CARE HOMES FOR OLDER PEOPLE
Heronswood Heronswood 51 Harestone Hill Caterham Surrey CR3 6DX Lead Inspector
Lisa Johnson Unannounced Inspection 5th December 2005 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 Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 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.V259031.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Heronswood Address Heronswood 51 Harestone Hill Caterham Surrey CR3 6DX 01883 344645 01883 341232 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 (3), Old age, registration, with number not falling within any other category (21) of places Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection: 12 July 2005 Brief Description of the Service: Heronswood is a converted and developed detached house providing accomodation for older people. The home is provided over three floors and the upstairs accomodation is accessed by a passanger 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. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over five hours. The focus of the inspection was to review any requirements made at the last inspection and to look at other required standards. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspector spoke to five residents who live in the home and spoke to the registered manager and responsible individual to the registered. The inspector would like to thank the residents and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
The home has now obtained the updated version of the local authority protection of vulnerable adult procedure. A risk assessment was completed for one individual in the home in relation to falls Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 6 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. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 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 Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 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): These standards were not assessed on this inspection. EVIDENCE: For further information please refer to the report 12th July 2005. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 11 Care plans were sampled and found to include personal goals for service users with regular reviews taking place. Policies and procedures for handling death and dying are in place and observed by staff. EVIDENCE: Two care plans were sampled and each individual is provided with a care plan which covered health, emotional and social needs. Care plans were reviewed regularly evidence was seen that residents have also signed their care plan. Although the homes medication records were not looked at in detail on this inspection a report was sampled from the local pharmacist who had carried out a recent audit. Medication systems were found to be of a good standard with no requirements being made. A policy is in place in respect of dying and death and each resident has a plan in place, which has been agreed with each individual. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 10 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 & 15 Activities in the home meet individual preferences and residents are able to exercise their choice. Residents are provided with a well-balanced and nutritious diet. EVIDENCE: Three residents spoken to were satisfied with the recreational activities provided in the home. Since the previous inspection there is a new Responsible Individual in place and an open evening was being arranged for everybody to meet him. It was pleasing to hear from two residents that they like to assist in maintaining their rooms. One resident likes to do the dusting in his room. The lunchtime meal was seen and was of a good standard and nutritious. Choices were available and alternatives can be arranged. The mealtime was unhurried and relaxed. Residents spoken to say that they are offered wine with their meals on Sundays. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The home is able to demonstrate that there is a. accessible complaint policy in place and that residents and relatives will be listened to. EVIDENCE: A complaints procedure is in place. The complaints register and occurrence book were sampled. One concern had been raised by relative which the manager had followed up and actioned. Staff were observed to be talking to residents in a respectful manner. Three residents spoken to said that staff are helpful and kind. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 12 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, 25 & 26 The home is clean and hygienic. Improvement in the decoration and maintenance to the communal areas, bathrooms and bedrooms in the home will ensure that residents will have an improved and more comfortable place to live. EVIDENCE: A tour of the premises was undertaken and a number of maintenance and refurbishment issues were identified including the main lounge, which must be redecorated. The downstairs corridor also requires repainting. A shower curtain requires replacing in an upstairs bathroom. Maintenance must also be completed to the tiles around the toilet cistern in the upstairs bathroom. A crack was found in the plasterboard in an upstairs bathroom, which must be attended . This is to ensure that residents have comfortable and pleasant communal rooms to live in. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 13 Bedrooms were generally well maintained. However one vacant bedroom had a set of chest of drawers, which must be replaced, and a carpet in one bedroom must be cleaned. This is to ensure that residents have comfortable bedrooms to stay in. Externally the window frames and front door need painting. The lighting in the main sitting room needs to be attended to ensure that adequate lighting is available for residents to read and undertake activities. All rooms are accessible by a lift. Grab rails have been installed and call bells are available. A further requirement was made that the registered manager provides a programme to the Commission for Social Care Inspection identifying timescales for the completion of this work. The home was clean and hygienic. Laundry facilities are sited away from the kitchen. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 14 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 & 29 A record should be made available of the disclosure number of the police check carried for staff. This is to ensure that residents are protected by the homes recruitment policies and procedures. EVIDENCE: Staffing levels are maintained to a level that meets the needs of residents. There are three staff during the day. At night there is one waking plus one sleep-in member of staff. The home also employs two cooks and two domestics. A deputy manager has now been appointed. A discussion took place in respect that if staffing levels were ever to be reviewed in the future. It was recommended that this should be based on guidance recommended by the department of health. The procedure file was sampled and there are a range policies and procedures in place. Two staff personal files were examined and were found to obtain the required information. Police checks have been carried out, however the disclosure number of the check was not present on all files. A requirement was made that a record of this number must be made available on staff files. This is to ensure that residents are protected by the homes recruitment policies and practices. A copy of the General social code of conduct was present in the home which all staff are made aware of.
Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 15 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): 34, 35, 37 & 38 Service users are safeguarded by the accounting and financial procedures of the home. All staff employed in the home must receive formal supervision at least six times a year. The home must ensure that all fire records maintained in the home are kept up to date. This is to ensure the health, welfare and safety of residents. EVIDENCE: Financial accounts are maintained by the Responsible Individual to demonstrate financial viability. The home does not manage of hold any finances belonging to residents. The home has still yet to implement formal supervision and a requirement was been made that all staff including the registered manager must receive supervision at least six times a year.
Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 16 Accident records were sampled and were recorded and maintained appropriately. Fire records were in place and up-to-date. However there were some omissions in the records for weekly fire alarm checks. A requirement was made that regular checks are made and recorded in the fire book. This to ensure the health, safety and welfare of residents. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 17 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 2 2 3 X 2 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 2 3 2 Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP 19 Regulation 23(2)(b)(c) (d) Requirement a) The registered manager must ensure that the large sitting room is redecorated. This is to ensure that residents have comfortable and pleasant communal rooms to use. b) The crack in the plasterboard in the upstairs bathroom must be repaired. c) The downstairs corridor must be repainted. d) The tiles behind the toilet in the upstairs bathroom must be sealed. e) The shower curtain in the upstairs bathroom must be replaced. f) The carpet in the downstairs corridor requires cleaning. g) The external window frames and front door
Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 19 Timescale for action 05/03/06 require repainting. 2 OP 19 23 The registered manager must provide a written programme for the renewal of the fabric, maintenance and decoration for the home and to make this available to the Commission for Social Care Inspection. The registered manager must ensure that the lighting in the main sitting room is sufficiently lit. This is to ensure that residents are provided with appropriate lighting to facilitate reading and other activities. The registered manager must ensure that a chest of drawers in one bedroom is replaced. This is to ensure that residents have comfortable bedrooms. The registered manager must ensure that a carpet in one bedroom is cleaned. The registered manager must ensure that a record of the number of the police check is maintained on all staff files. This is to ensure that residents are protected by the homes recruitment procedures and practices. The registered manager must ensure that all staff receive formal supervision at least six times a year. The registered manager must ensure that the fire alarm tests are carried out on a regular basis. This is to ensure the heath, safety and welfare of residents. 05/02/06 2 OP 20 23(2)(p) 05/02/06 3 OP 24 23(2)(b) 05/02/05 4 OP 30 23(2)(d) 19/12/05 5 OP 29 19(5) 26/12/05 6 OP 36 (18)(2) 05/02/06 7 38 23(4)(a)(c) 12/12/05 Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP 19 Good Practice Recommendations 1 The registered manager should consider replacing the gates at the entrance. Heronswood DS0000064646.V259031.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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