achieved a National Vocational Qualification at level 2 and the acting manager stated she had achieved a National Vocational Qualification at level 3. The recruitment process for three staff members was inspected and all the personnel files contained an application form, a photograph, two written references and a Criminal Records Bureau check number. However, the application form did not require sufficient information to ensure the safety of the residents. A full employment history and the reasons for leaving posts, which involved the care of children or vulnerable adults, and an explanation of gaps in employment, were not required. The acting manager stated she had reviewed the application form for future applicants. Some of the dates recorded were not clear, however, at least one staff member had commenced employment prior to the receipt of all the recruitment checks, which are in place to protect the residents from potential harm. One student with a residence permit was enrolled at a local college, but had signed a contract to work at the home for forty-eight hours per week. The acting manager stated this was a college placement. The responsible individual is advised to check this situation with the Home Office to ensure he is employing people to work within the law. The acting manager was in the process of drawing up a staff training overview to show the dates mandatory and specialist training had been received and when it was next due. Individual staff training logs showed gaps in mandatory training and lapses in updating this training. Manual handling, fire training and infection control training had taken place since the previous site visit and this was indicated on staff training logs. ‘First Aid and food hygiene were in the process of being planned’, the acting manager stated, ‘medication training was scheduled for the end of September, and the prevention of Abuse was planned for October’. Safeguarding Adults training had been a requirement at the previous site visit and records show that two of the four staff, whose training logs were viewed had no record of accessing this training and one had received this training in 2000. Three staff had no record of receiving food hygiene training. A recently inducted staff member had followed the ‘Skills for Care Common Induction Standards’ to ensure they were well prepared for the caring role. Some specialist training had also been accessed to ensure the staff had gained an understanding of the special needs of some of the residents, this included Dementia Care, Continence, Older People and The Care of Aging Skin. Two relatives, who completed surveys thought the staff always had the right skills and experience to look after the people properly and one commented, Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 22 ‘The staff always seem caring and helpful to the residents and seem to know how to handle people with mobility problems when I visit, but I don’t know if all of them are fully trained in a ‘formal’ manner’. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to be in need of a registered manager to give stability and leadership, to ensure the Annual Quality Assurance Assessment is completed and returned in a timely fashion and that compliance with regulations is achieved. The health safety and welfare of the residents is promoted by the implementation of maintenance checks. EVIDENCE: The acting manager was very enthusiastic about the work of creating a comfortable and relaxing home for the residents and stated she enjoyed the challenging role. She had been in post from February and stated she had spent three of those months, at the request of the provider, managing a nursing home, which he also owns, leaving this home without an acting manager. The acting manager was very keen to enrol in order to attain the appropriate qualifications for the role of registered manager and had put in an application Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 24 to be considered for this position in May 2007. It is some time since this home had an experienced and qualified registered manager to give stability and leadership and it is the responsibility of the provider to ensure this situation is rectified at the earliest possible time. The Annual Quality Assurance Assessment had not been returned to the Commission for Social Care Inspection to provide essential information with respect to the service, how residents and their relatives are consulted and how this information is used to improve the service. The home does not manage finances on behalf of residents. Since the previous site visit, radiator covers had been provided to ensure the residents were protected from burning themselves on the hot radiators and the doors leading to communal areas and to resident’s bedrooms had been fitted with devices to enable the doors to remain open when residents wished but would safely close in response to the fire alarm. Health and safety maintenance checks were sampled and certificates viewed were up-to-date. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 25 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 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation Requirement Timescale for action 07/11/07 2. OP1 4(1)(c)6(a The Statement of Purpose must )Schedule be reviewed to inform current 1 and prospective residents about the qualifications and experience of the responsible individual and the staff, the range of needs the home is intended to meet, and all the other essential information included in Schedule 1 of the Care Homes Regulations 2001 (amended). An updated copy of the Statement of Purpose must be sent to the Commission for Social Care Inspection. 5(1)(a)(b) The Service User Guide must be (ba)(bb)( reviewed and contain all the bc)(bd)(c) required information to enable (d)(e)(f)( prospective residents to make a 2)6(a) decision about the suitability of the home to meet their needs including details with respect to fees, terms and conditions and a full complaints procedure with a timescale and contact details for the Commission for Social Care Inspection. An updated copy of the Service User Guide must be sent to the Commission for Social Care Inspection. DS0000064646.V344025.R01.S.doc 07/11/07 Heronswood Version 5.2 Page 27 3. OP7 15(b) 4. OP16 22 5. OP18 13(6) The resident’s care plans must be reviewed regularly to ensure their changing health and welfare needs are met. A full complaints procedure with a timescale for responding to complaints and the full details of the Commission for Social Care Inspection and the details of the responsible individual must be made available to residents and their relatives to enable them to make a complaint should they wish to do so. The registered person must implement a local safeguarding adult policy that makes reference to the local authority multi-agency safeguarding adult procedures. All staff must receive updated training in safeguarding adults. The manager must attend the local authority safeguarding adult training. The external security arrangements must be reviewed to ensure the safety of the residents. Newly recruited staff must not take up employment until all the recruitment checks in place to protect the residents have been processed. All staff must receive mandatory training in a timely manner to ensure suitably trained staff support the residents. 10/10/07 10/10/07 05/12/07 6. OP19 23(2)(b) 05/12/07 7. OP29 15(5)(b) Schedule 2 18(1)( c ) (1) 10/10/07 8. OP30 05/12/07 9. OP31 8(1) The registered person must 07/11/07 appoint a manager for the home and an application must be made to the Commission for Social Care Inspection for registration. The Annual Quality Assurance DS0000064646.V344025.R01.S.doc 10. OP33 24(1)(2)( 10/10/07 Page 28 Heronswood Version 5.2 3)(4)(5) Assessment requested by the Commission for Social Care Inspection must be returned in a timely manner. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations The responsible individual is advised to check with the Home Office the rules with respect to the number of hours students from abroad, attending further education colleges, are allowed to work to ensure he is working within the law. Heronswood DS0000064646.V344025.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Heronswood DS0000064646.V344025.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. 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