Inspection on 23/01/06 for Heywood Court Care Centre

This inspection was carried out on 23rd January 2006.

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

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

Other inspections for this house

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 23/08/05

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 Care Centre Green Lane Heywood Rochdale Lancs OL10 1NQ Lead Inspector Jenny Andrew Unannounced Inspection 23rd January 2006 07:00 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 Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 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. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Heywood Court Care Centre Address Green Lane Heywood Rochdale Lancs OL10 1NQ 01706 361900 01706 361944 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) Southern Cross Care Homes No 2 Limited Miss Jacqueline Paul Care Home 36 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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) The service should employ a suitably qualified and experienced Manager who is registered by the Commission for Social Care Inspection. 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. 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. 23rd August 2005 4. Date of last inspection 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 Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection, the registered manager had left and a new person had been appointed to take over as the home’s manager. This person had been deputising, having transferred from another dementia care home. This unannounced inspection took place over one full day with the Inspector arriving at the home at 07.00 to speak with the night staff. Extra visits had been made to the home in December and early January to check whether the home had done all the things they needed to do from the last inspection. In addition two more visits in October and December had been made to investigate two complaints. The Inspector looked around the building, checked care plans and some records. In order to get information about the home, the manager, operations manager, 6 residents, 7 relatives, the cook, 1 night and 3 day care assistants and the activity worker were spoken to. 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? The atmosphere in the home was calmer and staff were encouraging residents to use more of the lounges, rather than wandering around the front hallway. On most days, two lunchtime sittings were arranged so that the staff could spend time with the residents who needed more help to eat their meals. The manager was looking at ways of making sure the residents did not lose weight. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 6 The residents on the top floor unit were being cared for by the same staff, which meant they knew the residents needs much better. Team work had improved and the staff felt the new manager listened to them and knew a lot about the needs of people with dementia. All the right checks were now being made before staff started work so that the residents would be protected. 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 Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 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 Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 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): 4 Not all the staff working at the home had the skills and expertise required to ensure the needs of the residents were being met. EVIDENCE: Whilst standard 1 was not inspected on this visit, it was identified that the Statement of Purpose and Service User Guide had recently been revised and copies of each document must be forwarded to the CSCI Horwich office. A new manager had been appointed who was a trained nurse with a lot of experience in looking after people with dementia. She had only worked at the home for approximately 5 weeks but was already looking at improving care practice. Feedback from relatives interviewed was extremely positive about the care and support given to the people they visited. However from training records seen, it was noted that although it is a condition of the home’s registration that all staff receive dementia care training, only 5 people had received such training. A further 4 had been identified as needing the training but no date had been set. One of the carers spoken to had had no previous experience of this client Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 9 group before coming to work at the home and had not received any specialist training. In order that all staff have the skills and expertise to look after the present client group, action must be taken to ensure they all receive appropriate dementia care and awareness training. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 Whilst the care planning format is comprehensive, not all residents had a detailed care plan in place, which meant that staff did not have the information they needed to be able to care properly for the residents. The medication policies and procedures are clear but there is inconsistent implementation, resulting in some unsafe practices. Relative feedback and observations made indicated personal support is offered in such a way as to promote residents’ privacy, dignity and independence. EVIDENCE: Three care plans were inspected at random, one from each of the three floors. One care plan, for a resident who had moved in around September 2005 was incomplete as only risk assessments were in place. The care plan, social profile and life history were missing. The operations manager said the original care plan must have gone missing when the care planning documentation was being changed to the format issued by Southern Cross Healthcare. Another file, for a resident admitted 5 days before the inspection, did not contain a detailed care plan, even though the risk assessments showed the resident was at high risk with regard to skin, nutrition and falls. The third care plan was Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 11 detailed but where it showed fairly significant weight loss, the care plan did not state what action was being taken to address this concern. Whilst risk assessments on the file were up to date, the care plan had not been evaluated since 16 November 2005. All care plans should be reviewed and updated on at least a monthly basis. From speaking to the operations manager and newly appointed manager, it was clear that action to address the identified above shortfalls had already been discussed. Minutes from a recently held staff meeting, showed that the importance of care plans had been reinforced to the staff and the recently formulated action plan for the home also addressed the need for care plans to be audited by 31 January 2006. Senior care staff had received some training in the completion of care plans but further staff training, was being arranged. None of the files inspected showed that residents and/or their relatives had been included in the care planning process although where bedsides were in use, the written consent of the relative had been obtained. Good practice was noted where staff were including relatives feedback comments on new sheets, recently introduced. Two of the files inspected did not contain photographs of the residents and this must be addressed. Appropriate, completed and up to date risk assessments were in place in each of the files inspected. Whilst the organisation had detailed medication policies/procedures in place, they were not always being adhered to. The systems in place for the receipt, recording, administration and disposal of medication were found lacking. Medication was observed being given out on the morning of the inspection and on one occasion, the trolley was left opened and unattended by a senior care assistant who was taking drugs to a resident who was in her bedroom. Whilst medication sheets with printed times and doses of medication are supplied by the pharmacist, one persons medication administration record was altered by the person giving out the medication as it was said to be incorrect. This error should have been identified when the drugs were checked in and been notified to the pharmacist. Both the regional and home manager said they had been experiencing a lot of problems with the supplying pharmacy who had not been fulfilling their contractual obligations. They were therefore in the process of changing to the Boots monitored dosage system. The amount of medication waiting to be returned to the pharmacy was excessive. Whilst a drugs return sheet had been completed up to the end of December 2005, a large amount of medication had not been so recorded and Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 12 was stacked in boxes in the medication room. This is extremely unsafe practice and an immediate requirement notice was issued to the manager for a full stock take to be undertaken, with the supplying pharmacist so that all drugs could be accounted for and immediately returned. Control drugs were checked and the correct policies/procedures were being followed. Senior staff responsible for the administration of medication had received training. However, in view of the identified problems, the manager should consider offering further training to the senior staff team. Good practice was observed throughout the inspection in respect of the way staff made sure they were observing residents rights to privacy and dignity. They were also able to describe what they did, when assisting residents with their daily routines, to make sure residents were treated with respect and dignity. Staff knocked on bedroom doors before entering, they locked toilet doors when assisting residents or stood outside if this was preferred, made sure residents hair was brushed and combed and when residents were inappropriately dressed, they were taken to the toilet or their rooms for assistance. A visiting chiropodist was shown to one of the empty conservatories so that some degree of privacy was maintained, as he did not have the time to wait for each person to be taken to their bedrooms. The manager said she was spending a lot of time working alongside staff, so that she could monitor and improve care practice. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Provision of leisure activities and social stimulation was inadequate, resulting in residents becoming bored and feeling unfulfilled. Contact with family and friends was promoted but community links need to be addressed so that all residents, irrespective of disability have the choice to go out into the local community. The dietary needs of residents were well catered for with a balanced and varied selection of food offered at each meal. EVIDENCE: The activity worker had only just returned from work after having been absent for several weeks. During her absence, very few activities had been organised as staff were kept busy looking after the residents personal care needs and did not have the time to spend one to one time with them. There was no planned programme of activities, although on the day of the inspection, residents in one lounge were seen to enjoy and benefit from throwing and catching bean bags and balls. In another lounge some residents were painting pictures. From discussion with staff and relatives and observations made, it was usual for the more able and independent residents to be included in such activities. The manager said she was presently Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 14 addressing the identified shortfalls by arranging regular supervision with the activity worker so that a programme, which met both individual and group needs, could be formulated. The home’s action plan also identified that the manager was arranging to visit another of the organisation’s centres to get ideas for ways of introducing more stimulation for residents. She had already organised two newspapers to be delivered to one resident, who enjoyed doing crosswords. Whilst trips out to other homes and places of interest had been organised last year, no planned events had been formulated for this year. Feedback from the relatives indicated how much residents had enjoyed the outings and that they hoped these would be arranged for this year. Some of the residents had even been away on a holiday last year, organised by a previous manager. Relative feedback was good with regard to how the staff kept them up to date and involved in the care of the person they visited. They said they could visit at any time of the day/night and were always made welcome. The corporate statement of purpose also refers to arrangements for consultation with relatives and that the home has an “open door” policy. The manager also holds a weekly “surgery” out of hours, to give relatives an opportunity to meet privately with her. Since the manager’s appointment a relatives meeting has been held with others being planned on a monthly basis. Four weekly rotational menus were in place, which showed that a varied and nutritious diet was being offered to the residents. They were given choices at each meal with lunch being the main meal of the day. The cook made enough of each of the meals at lunchtime, so that residents could choose to have either meal. Staff were observed showing residents the food, plated up, so they could see what was being offered and have a real choice. Second helpings were offered to the residents with a larger appetite. Liquidised food was done in individual portions in order to retain texture, flavour and appearance. On the day of inspection, the chef due to be on duty had rung in sick and the second chef had been contacted early that morning to see if he could cover on his day off. He arrived during breakfast and managed to stick to the planned menu for that day. The choice was pork casserole or baked fish with parsley sauce. The Inspector sampled the pork, which was very tender and extremely tasty. Any known food allergies are noted on the kitchen notice board and the chef was aware of residents who needed special diets. He said he was going to make a birthday cake that day as all birthdays were celebrated with a cake and buffet tea. Sufficient drinks were offered throughout the day, with staff being watchful to make sure that they had enough to drink. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Effective systems were in place with regard to the investigation of complaints, ensuring that residents and/or their relatives are listened to and protected. EVIDENCE: The complaints procedure is displayed within the home and is also included in the Statement of Purpose and Service User Guide. Relatives spoken to said they felt able to speak to the staff and/or manager if they were dissatisfied with anything and that they felt the problem would be addressed. The good practice of logging all complaints, irrespective of whether they were grumbles, was evidenced. Since the last inspection, 15 had been logged and appropriate action had been taken to address them. Since August 2005 when the home had last been inspected, the Commission for Social Care Inspection (CSCI), had had cause to investigate two complaints which had been directly received. These were in relation to medication (upheld), poor care practice (not upheld), management (partly upheld), shortage of staff (upheld) and lack of staff training (upheld). The home had taken action to address these although staff training was still an ongoing requirement. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed at the last inspection and none of the above standards were inspected on this occasion. EVIDENCE: Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28 Staffing levels were adequate but sickness levels and staff absences affected the capacity to meet the needs of residents to a consistent standard. Additional staff training was needed to ensure the staff were properly equipped to meet the needs of the residents in their care. EVIDENCE: After a period of considerable instability in staffing, there are signs that the situation has improved although due to care staff vacancies, agency staff are still having to be regularly utilised. Following a complaint about inadequate staffing, which was investigated in December 2005, the CSCI have been closely monitoring the staffing levels within the home. From checking the rotas and speaking to staff, residents and relatives, it was identified that adequate staffing levels are being maintained on all shifts. On the morning of the inspection however, the home had been let down by an agency who were unable to fulfil their request for 2 care assistants and the chef and another care assistant had rung in sick. Within an hour, arrangements had been made for another agency to supply two workers, the second Chef had been contacted and a worker from another home in the group, had also arrived to provide cover. During this initial period, the staff on duty, together with the administrator, manager and operations manager, worked well together as a team in order to ensure the needs of the residents were met under difficult conditions. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 18 The staff handover from night to day staff was detailed and equipped the day staff with the necessary information in order they could continue caring appropriately for the individual residents. Two of the night agency workers were spoken to and it was evident they were aware of the needs of the individual residents, having worked at the home on a regular basis. It was also noted they knew the names of several of the residents. The top floor unit is now staffed by the same care assistants, which meant that consistent care was being given. The residents were clearly benefiting from staff who knew their likes/dislikes and preferred routines. At the time of the inspection, the unit was not full and one care assistant only was on duty, which met the needs of the residents. However, it was noted that just prior to lunch time, residents were left unsupervised whilst the care assistant went down to the kitchen and waited for the meals to be plated up and put on the trolley. Also, when she was taking a break, there was no-one covering in her absence. A system must be set up whereby staff cover is provided at all times. Of the 20 care staff currently employed, only 3 had completed NVQ Level 2 training and one had successfully completed her NVQ level 3. Clearly the home need to address this shortfall of trained staff and ensure more are enrolled on the training within the very near future. The Inspector was aware that several trained staff had recently left and they had not been replaced by qualified staff. The manager was in the process of recruiting new staff and was still having to use agency until all vacancies had been filled. An outstanding requirement, from the last inspection, was for all staff to undertake mandatory training. The manager was in the process of auditing staffs training needs to check which staff still needed to receive the training. From records previously inspected, it was identified that many of the staff were still waiting to undertake training in food hygiene, moving/handling, first aid, infection control, health and safety and fire. Some of the staff had however, been booked on fire training on 23 February and food hygiene training on 17 February 2006. From speaking to staff, it was identified that problems in the past had been experienced with staff who had been booked on training courses having to cancel due to the home being short staffed. The manager said she would ensure this practice ceased. As identified in standard 4 above, as the home provides specialist care for people with dementia, all staff must receive appropriate training. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 33 Although the manager had only recently been appointed, she had already prioritised areas to address in connection with good care practice and management issues. Quality monitoring systems were in place but they were not always being implemented which could result in the home not being run in the best interests of the residents. EVIDENCE: The previous registered manager had left in December 2005 and the present manager had transferred from another of the group’s homes to act up during her absence. She had subsequently applied for the position and been successful. She is a registered general nurse who has undertaken conversion training to work with people with dementia. She has been in the caring profession for 34 years and was the deputy manager at the home she previously worked at. She did commence the Registered Manager’s Award last Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 20 year but did not complete it. She was however, willing to sort out the necessary arrangements so that she could finish this training, which is required for all registered managers. The operations manager said she would ensure that an application for the manager to be formerly approved by the CSCI would be submitted without delay. Staff interviewed confirmed that morale was better, especially since the new manager had come to work at the home. They felt she had a lot of knowledge and experience of the client group and also had the necessary skills to handle staff issues. Discussions with the manager and operations manager highlighted many management and care practice issues, which she had already prioritised and begun to address. Since her appointment, she has commenced staff supervision, had arranged for the falls co-ordinator to visit the home for advice, worked alongside staff in order to assess their practices and attitudes, had both staff and relative meetings and identified the need for care plans to be reviewed and updated more regularly. Practice issues currently being addressed were the labelling of all residents clothing, weight loss/food record charts being written, 2 sittings being introduced at lunch time, the removal of seating in the hallway to discourage residents from continually wandering around the entrance hall and looking at introducing more meaningful activities for the residents. A corporate quality monitoring and assurance system was in place but the audit tools were not always being utilised i.e. care planning audits. Regular visits to the home were being made by senior managers and the operations manager was spending a lot of time in the home, supporting the new manager through her induction process. Relative meetings had recently been introduced and staff meetings were taking place on a regular basis. Staff supervision had re-commenced but those interviewed had still not had supervision. The manager should consider delegating some responsibilities for staff supervision to the deputy manager. Whilst resident, relative and staff questionnaires have in the past been circulated, this has not been done for sometime. The operations manager said plans were in place for questionnaires to be formulated, which will be targeted at visiting professionals to the home i.e. Doctors, District Nurses and Social Workers. Although standard 38 was not inspected on this visit, it was identified, during the inspection, that on occasions, problems were being experienced with one or two of the more dependent and frail residents slipping down the satin type surface of the lounge chairs, sometimes falling on to the floor. In order to ensure the safety of the residents, non-slip chair covers or other appropriate means must be utilised to protect their safety. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 21 Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 22 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement Copies of the revised Statement of Purpose and Service User Guide must be sent to the Horwich CSCI office. All staff must receive dementia care and awareness training. Care plans must be in place for each resident and they must be reviewed and updated on at least a monthly basis. (Previous timescale of 31.10.05 not met). Each file must contain a photograph of the resident. The home’s policies/procedures must be adhered to for the handling, safekeeping and disposal of all medication. A full stock take with the pharmacist must be undertaken and all unused medication be immediately returned to the pharmacy. An activity programme must be formulated in full consultation with residents and/or their relatives, which meets both individual and group needs and abilities. The residents on the top floor DS0000049296.V278628.R01.S.doc Timescale for action 28/02/06 2. 3. OP4 OP7 18 15 31/03/06 31/03/06 4. 5. OP7 OP9 17 13 28/02/06 31/01/06 6. OP9 13 24/01/06 7. OP12 16 28/02/06 8. OP27 18 31/01/06 Page 24 Heywood Court Care Centre Version 5.1 9. 10. OP28 OP30 18 18 11. OP30 18 12. OP38 13 unit must not be left unsupervised at any time. A minimum of 50 of the staff team must be trained to NVQ Level 2. All staff must undertake all identified health and safety training i.e. moving/handling, fire, first aid, infection control and food hygiene. (Outstanding from last inspection). Induction and foundation training to the TOPSS specification must be undertaken by all new staff including those who have recently started. (Previous timescale of 31.10.05 not met). The manager must ensure the safety of the more dependent residents, who may have an accident from sliding from the lounge chairs. 30/07/06 31/03/05 31/03/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 3. 4. 5. Refer to Standard OP7 OP7 OP9 OP12 OP12 OP30 Good Practice Recommendations A key-worker, co-key-worker system should be set up so that residents receive consistent care. Care plans should be agreed and signed by the resident and/or relative. The manager should identify which members of staff require additional medication training and arrange appropriate training for them. An activities programme should be displayed within the home and details of activities undertaken be recorded on the individuals’ files. More trips out into the community should be arranged for the residents. All staff should receive a minimum of 3 days training per DS0000049296.V278628.R01.S.doc Version 5.1 Page 25 Heywood Court Care Centre 6. OP38 year. A new accident book with tear off pages should be purchased in order to ensure resident confidentiality. Heywood Court Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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 Care Centre DS0000049296.V278628.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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