Inspection on 10/07/07 for The Heathers

This inspection was carried out on 10th July 2007.

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

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

Other inspections for this house

The Heathers 30/11/06

The Heathers 15/11/05

The Heathers 13/04/05

The Heathers 29/11/04

The Heathers 07/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Heathers 50 Beccles Road Bradwell Gt Yarmouth Norfolk NR31 8DQ Lead Inspector Mrs Susan Golphin Unannounced Inspection 10th July 2007 09:30 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 The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Heathers Address 50 Beccles Road Bradwell Gt Yarmouth Norfolk NR31 8DQ 01493 652944 F/P01493 652944 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) Mrs Shereen Arunthathi Jesudason Miss Carol Ann Preston Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. From time to time a maximum of two (2) service users between the age of 50 and 65 years may be admitted to the home. Forty-five (45) service users may be accommodated of either sex who are aged over 65 years. The total number not to exceed 45. Date of last inspection 30th November 2006 Brief Description of the Service: The Heathers is a single storey extended property situated in the village of Bradwell, on the outskirts of Great Yarmouth. 45 older people can be accommodated in 21 double rooms (11 en-suite) and 3 single rooms (1 ensuite). A new 13 bed extension has recently been added to the property and will be commissioned in August 2007. Most of the bedrooms open out on to a patio area and garden which is mainly laid to lawn with small flower beds and attractive containers arranged on the patios. In addition there are three communal rooms including a dining room which service users and their families can access. There is ample off street parking space to the front of the premises. The fees range from £325 to £510 per week. There are additional charges for personal toilet requisites, newspapers, hairdressing and chiropody services. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers the service to people. The key inspection has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. The key inspection took place over 7.5 hours on the 10th July 2007. A brief tour of the premises was undertaken as well as looking at records and procedures and talking to staff and residents about the service the home provides. Eight comment cards from residents and seven from relatives out of a total of twenty five were returned to the Commission. Overall the survey showed that residents and relatives are satisfied with the service and one comment card personally praised managers and staff for their attention and care. Two relatives raised concerns about residents’ use of the call bell system, especially those with limited understanding and awareness and one said that they would like a contact member of staff so that they can share any worries they might have about their relatives care. The information from the comment cards was fed back to the management group for their attention. Residents said that they are very happy with the care and support they receive. One resident raised some issues around their personal care and these were addressed on the day with the senior staff. The manager provided pre inspection information using the new Annual Quality Assurance Self Assessment form. It was agreed that the information provided through the form was detailed and provided evidence of progress and development within the service in the last year. What the service does well: Good information about the home and the service provision is available to prospective service users. People visiting the home confirmed that they are made welcome and that staff are helpful and friendly when they visit the home. The management and staff liaise with other health care professionals to gain advice and share professional experiences and skills. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 6 There is evidence that relevant training courses are available for all staff including NVQ training. 50 of the staff have achieved NVQ qualification at level 2 or above. A full assessment need for all new service users is carried out prior to admission, and pre admission visits are encouraged and welcomed by the staff. Residents individual healthcare needs are consistently met by the staff and management. The home is well equipped and furnished to meet the assessed needs of residents. There are good system in place for recording and monitoring complaints. What has improved since the last inspection? What they could do better: The management could implement a QA system that seeks the views of residents, staff and other health care professionals and collate the survey details and publish the results and outcomes and action. Management could promote meetings with relatives and staff to improve levels of communication. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 7 A review of record keeping procedures could be undertaken to ensure documents are appropriately dated, and care reviews are detailed and reflect changes in care, and practice to safeguard risks. The call bell system could be reviewed to ensure those unable to call for assistance because of limited understanding or mobility are monitored appropriately and a record maintained. Management could ensure relatives are given the opportunity to meet with nurses and care staff on a regular basis to discuss individual care of residents so that they are reassured about their relative’s care and progress. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 8 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 The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3,6 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People using this service can currently access detailed information about the home that will assist them to make an informed choice about where they wish to live. Good assessment processes are in place and new residents are only admitted to the home on the basis of a full assessment of need to ensure their individual needs can be met. There is no separate rehabilitation service provision in this home. EVIDENCE: The home provides prospective residents with a general brochure about the service and the home. The brochure has recently been re issued and provides a brief summary of what is provided and invites prospective clients to visit or contact the home for more information. Residents spoken to on the day said that they were given information about the home before they moved in. One relative said that the staff had been ‘very helpful and honest about the details The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 10 of the service and that they had not been disappointed once their relative had moved in to the home’. The home has a good pre admission format and both the Manager and Deputy Manager carry out pre admission assessments. Five files were seen during the course of the inspection and the information about the need healthcare needs for each person were stated and in place. Risk assessments had also been completed in respect of individual risks. The home does not have a separate intermediate service, but does provide respite care as part of supporting people in the community and as an introduction to longer term care. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. There is evidence to show that residents receive good standards of care based on their assessment of need and care plans including good medication procedures and provision. Residents are treated in a dignified way and their personal wishes and choices respected. EVIDENCE: The deputy manager confirmed that the care plans are being reviewed each month including a completed risk assessment. Five care plans were seen during the course of the day and each offered a brief picture of the person and their healthcare needs. The reviews are being carried out by three different members of the nursing team. Some of the reviews lack depth and clarity of detail and need to be audited to ensure consistency of style and input. There is some evidence that residents or their relatives are involved in the process, but not all of those seen contained the views or comments from the resident or their representative. Relatives can access nursing staff and the administrator of the home for updates on their relative’s care when they visit. The The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 12 opportunity to share concerns or discuss progress through a relatives/residents meetings would be reassuring for relatives. See recommendation Fifteen comment cards from residents and relatives were received by the CSCI out of the twenty five sent. Overall the comments are positive about the service and include personal thanks and appreciation expressed by relatives to individual care staff and nurses. Less positive comments raised included concerns about general monitoring and attention to residents with limited understanding and who are unable to call for assistance through the normal call bell route. Other comments from the cards asked about the management and the prevention of cross infection. (See standard 26) All the comments were passed directly to the registered provider and the manager for their attention. Staff spoken to on the day of the inspection expressed some concerns about the staffing levels at crucial times of the day because the current resident group is so dependent on staff for their complete care. The management were able to reassure the staff that the management are aware of the staff pressures of work and additional staff are being recruited to meet that growing need. See recommendation Three residents are receiving wound care treatment and the records and monitoring of the treatments show that they are responding well. Wound care practice is audited each week and advice or guidance is sought from external health care / and medical support where appropriate to promote good mobility and skin tone. One resident said that the staff are ‘always helpful and attend to their needs as quickly as possible’. Another said ‘sometimes the staff are a bit rushed at times and would like it if they could do things with more care and attention’. Another resident said that ‘all their care needs are met and that they would not want to live anywhere else’. One relative visiting at the time of the inspection spoke highly of the service they and their relative receive and also the friendliness and kindness of staff and management, adding that ‘they are very pleased with the service and care’ .One resident said that the quality of service has been steadily improving over the years and the staff are ‘much better at looking after people here’. Another resident who had raised some concerns about her personal care through the comment card said that ‘she brought these matters to the attention of the management because she wanted her care and her home life to be as good as it would be if she were still in her own home’ All the residents spoken to on the day said that the staff treat them with respect and are always considerate and kind. During the discussions with the management it was acknowledged that the staff team are more stable and are continuing to improve their approach to ensure they achieve a good standard of care. Specialist equipment is being installed and replaced where appropriate and this year two additional stand aid The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 13 hoists have been purchased as well as three new ‘profile’ beds and three electric beds that move in various ways through a pump action process to ensure even pressure, promote circulation and improve and maintain a good skin tone for those who may be confined to bed. There has recently been a revue of the administration and management of medication for the home. There is a dedicated room, which is secure and well maintained. A random check on three of the residents medical administration records was made as well as the recording of and the storage for controlled drugs; they were found to be in good order and up to date. The deputy Manager for the home has recently changed the routine ordering process for residents medication which provides additional safeguards to ensure medication is replaced on a timely basis avoiding over ordering and reducing the possibility that a prescribed medication may ‘run out’. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The majority of social and recreational activities provided at this home meet the needs and expectations of the residents. Residents are encouraged to maintain family and community contacts as far as they are able. Residents are offered a varied and well balanced diet. EVIDENCE: There are three or four regular activities or social stimulation for residents in place each week. There is a dedicated member of staff who takes responsibility for ensuring there is a planned programme in place. A list for the each month is printed out and issued to residents so that they can decide which activity they may like to join. The list also includes the dates and times of the hairdressers visits. Staff spoken to on the day confirmed that they do try to give some personal time with residents other than when they are providing support or care. During the discussions it was said that local outings are also arranged on a regular basis. The trips are short because residents have said this is what they prefer and people go in small groups of four each allocated with a carer. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 15 It was also said that arranging more detailed trips of interest or outings further a field this year have met with a poor response. Residents spoken to on the day said that they enjoy the in-house entertainments most, especially the musical ones and of course the regular bingo sessions. The menu is distributed each week to each resident’s room. The daily menu is also displayed on a chalk- board. Residents spoken to on the day could not remember what they had ordered for lunch with the exception of one resident who has special dietary requirements and her menu for the week had been marked with the choices she had made. Residents and one visitor said that they thought the meals and choices available to them were varied and appetising. One resident said that there are occasions when the food is not hot enough, especially the vegetables. The housekeeper was contacted regarding this matter on the day and it was agreed that the meals will be monitored to ensure they are served at the appropriate temperature. The registered provider also confirmed that a new heated trolley has been purchased to improve the distribution of meals. See recommendation. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People who use the service are aware of the homes complaints procedure and are confident that any concerns about the service will be dealt with. The staff receive training which helps them to recognise and respond appropriately to allegations of abuse. EVIDENCE: No formal complaints about have been received about the service in the last year. From the comment cards received relatives and staff said that they are aware of the complaints process for the home and also who to contact with any issues. Only one resident said that they were not clear about who to contact with concerns and on a previous occasion had been given different names and found it confusing. This issue was dealt with on the day of the inspection and the resident has now been given a contact name at the home they can get in touch with and who will deal with their queries directly. The home maintains a complaints and compliments file. Minor issues relating to individual residents or their care are recorded in the relevant resident’s files. See recommendation. The home uses an independent agency to deal with all their Criminal Records Bureau disclosures and Protecting Vulnerable Adults enquiries. Staff also attend training sessions to promote their knowledge and understanding on the protection of vulnerable people. The information about training is maintained in The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 17 each of the staff evidence of learning files, but there is no date to indicate when the training has taken place. See recommendation. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20,22,26 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The home provides a comfortable, safe environment that suits the needs and wishes of the residents. EVIDENCE: The environment standards in the home continue to improve. The new extension to the building is nearing completion and is due to be commissioned in August 2007. The extension comprises of thirteen single rooms en-suite with full shower facilities. There is a separate sitting and dining room and an assisted bathroom. There is also additional storage space being created. The new communal rooms look out on to the landscape garden and paths. Attractive patio areas are also being laid complimented by flowerbeds. Once the extension is in use the smaller double rooms will be used for single occupancy. These rooms currently offer very limited space and the reduction to single occupancy will improve and enhance the personal space for many of The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 19 the residents. The overall number of residents that can be accommodated in the home will not change. In the last year new equipment has been purchased to assist staff to move residents safely. They include stand aids and hoists and special beds to replace old ones. They are equipped with ‘profile’ mattresses to provide good support for those residents confined to bed. The communal areas and corridors in the main building are well maintained and appropriately furnished and equipped. New laundry equipment has been installed this year and the laundry area resited. Although not ideal it frees up the access area to the corridor and is a safer option. The staff are continuing to follow the programme of continence management which was set up last year. This ensures that soiled materials are confined to each room until removed in closed containers to the laundry. This practice minimises the problems of possible odours and cross infection. The staff receive training in infection control and the home also have annual visits by the Community Nurse (infection control). One comment card said that the hygiene practices in the home are excellent. The manager confirmed that bed rails and frames are disinfected weekly or when the bed linen is routinely changed. The current call system in the home is being updated. The system has three stages and can indicate when staff attending the call may need added staff assistance. From the comment cards received both from relatives and residents some concerns were raised about those residents who may not be able to access a wall mounted call bell, and should be able to access either a pendant or portable call bell to summon assistance as needed. The manager confirmed that residents confined to bed can be provided with extension call bells which attach to clothing or bed linen. See recommendation. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28, 29,30 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. The staff have good knowledge of the residents needs and receive formal training to promote and improve consistent care standards. Robust recruitment and selection processes help to protect residents. EVIDENCE: Residents and relatives stated in the fourteen comment cards received by the CSCI that they are generally satisfied with the service provided. However, four of the comment cards returned from relatives did not think there are enough care and domestic staff on duty at times especially in the evenings. During the discussions with staff it was said that ‘things have improved’ meaning that there are better working relationships and there is more stability within the staff group. The Deputy Manager is establishing protocols for monitoring the staff skills and abilities as part of the ongoing training and supervision processes. It is acknowledged that there is work to do in ensuring the staff have good levels of communication and understanding with residents especially those with limited awareness of their own needs. During the discussions with staff, one said that the workload could be heavy at times especially in the evenings because most residents needed two staff to help them at all times. A review of the staffing levels for the home is being The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 21 monitored and additional staff have recently been recruited to work in the evenings and also to act as additional staff able to cover for sudden absences and leave. Residents seen on the day said that the staff ‘are very good and helpful them ’ and ‘ are always kind ‘One resident and one visitor gave good examples of individual kindness and help shown to them by staff. One relative writing in the comment card for a resident said that during a recent illness they had found the staff of the home very supportive and caring and ‘could not have been better cared for’. Four staff files were seen on the day of the inspection and are well maintained. There is evidence of good recruitment and selection procedures, including identity and Criminal Records Bureau checks. Information relating to staff Criminal Records Bureau disclosures is maintained in a separate and confidential file. Details relating to CRB checks and staff suitability for care work is obtained through an independent agency. There is evidence to show that regular training for staff is in place and in the last year staff have attended courses on Moving and Handling (14), Nutrition and Health (14) Fire Training,(40) Dementia Awareness,(14) Palliative Care (16) Equality and Diversity (12) however the date of the training is not recorded and this needs to be remedied. See recommendation. 50 of the care staff have an NVQ level 2 or above. In addition there are two level 1 nurses and a midwife and a student nurse employed as carers in the home providing additional skills and knowledge. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,38 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. There is an open and approachable management group in place and the managerial and supervision process in place promote good practice. The quality assurance and monitoring system in place is not being used to reflect the views of those using the service. The financial interests of the residents are safeguarded by good practices and procedures. Formal staff supervision procedures are now in place to promote consistency of care and maintain good standards. The health and safety of residents is protected by good procedures. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 23 EVIDENCE: There is a robust management structure in place for the home. The registered provider attends the home on a daily basis, whilst the registered manager and deputy manager work directly with the nursing and care staff to monitor practice and service standards. The deputy manager works all shifts so that staff on duty in the evenings and weekends can be monitored and also have access to senior staff for support and guidance. This practice is to be commended. From the discussions with staff it was confirmed that the working relationships with their supervisors is good and continues to improve. The deputy manager said that there are still some areas of practice that need to be monitored to establish consistency of care and promote staff confidence and competency. Formal staff supervision is now in place and is the responsibility of the registered manager and the deputy manager, and the housekeeper will undertake to supervise the ancillary and domestic staff. All those with a responsibility for supervising staff have attended a one day training course this year. A small sample of the supervision records being carried out by the deputy manager were seen on the day The process in use is clear and offers staff the opportunity to discuss their own progress and development and training needs. This standard was the subject of a requirement at the last inspection. This requirement has now been met. The last quality assurance survey for the home was sent out to residents and relatives in May 2007, a small number of surveys have been returned to the home, but have not been collated as yet or the information analysed. The surveys are not dated and it is not clear to those completing the forms when the deadline is, or when the information will be reviewed and the outcomes and results published. Two of the returned surveys signed by those completing the form, contain information relating to minor concerns that do not appear to have been acknowledged. The survey process needs to be reviewed and its purpose re-assessed to ensure that it is an effective monitoring tool that measures the success of meeting the aims and objectives of the home The survey should be extended to the staff and other health care professionals attending the home. The outcomes of the survey should be collated and the results and any planned action published or /and displayed in the home or the bi annual news- letter. See requirement Regular staff meetings and open meetings with residents and relatives would promote a more open style of information sharing and improve communications at every level. During the inspection staff and visitors said that updates or regular meetings on the management of and future plans for the home would be reassuring. See recommendation. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 24 There is a fulltime administrator who deals with initial enquiries and assists relatives and residents with administrative matters. The management do not involve themselves in resident’s financial affairs however they do hold and administer small amounts of personal allowance on behalf of residents. A separate record and cash wallet for each person is maintained. Two signatures are required for any expenditure or debit or credit transaction, and receipts are obtained to verify purchases. Building and equipment and safety records are in place and well maintained. A maintenance file is kept in date order. Aids and adaptations have been serviced and safety checks carried out on the equipment. Gas and boiler records and services have also been carried out and the records in place. The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 3 The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24 Requirement The registered providers are required to review and reassess the purpose of the quality assurance process to ensure the process seeks the views of residents relatives and others who use the service and the outcomes of the annual review are collated acted upon and made available in a documented form. Timescale for action 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the care planning reviews processes are audited to ensure there is consistency in the reviewing and that relatives and residents are involved in the process and this is indicated in the review summary. It is recommended that staffing levels reflect residents dependency at all times especially at crucial times of the day. DS0000015646.V346643.R01.S.doc Version 5.2 Page 27 2 OP8 The Heathers 3 OP15 It is recommended that the delivery of meals is audited to ensure they are maintained and served at the right temperature and meet residents personal choices. It is recommended that residents are provided with the opportunity to meet with each other and staff and management on a regular basis to raise any issues or concerns about their home life and care. It is recommended that staff training details relating to the protection of vulnerable people should be dated and review/ refresher dates indicated. It is recommended that staff regularly check that residents with limited mobility or awareness are provided with means by which they can summon staff assistance when required or the agreed monitoring process is documented in the daily care records. It is recommended that all evidence of learning and training documentation for staff is appropriately dated and refresher courses or renewal certificate dates recorded . 4 OP16 5 OP18 6 OP22 7 OP30 The Heathers DS0000015646.V346643.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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