Inspection on 13/06/08 for The Heathers

This inspection was carried out on 13th June 2008.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Heathers 10/03/10

The Heathers 08/12/09

The Heathers 11/12/08

The Heathers 13/06/07

The Heathers 16/06/06

The Heathers 15/11/05

The Heathers 09/06/05

The Heathers 08/03/05

The Heathers 21/09/04

The Heathers 19/03/04

Similar services:

Oakmount Hostel

Ark House

St Anne`s Alcohol Services - Leeds

Lynwode Park

Parkfield Rest Home

Priory Road

Elmhurst

Linwood Court

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 The Heathers 1 St Pauls Road Manningham Bradford West Yorkshire BD8 7LU Lead Inspector Steve Marsh Key Unannounced Inspection 13th June 2008 09:30 The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 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 DS0000001162.V366758.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 Adults 18-65. 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 DS0000001162.V366758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Heathers Address 1 St Pauls Road Manningham Bradford West Yorkshire BD8 7LU 01274 541040 P/F 01274 541040 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) Yorkshire Regency Health Care Ltd Vacant Post Care Home 29 Category(ies) of Past or present alcohol dependence (29) registration, with number of places The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: 2. Past or present alcohol dependence - Code A The maximum number of service users who can be accommodated is: 29 13th June 2007 Date of last inspection Brief Description of the Service: The Heathers is a care home, which does not provide nursing care. It is privately owned by Yorkshire Regency Health Care Limited. The company also have other care homes in the area. The Heathers is a detached adapted property located within walking distance of the city centre. It is close to local shops, a bus route and Lister Park. To the front of the building is a garden with a small car park. Bedroom accommodation is provided on the ground, first and second floors of the building. A passenger lift provides access to all areas. The home recently changed the category of people it is registered to care for and now only provides accommodation for twenty-nine people who have past or present alcohol dependency. The fees for the service currently range from between £495:00 and £550:00 per week depending on need. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0* Star. This means the people that use the service experience poor quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection, as well as this unannounced visit to the home, which was carried out between 09:30 and 17:00hrs. The purpose of this inspection was to assess what progress the service had made in meeting the requirements made in the last inspection report and the impact of any changes in the quality of life experienced by people living at the home. The methods we used included looking at records, watching staff at work, talking to people living at the home and their relatives, talking with staff and looking around the property. The manager had also completed an annual quality assurance assessment (AQAA) form, although we did not receive the form until after the date of inspection. The information provided has been used as evidence in the report. Survey questionnaires were left at the home so that people living there, their relatives and other healthcare professionals could share their views and opinions of the service with us. Three relatives, four people living at the home and one healthcare professional returned the questionnaires and the information they provided has been used as evidence in the report. The registered manager left the home at the end of May 2008 and the post is currently being advertised. Until a new manager is appointed the area manager will take responsibility for the day-to-day management of the service. The providers and area manager have a positive approach to the inspection process, are now aware of the shortfalls in the service and show a willingness to work with us to maintain and improve standards. Feedback was given to the area manager and provider at the end of the visit. What the service does well: The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 6 The staff are approachable, have a caring attitude and try hard to create a warm and friendly atmosphere. The admission procedure is thorough and the area manager will not admit people unless she feels that the staff can provide the level of care and assistance they require. People’s healthcare and personal needs are met in a way that maintains their dignity and independence. People were generally happy with the standard of meals provided. What has improved since the last inspection? What they could do better: Care plans must be completed for all people living at the home and give clear guidance to staff on how people’s needs are to be met. So that people living at the home receive the level of care and support they require. Risk assessments must be completed for people living at the home where areas of risk have been identity, which puts either themselves or others at risk of harm. Risk assessments must give clear guidance to staff on how to manage people’s challenging behaviour while respecting people’s rights as individuals. People must be offered a range of appropriate social, educational, training and leisure activities so they have the opportunity to lead a full and active life. An accurate stock control system must be maintained for medication administered on a PRN (as and when required) basis so that people can be confident that medication is being given as prescribed. A new controlled drugs cabinet must also be installed so that controlled drugs can be stored safely and in line with current legislation. Staff must receive further training on the recognition and reporting of abuse so that people can be confident that they are safe and protected from any form of abuse. The home must provide us with an updated programme of refurbishment so that so we can be sure people are living in a safe and comfortable environment. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 7 Recruitment and selection procedures must be followed so that people can be confident that they are being cared for by staff that are suitable to work in the caring profession. All staff must receive the specialist training they need to care for people with past or present alcohol dependency and associated mental health problems. So that people can be confident they will receive the care and support they need. Effective quality assurance monitoring systems must be put in place so that shortfalls in the service are identified sooner and people can be confident that the home is run in their best interest. 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 DS0000001162.V366758.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they are admitted and they can visit and stay for a trial period to make sure that the home is right for them. EVIDENCE: The home is currently reviewing the service user guide following the recent change in registration. Once completed the documents will be made available to people considering moving into the home and their relatives. Records showed that people’s needs are assessed before they move into the home. The area manager told us that people are encouraged to visit before making a decision about moving in although in many cases it is relatives who visit on behalf of the person needing care. People offered a place at the home are always supported throughout the admission process and care is taken to make sure they settle into their new environment. The area manager confirmed that the home will take emergency admissions if a full assessment of needs as been completed and staff feel they can meet their needs. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments do not give staff clear guidance on how to care for people’s complex mental health needs. EVIDENCE: Care plans have been completed for all people living at the home, which cover all aspects of their social and healthcare needs. There was no evidence to show that people are involved in the care planning process, which means that they are not consulted about how they want their care and support to be provided. The care plans reviewed generally focused on people’s personal care needs and gave little guidance to staff on how they should deal with and manage the complex mental health needs of many people living at the home. The care plans for at least two people known to become agitated and physically aggressive at times, did not make it clear how staff should respond The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 11 to this behaviour. There was no care plan, risk assessments or protocols in place for one person who had recently slapped a member of staff across the face resulting in the police having to be called. This is unsafe practice, which puts people living at the home and staff at risk of injury. Some risk assessments had been completed, where areas of potential risk to people’s general health or welfare had identified but they were not specific enough and did not give clear guidance to staff. People said that they are encouraged by staff to make decision about their daily life and lifestyle and wherever possible manage their own finances. However, risk management strategies need to be put in place to make sure that people are safe and not at risk of any form of abuse. For people continuing to drink alcohol while living at the home agreements about the amount they drank on a daily basis were in place and they were on a monitored drinking regime. The area manager confirmed that amount of alcohol individuals are allowed to drink on a daily basis is usually agreed during the initially assessment process. The agreement is signed following consultation with the person concerned and other professionals involved in their care. Generally the case files reviewed were poorly maintained and information was at times difficult to find. This means that important information may be lost or misplaced. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. More could be done to provide people with a more extensive range of recreational, educational and leisure activities both within the home and the wider community. EVIDENCE: At the present time no one living at the home is in paid or voluntary employment or attends any type of further education or training courses. The home does not employ an activities co-ordinator although a designated member of care staff undertakes activities for people for approximately two hours every afternoon. Through discussion with people it was apparent that they felt there was very little to occupy them during the day and most spent their time watching television either in one of the communal lounges or in their own room. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 13 Some people said that they use the local amenities such as the library, leisure centre and shops but generally felt more could be done to assist them integrate back into the community. Three people in particular said that they were bored with the same daily routines and wanted more out of life than spending every day just sitting around the home. Feedback from relatives also confirmed that the home did not provide a stimulating environment for people. Comments included “there is nothing at all for people to do apart from watching TV – no wonder people become agitated and frustrated” and “my relative needs more therapy and stimulation then he is getting at present”. The area manager said that staff had tried several times to get people interested in participating in activities outside the home but had found it difficult to motivate people. However, she acknowledged that more could be done to provide people with a more stimulating environment. One proposal is to set up an independent living unit within the home were people could improve their daily living skills by having responsibility for cleaning, shopping and cooking meals. The home is also planning to establish close links with local community groups and encourage people to resume past interests and activities. Relatives said that they are able to see people in their own room if they wish to do so and confirmed that they were always made to feel welcome and offered light refreshment. People living at the home said that mealtimes are unhurried and each person takes all the time they need to eat their meal. There is a good choice of dishes on the menu, and alternatives are offered if people prefer something different. People were generally happy with the standard of meals provided. Comments included “the food is tasty and I enjoy all my meals” and “I have no complaints about the food – the cook does a good job”. Following a recent Food Hygiene Inspection by the Environmental Health Department the home was awarded a four star rating (out of a possible 5 stars). The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s healthcare and personal needs are met in a way that maintains their dignity and independence. EVIDENCE: The area manager said that the daily routines are flexible and people are encouraged to make choices about how they will spend their time whilst living at the home. People spoken with said that there was no set time for getting up or going to bed and they could plan their day as they wished. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the documentation available, which shows that staff are seeking advice if they have concerns about an individual’s health. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 15 A survey questionnaire returned by one healthcare professional showed that they felt people’s healthcare needs were being met, given the fact that people at times exercised their right to refuse treatment. People said that they were generally pleased with the care and attention they received. Comments included “I am able to see my GP when I wish and are well looked after” and “we are well cared for – the staff are very good.” Through discussions with staff it was clear that they were aware of the importance of people being in control of their own health care wherever possible and maintaining their independence. On reviewing the medication system we found that overall medicines are managed safely. However, the stock control figures for PRN (as and when required) medication prescribed for two people were wrong and the two drug trolleys in use require securing to the wall. Controlled drugs are currently stored in locked cupboard within a locked cupboard. However, the legislation relating to the storage of controlled drugs changed in 2007 and the present arrangement does not meet the new standard. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Adult protection policies and procedures are not being followed and staff are unclear about what constitutes abuse, which puts people at risk. EVIDENCE: There is a complaints procedure available and people said that they would have no problems approaching staff if they had any concerns about the standard of care being provided. During the course of the visit one person brought some concerns to our attention, which the area manager was asked to investigate under the home’s complaints procedure. Adult protection (safeguarding) policies and procedures are in place and the area manager confirmed that with the exception of six all staff had attended a training course on the recognition and reporting of abuse. Staff spoken with said that they were aware of the home’s policy on “whistle blowing” and their responsibility to safeguard people living in the home from any form of abuse. However, records show that there have been a number of incidents at the home, which should have been treated as safeguarding issues but were poorly recorded and not referred to the Adult Protection Team or us. This raises concerns about staff’s understanding of what constitutes abuse and how they record and report incidents of possible abuse, which puts people at risk. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 17 Policies and procedures are in place to protect people from financial abuse, which precludes staff from being involved in the making of, or benefiting from people’s wills. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is an ongoing programme of refurbishment and renewal at the home to make sure that standards are maintained and improved. EVIDENCE: Some parts of the home are still in need of upgrading and there is an ongoing programme of refurbishment and renewal in place. We asked the provider to provide us with an updated copy of the refurbishment plan. All the communal areas including lounges and the dining room are situated on the ground floor of the home, conveniently close to toilet facilities. Bedrooms are located on three floors of the home and consist of fifteen single and seven double rooms, thirteen of which have en-suite facilities. The bedrooms we looked at were furnished to a satisfactory standard. The area manager said that on admission people are encouraged to bring personal The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 19 possessions into the home to personalise their room and it was evident during the tour of the building that many people had done so. A passenger lift is available to all floors so that people with mobility problems can access the accommodation and handrails are in place where required. People living at the home said that they were generally satisfied with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. We noted that the carpet in one bedroom was badly marked and requires replacing. The area manager confirmed that she was aware of the problem but the home was having difficulty sourcing a floor covering suitable to the needs of the person occupying the room. Feedback from relatives showed that they had mixed feeling about the standard of accommodation although the majority felt it was satisfactory. Comments varied from “the home is very shabby and the smoke room is disgusting – the furniture is old and mismatched” to “some areas would benefit from decorating and modernising but overall I am happy with the standard of accommodation provided”. On the day of the visit the home was clean and tidy and free from offensive odours. Externally the grounds are well maintained. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff employed on day and night duty to meet people’s needs. However, recruitment and selection procedures must be followed to make sure that people living at the home are protected. EVIDENCE: The staff rota showed that sufficient staff are employed on day and night duty to meet people’s needs. Recruitment and selection procedures are in place, which include checking the Protection Of Vulnerable Adult (POVA) register and obtaining at least two written references and a Criminal Record Bureau (CRB) report before new staff are permanently employed. However, we looked at the employment files for four staff and in two instances could find no evidence that written references had been received for them before they started work. This is unsafe practice, which might put people at risk. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 21 The manager confirmed that all new staff receive induction training using the Skills for Care Common Induction standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction training there is an expectation that staff will study for a National Vocational Qualification (NVQ) at either level two or three depending on the post they hold. On the day of the visit the area manager had difficulty finding some records relating to staff training. However the manager confirmed that all staff have received training on managing challenging behaviour and some staff have attended a course on alcohol awareness and mental illness. However, as the home now specialises in providing care to people some with very complex mental health needs associated with past or present alcohol dependence the above training should be mandatory for all staff. People could then be confident that staff have the knowledge and skills to provide the level of care and support they require. We asked the area manager to carry out a full staff-training audit and send us a copy. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41 and 42 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lack of effective quality assurance monitoring systems means that shortfalls in the service are not being identified and the home is not being run in the best interest of people living there. EVIDENCE: The registered manager left the home at the end of May 2008. The area manager is therefore currently responsible for the day-to-day management of the home, as well as having line management responsibilities for other homes in the Yorkshire Regency Care Health Care group. From the beginning of July 2008 the area manager will be permanently based at the home until a new manager is appointed. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 23 The area manager confirmed that two people had already been interviewed for the post but due to the specialist service the home provides no one had yet been appointed. At present both the area manager and providers visit the home on a regular basis to deal with any queries/concerns raised by either the staff or people living there. However, given the issues raised in the body of the report regarding the poor awareness of safeguarding procedures, poor care planning and the lack of risk management strategies, all of which put people at risk, we have concerns about the management of the service. Regular audits of policies, procedures and staff training would have highlighted the shortfalls in the service without us having to bring them to the attention of management through the inspection process. Some quality assurance monitoring measures are in place including sending out survey questionnaires to people living at the home, their relatives and visiting healthcare professionals. The survey gives people the opportunity to express their views of the service and is an important part of the quality assurance monitoring process. Information provided in the self–assessment form showed that policies and procedures are in place to make sure staff follow safe working practices and all equipment in use at the home is serviced in line with the manufacturer’s guidelines. People can therefore be confident that their health and safety is not being compromised. However, during the tour of the building it was apparent that a number of people are smoking in their bedroom, which for health and safety reasons the home does not allow. The area manager confirmed that she is aware of the problem and is taking steps to make sure people are made more aware of the home’s policy on fire safety. The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 1 X 3 3 X The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement Care plans must be in place for everyone living at the home and wherever possible people must be involved in the care planning process so that they can receive the care they need in that way that they prefer. Care plans must also give clear guidance to staff on how people’s needs are to be met. So that they receive the level of care and support they require. Risk assessments must be in place for all people living at the home where areas of risk have been identity, which either put themselves or others at risk of harm. Risk assessments must give clear guidance to staff on how to manage people’s challenging behaviour while respecting their rights as individuals. Outstanding from the last inspection report – Timescale 30/07/07 not met. People must be offered a range of appropriate social and leisure activities, including educational and training opportunities, so DS0000001162.V366758.R01.S.doc Timescale for action 31/08/08 2. YA9 13 31/08/08 3. YA12 16 30/09/08 YA14 The Heathers Version 5.2 Page 26 they have the opportunity to lead a full and active life. 4. YA20 13(2) A new controlled drugs cabinet must be installed so that controlled drugs can be stored safely and in line with current legislation. An accurate stock control system must be maintained for medication administered on a PRN (as and when required) basis so that people can be confident that medication is being given as prescribed. Drug trolleys must be securely fastened to the wall. 6. YA23 13(6) Staff must receive further 31/10/08 training on the recognition and reporting of abuse so that people can be confident that they are safe and protected from any form of abuse. The home must provide us with an updated programme of planned refurbishment so that so we can be sure people are living in a safe and comfortable environment. The floor covering in the room identified on the day of the visit must be replaced, so that the occupant can live in a clean and comfortable environment. All staff must receive the specialist training they need to care for people with past or present alcohol dependency and associated mental health problems. So that people can be confident they will receive the DS0000001162.V366758.R01.S.doc 31/10/08 5. YA20 13(2) 31/07/08 7. YA24 23 30/09/08 8. YA26 16(c) 31/08/08 9. YA32 18(c) 31/10/08 The Heathers Version 5.2 Page 27 care and support they need. 10. YA34 19 Recruitment and selection procedures must be followed so that people can be confident that they are being cared for by staff that are suitable to work in the caring profession. Effective quality assurance monitoring systems must be put in place so that shortfalls in the service are identified sooner and people can be confident that the home is run in their best interest. 31/08/08 11. YA39 24 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Heathers DS0000001162.V366758.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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