Inspection on 23/08/05 for Heywood Court Care Centre

This inspection was carried out on 23rd August 2005.

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

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

Other inspections for this house

Heywood Court Care Centre 29/07/08

Heywood Court Care Centre 01/02/08

Heywood Court Care Centre 11/07/07

Heywood Court Care Centre 22/05/06

Heywood Court Care Centre 23/01/06

Heywood Court Care Centre 12/02/05

Heywood Court Care Centre 21/09/04

Heywood Court Care Centre 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Heywood Court Green Lane, Heywood, Rochdale, OL10 1NQ Lead Inspector Jenny Andrew Unannounced 22 & 23 August 2005 nd rd 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 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. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heywood Court Address Green Lane, Heywood, Rochdale, OL10 1NQ. 01706 361900 01706 361944 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Homes No 2 Limited Vacant Care Home Only 36 Category(ies) of Dementia Elderly 45 registration, with number of places Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 45 service users to include: up to 45 service users in the category of DE(E) (Dementia, over 65 years of age). 2. The service should employ a suitably qualified and experienced Manager who is registered by the Commission for Social Care Inspection. 3. The Registered Person must ensure that all staff working in the home have dementia awareness and dementia care training, which equips them to meet the assessed needs of the service users accommodated, as defined in the individual plan of care. 4. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. Date of last inspection 12th February 2005 Brief Description of the Service: Heywood Court is a dementia care residential unit, owned by the Southern Cross Group. The home can accommodate up to 45 elderly service users on both a permanent and respite stay basis in two separate units, the most recently opened being on the second floor of the building. With the exception of one double bedroom, all others are single and all rooms are equipped with en-suite toilets and wash hand basins. Bedrooms are situated on the ground first and second floors of the home. A passenger lift is provided to all floors. The home has disabled access and a safe enclosed paved garden area is situated to the rear of the home. This area may be accessed via the conservatory lounge doors. In addition, the entrance to the home has been fenced to provide an attractive additional garden area. The home is well maintained both internally and externally and a large car park is provided. Public transport passes the home and the motorway network is also nearby. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection in February 2005, another dementia care unit for 9 people had been opened on the second floor of the home. The registered manager had left and a new manager was in post who was waiting for her application to be approved by the Commission for Social Care Inspection. This unannounced inspection took place over one full day and an evening. An extra visit had been made to the home in April to check whether the home had done all the things they needed to do from the last inspection. The Inspector looked around the building, checked care plans and some records. In order to get information about the home, the first evening was spent going to a staff meeting and speaking to 3 residents 1 evening care assistant and two night staff. On the second day, 7 more residents were spoken to as well as the project manager, manager, deputy, 3 care assistants and a domestic. The visiting district nurse was also spoken with as well as 5 relatives. About 3 hours was spent watching how much time staff spent with the residents and how they found out what residents wanted. What the service does well: What has improved since the last inspection? No improvements were noted on this inspection. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 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. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 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 standard(s) 3 & 4 Pre-admission assessments were not always being undertaken, which could result in the home not being able to meet the needs of residents. EVIDENCE: As the second floor unit had only recently opened, three files for the most recently admitted residents were checked. Two of the files contained detailed pre-admission assessments from care managers of the Merit Team and the information from the assessments had been included in the care plans. The third file did not contain any pre-admission documentation. The manager stated that the resident had been transferred from another Southern Cross Home and that the previous manager had completed an assessment of need. Before any new residents are admitted, a full assessment of their needs must be done. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 9 For self-funding residents, the home had a detailed pre-admission assessment form which covered all required areas. Heywood Court provided care and accommodation for up to 45 residents with dementia. The ground floor environment had been designed to meet the needs of elderly people with dementia with a range of aids/adaptations having been supplied. Appropriate signs on doors depicted the rooms usage i.e. cutlery set on the dining room door, the provision of “touch pads” along sections of corridors. It was noted that on the second floor unit, no sign had been put on the toilet/shower room to make sure residents could find the communal toilet. Although several of the staff had undertaken dementia care training, many of them had not. A training day on dementia had however, been arranged for 19 October, 2005 which 11 of the staff were to attend. A further course on managing challenging behaviour had been arranged in November but numbers of staff to attend this course had not yet been finalised. Feedback from the relatives spoken to indicated they were, in the main, pleased with the care the person they visited was receiving. Thank you cards displayed within the home also commented on the good care staff were giving to residents. From interviewing staff and observations made during the inspection, it was evident that staff spent as much time as they could reassuring and comforting the residents who were showing signs of distress. The good practice of requesting residents be re-assessed when the home could no longer meet their needs was noted in 2 instances. On the second day of the inspection, one resident was transferring to a nursing home due to her deteriorating condition and only the week before another resident had been reassessed for nursing care. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8 Whilst the content of care plans and risk assessments was detailed, they were not always kept updated, which could result in staff working inconsistently with residents and not giving the correct care. The health care needs of residents were being met with close working links with health care professionals. EVIDENCE: Care plans for 3 of the most recently admitted residents were looked at, two of which did not contain a photograph of the individual. They were detailed and covered all relevant areas including health care needs. Risk assessments for skin/pressure relief, nutrition, falls, dependency and moving/handling had all been done upon admission. However, where staff had identified a weight loss for one resident, the care plan had not been updated to show what action staff were to take as a result of their findings. Personal care records were not up to date for any of the residents and it was difficult to determine who was responsible for ensuring that residents had been supervised or assisted in washing/bathing, nail care etc. The manager should consider setting up a keyworker/co-key worker system in order to ensure that named staff were responsible for over-seeing the personal care of their own residents, updating care plans and risk assessments and noting any other changes in a persons care. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 11 Southern Cross were just about to introduce their own care plans into the home and the manager had recently sent out letters to relatives asking them to make appointments to discuss the care needs of the residents and to sign their agreement to the new plans. Staff were also in the process of being trained to complete the new plans properly and 3 training sessions were being held at the home the week of the inspection. The good practice of utilising fluid/dietary intake sheets was noted when service users were ill or not wishing to eat and drink at the usual times. Feedback on the day, from relatives, was extremely positive regarding the health and personal care afforded to those they were visiting. The Inspector’s observations were that residents looked cared for, their nails were clean, they were wearing appropriate clothing and soiled clothing was changed, as necessary, after meals. Discussions with both night and day care assistants took place with regard to their respective routines. All clearly demonstrated their commitment to providing a caring and sensitive service. The incidence of falls was high but risk assessments were in place and all accidents had been appropriately recorded in the accident book. A visiting district nurse was spoken to during the inspection and she indicated that staff were co-operative, she was always accompanied by a carer when seeing a resident and any instructions she left were implemented. The outcome of any visits made by health care professionals, were recorded on individual files. Any instructions on the care to be given to service users was then transferred to the care plan. Medical conditions were recorded in detail on the individuals care plan. Health services were accessed as required. During the inspection, one resident was complaining of a sore foot and the chiropodist was immediately contacted and an appointment made for him to visit the home. Pressure relieving equipment was available on site, with further provision from the District Nursing service as required. Although a full medication check was not undertaken on this inspection, the administration of night-time medication by the senior carer was observed and some unsafe practices were seen. The signing of the medication record sheet, before giving out the medication, meant that when a resident refused to take their medication, she was crossing out her signature and amending it with an “R” for refused. Controlled drugs were also being dispensed with only one staff member being present when in fact, there should always be 2 present who should both sign the medication administration record. Whilst the senior said she had undertaken medication training, records showed that she had not fully completed the training. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 12 All staff, responsible for the administration of medication must receive training. The manager must ensure that these unsafe practices cease. A full medication inspection will be taken over the next few months. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 14 Residents’ lifestyles were flexible and social activities appropriate to the service user group and to individual tastes and capacities. Residents were helped and encouraged to exercise choices in their daily routines, which meant they continued to enjoy their chosen lifestyles. EVIDENCE: Since the opening of the new unit, the Activity Workers hours had increased from 20 to 25 per week. She was on annual leave the week of the inspection and no activities were seen during the inspection. However, feedback about activities indicated they were arranged to meet the needs of individuals as well as for groups of people. One resident spoken to said she had been out shopping and was waiting for another trip to be arranged. Other shopping trips and visits to the park had taken place. A group of 6 residents had been out to another Southern Cross home the week prior to the inspection, for a social evening and an entertainer had also recently visited the home. The home had access to a mini bus, equipped with a tailgate lift, so that those service users reliant upon wheelchairs were not excluded. The previous manager had arranged a self-catering holiday in Southport for 8 of the residents and the feedback about this was excellent. The manager said she was in the process of checking out with residents and/or their relatives whether religious needs were currently satisfactory. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 14 There was no activity programme displayed within the home and the care plans inspected, for the residents living on the second floor unit did not contain any details of what social activities they had been involved with. This should be addressed. Many examples of good practice were seen during the inspection, of staff offering choices to residents with regard to their daily preferred routines. They could eat where they chose, were offered choices of food and could choose to sit anywhere in the home. Several were seen to prefer sitting in the large foyer area where they could watch what was going on. During the evening, one resident had requested to go to bed and staff had assisted her to do so. She did however, return to the lounge on 3 occasions whereby staff would patiently take her back to her room and settle her down again. Where residents became disturbed and agitated in the dining room, staff would settle them elsewhere in the home and let them eat wherever they wanted. One resident during breakfast became very upset and finished her meal in the foyer of the home with a care staff sitting with her. Another example was seen where a resident was consistently wandering out of the dining room and the carer simply followed her until she had settled down and then gave her a meal. When a resident said she had not received any breakfast or lunch, the care staff did not make a fuss but simply went and got a plate of sandwiches for her which she was seen to enjoy. She had in fact already had her breakfast and lunch but had no recall of this. Two residents, on the second floor unit, were seen to access the lift and move freely between the two floors. Due to the client group being accommodated, relatives were responsible for the finances of the residents, although the administrator kept an amount of money for each person, in case they needed toiletries, hairdressing or chiropody services. The notice board gave details of a local advocacy service should this be needed. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Arrangements for protecting service users from abuse were unsatisfactory, placing them at risk of harm. EVIDENCE: The home had an adult protection policy/procedure and a copy of the Rochdale MBC Vulnerable Adult Procedure was also in place. The staff handbook, which is issued as part of the induction process, contained guidelines on whistle blowing. The deputy manager and 3 staff had attended “Protection of Vulnerable Adult” training and the manager said more staff would be undertaking this training in the future. During the inspection, it was identified that 3 staff had commenced working at the home within the last 4/5 weeks, without POVA First or Criminal Record Bureau (CRB) checks being undertaken. Clearly, this is putting service users at risk and an Immediate Requirement Notice was issued instructing the home to immediately obtain the necessary checks. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The standard of décor and furnishings/fittings within the home was good, providing residents with a safe, comfortable and well-maintained environment. The staffs’ good hygienic practices together with effective laundry equipment ensured that spread of infection was reduced as far as possible. EVIDENCE: The home had been well maintained both internally and externally and a handyman was employed to undertake all minor jobs and repairs within the home. A record was kept of all work undertaken. More specialist contractors such as plumbers and electricians were contactable to respond to requests within 24 hours. Since the last inspection, a 9-bedded unit had been opened on the second floor of the home. The unit had been well furnished and fitted with en-suite toilet facilities in each of the bedrooms. Some shortfalls in furniture were identified at the site visit undertaken on 17 June 2005 and these had not been addressed i.e. not all rooms contained 2 comfortable chairs and bedside lamps. There was no shower curtain or screen fitted and a cupboard had not been fitted in the activities room. Given the activities room will be accessed by service users Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 17 living on this floor, to give them a choice of sitting area, this must be addressed and a fire release stopper fitted in order the door may remain open, to encourage residents to use it. The Greater Manchester Council Fire Service had approved the second floor unit, prior to it opening. All stairways and exits were fitted with keypads for residents’ safety. At the last inspection, it was identified that carpets in bedrooms 4, 32 and 33 were replaced. This had not been done. Two separate safe outdoor areas were provided for the residents, one accessed via the conservatory doors and the other from the front door. The front area was well used by several residents throughout the inspection with the front door being left open so that residents could wander freely outside, independent of staff. Railings and a safety gate had been fitted so that residents were not able to access the car parking area. CCTV cameras were restricted to the entrance area only for security purposes. Relatives interviewed commented on the consistently good standard of cleanliness throughout the home “at whatever time they visit” and that the home “was always free from unpleasant odours”. A domestic was employed to work on each of the floors and from discussion, it was clear that this was working well. Laundry facilities were sited away from bedrooms and 2 industrial washers and 2 dryers were provided. The washing machines had a sluice programme. The laundry personnel were responsible for collecting, washing and re-distributing all laundry. Appropriate colour coded laundry bags and protective clothing were in use for this service. Liquid soap and paper towels were supplied in bathrooms/toilets and bedrooms for staff to use. During the inspection, staff were seen practicing good hygienic practices when assisting residents with personal care tasks i.e. the wearing of disposable gloves and aprons, washing their hands etc. They also used blue disposable aprons when assisting residents with their meals. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Night staffing levels were not always sufficient to meet the needs of the resident group. Some shortfalls in the home’s practice of recruiting staff could place residents at risk. Many staff had not undertaken the required training, which could place residents at risk. EVIDENCE: It was impossible to determine whether staffing levels were appropriate for the number of residents currently living at the home, as the staff rota for the week of the inspection and the week prior, were inaccurate. The staff rota is part of the legal records required to be kept within the home and must be an up to date accurate account of staff hours. The manager faxed an accurate rota to the Commission for Social Care Inspection, the day following the inspection and from this rota it was clear that for the week of the inspection, there were sufficient day staffing hours to meet the needs of the residents currently being accommodated. From the night rotas, it was identified that over the last two weeks, there have been 5 occasions when only 4 staff have been on duty from 20.00 – 08.00. Given the dependency level of residents and the fact that bedrooms are situated on each level of the home, 5 staff must be on duty each night. There was always a senior care assistant on night duty. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 19 The new unit, which currently accommodates 7 residents, was staffed by one senior care assistant, with assistance at peak times, by another carer. From the rota, it could not be identified which carer was on duty on the 2nd floor unit but this was addressed the day following the inspection, when an amended rota was faxed to the CSCI office. On the day of inspection, a senior carer was on duty, who was unfamiliar with the residents and did not know all their likes and dislikes. In order to ensure continuity of care for these residents, consideration should be given to making sure that the same staff cover is provided when the identified senior carer for the unit is off duty or on annual leave. When the unit is full with 9 people, two staff must be on duty during the day at all times. From attending the staff meeting and discussion with staff, it was determined that staff morale was low. This was said to be mainly due to having to work additional hours, on a regular basis, covering for staff vacancies and sickness and staff were particularly aggrieved when colleagues failed to turn up for work, without notice, on a regular basis. The new manager was currently addressing staff morale and had already taken action to recruit two new care assistants who were to start work following appropriate checks being made. From discussions between the staff and manager at the team meeting, it was clear the new manager was identifying areas, which needed to be addressed, in order to make sure the residents’ care was prioritised. The administrator clearly played a large part in supporting residents, not only with office matters but also by making cups of tea, comforting residents when they were distressed and assisting them to different areas of the home. She had worked at the home since it opened and had good relationships with all of the residents. From checking 4 files for the most recently recruited staff, several shortfalls were identified namely: not all contained photographs; some application forms had gaps in employment histories which had not been explored; date of commencement of employment was not identified; staff had not been issued with copies of the General Social Care Council “Code of Conduct”; no induction training records were in place; CRB/POVA First checks had not been undertaken for 3 staff. The manager must ensure that staff files contain all the required information. It was of concern that staff were starting work before POVA First/Criminal Record Bureau checks had been received. An Immediate Requirement Notice was issued during the inspection in connection with this bad practice. When new staff start work, they must undertake induction and foundation training which is to the TOPSS specification. None of the files contained any evidence of staff even receiving the very basic first days induction training. Action must be taken to address this shortfall. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 20 One staff had completed NVQ level 3 training, 1 had completed level 2 and 4 had almost completed their NVQ level 2 awards. At least a further 5 staff were due to register for NVQ level 2 training in September 2005. From checking staff personnel files, not all contained up to date training records. All staff should have a training and development assessment and profile and copy certificates must also be held on file. Following the inspection, a fax was sent to the CSCI office setting out what training staff had received. From this information, it was clear that staff had not received all the required training. From a day/night staff team of 25, 3 had completed first aid, 11 had done fire training, 10 food hygiene, 5 medication, 8 infection control and 5 care skills. There was an absence of moving/handling training. Some of the staff employed had not done any training since they started work. All staff should receive a minimum of 3 days training per year and all health and safety related training must be undertaken. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 38 The new manager had made a good start at addressing problem areas within the home in order to ensure residents best interests were promoted. Effective financial systems were in place to safeguard residents’ interests. Maintenance of equipment was up to date but not all staff had received relevant health and safety training, which could result in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Since the last inspection, a new manager had been appointed. Her application to be formally approved by the CSCI, had been submitted and was currently being processed. She had been in post for approximately 4 weeks and was undertaking formal induction training. The project manager of the organisation was providing support during this period. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 22 Since appointment, she had held 2 staff meetings and also sent out a letter to all relatives/advocates, asking they make an appointment to review the care plans for the person they visited. In order to observe and check out care practices, she was working on the floor, alongside staff, for some periods during her shifts and was alternating between the 2 units. She was also seeking out appropriate training courses in order to ensure her identified training needs would be met. The administrator, who had worked at Heywood Court since it opened, was responsible for the residents’ finances. Written records and receipts were in place for all financial transactions and upon request, individual accounts could be accessed by computer. Service user accounts were audited on a regular basis and the manager was not appointee for any service users. Relatives/advocates were responsible for the handling and investing of service users money. Small amounts of money were held in house in order staff could purchase any necessary items between relative visits. Secure facilities were provided for the safe keeping of money and valuables and receipts were issued for items held. During the inspection, one resident, who was clearly distressed about the whereabouts of her jewellery, was spoken to sensitively by the administrator who patiently explained and showed her where her jewellery was being kept. A health and safety policy was in place and condensed versions of some health & safety policies were contained in the Staff Handbook, which was issued to each new employee. The handy man had responsibility to ensure that all equipment and testing within the home was maintained on a regular basis and the records inspected were satisfactory. Shortfalls in health and safety staff training i.e. moving/handling, first aid, food hygiene, infection control and fire for staff are identified above. The manager must ensure that staff training is prioritised. Accidents were being appropriately recorded in the accident book. The home had not however, transferred accident recordings to the new system whereby individual records of accidents were held on each persons file for confidential purposes. The manager should ensure an updated accident recording pad is utilised. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 x x x 3 x x 2 Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 24 YES 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 3 Regulation 14 Requirement A pre-admission assessment must be undertaken for all new residents, to ensure the home can meet their needs. Care plans must accurately record the individuals needs and be reviewed and updated monthly. All staff, responsible for the administration of medication, must receive appropriate training. Staff must not be employed before a satisfactory POVA First/CRB check have been received. (Immediate requirement notice issued) All shortfalls in the report must be addressed with regard to the second floor accommodation and carpets in rooms 4, 32 and 33 be replaced (previous timescale for replacing carpets of 31.03.05 not met). Five night staff must be on duty. The staff rota must accurately reflect the hours worked by the staff. Staff files must contain photographs, fully completed application forms, date of F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Timescale for action 31.10.05 2. 7 15 31.10.05 3. 9 18 31.10.05 4. 18 & 29 19 Immediate 5. 19 16 31.10.05 6. 7. 8. 27 27 29 18 17 17 30.09.05 25.08.05 31.10.05 Heywood Court Version 1.40 Page 25 commencement of employment. 9. 30 18 Induction and foundation training to TOPSS specification must be undertaken by all new staff. All staff must undertake all identified health and safety training i.e. moving/handling, fire, first aid, infection control and food hygiene. 31.10.05 10. 30 18 31.12.05 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. 7. 8. 9. 10. Refer to Standard 7 7 12 27 27 29 30 30 38 19 Good Practice Recommendations Personal care records on each resident should be completed on a daily basis. A key-worker/Co-keyworker system should be set up so that residents receive consistent care. An activities programme should be displayed within the home and details of activities undertaken be recorded on the individuals files. A key-worker/Co-key-worker system should be introduced. Service users on the 2nd floor unit should be cared for by the same team of staff in order they get to know and trust them. All staff should receive a copy of the General Social Care Council Code of Conduct. Staff files should contain up to date training records together with copy certificates. All staff should receive a minimum of 3 days training per year. A new accident book with tear off pages should be purchased in order to ensure resident confidentiality. A sign depicting the 2nd floor shower/toilet should be fitted on the door. Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 26 Commission for Social Care Inspection Turton Suite, Paragon Business Park, Chorley New Road, Horwich, Bolton, BL6 6HG. National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heywood Court F06 F56 S49296 Heywood Court V230381 Stage 4 24.08.05.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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