Inspection on 15/11/05 for The Heathers

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

The Heathers 10/03/10

The Heathers 08/12/09

The Heathers 11/12/08

The Heathers 13/06/08

The Heathers 13/06/07

The Heathers 16/06/06

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 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Heathers 1 St Pauls Road Manningham Bradford West Yorkshire BD8 7LU Lead Inspector Susan Knox Announced Inspection 15th November 2005 09:30 X10029.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 DS0000001162.V252896.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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.V252896.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Heathers Address 1 St Pauls Road Manningham Bradford West Yorkshire BD8 7LU 01274 541040 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 Care Home 27 Category(ies) of Past or present alcohol dependence (1), Past or registration, with number present alcohol dependence over 65 years of of places age (1), Dementia - over 65 years of age (4), Old age, not falling within any other category (17), Physical disability (2), Physical disability over 65 years of age (5) The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category of A be used for the specified service user only. The category of PD be used for the specific named service users. Date of last inspection 9 June 2005 Brief Description of the Service: 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. Accommodation is provided for 27 service users on the ground, first and second floors. The first phase of renovation to the second floor has been completed and is newly registered for five beds. The second phase of this same area is underway. A passenger lift provides access to all areas. The home provides accommodation for a mixed category of older and younger service users, the are elderly. A number may have mental health and/or physical needs; are younger than retirement age; have alcohol dependency. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this announced inspection. Present were Mirage Bibi acting manager, Denise Smith operations manager and Stuart Crabtree provider. The inspectors focused on admissions procedures and documentation, the building and had discussions with service users and staff. Since the last inspection the first stage of the building work to renovate the second floor has been completed and registered. Comment cards were sent before the inspection to be distributed to service users and/or representatives. None had been returned in time for the inspection. Detailed feedback was given to acting manager Mirage Bibi, Stuart Crabtree and Denise Smith. Additional inspections will be carried out due to concerns the inspectors had about categories of admissions and the poor quality of the environment in some parts of the building. What the service does well: What has improved since the last inspection? Care planning documentation continues to improve. Staff training continues to improve. Where renovation is complete this is to a good standard. The environment in the smoking room has improved but further work is necessary. The triple bedrooms have been reduced to two people sharing. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4. Service users and/or their representatives have been unable to make an informed choice about the home because written information was not available. The admission process is very poor. The purpose of each admission must be clearly established to enable service users and staff to plan accordingly. Service users must know how long they are expected to stay at the home. Some service users are not appropriately placed at the home because staff are not trained to meet their needs. EVIDENCE: The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 9 The information on the recently issued registration certificate is wrong. In consultation with the providers this will be amended. Information about the home in the form of the statement of purpose and service user guide is not readily available for prospective service users as no stock of documents is kept. The photocopier is broken therefore copies are not immediately available. One admission was an emergency but the home failed to provide the service user with information about the home within 48 hours of admission as required. Service users are not given contracts when they move into the home. One service user had moved rooms several times. The reason for the move must be recorded, and a new contract with the room number must be issued. There have been other moves due to internal building works. An audit of service user contracts would make sure that all were up to date. The operations manager and/or the acting manager of the home assesses service users before admission to the home. Written assessments were available but one did not contain very much information. Detailed information must be gathered before deciding if the home and staff can meet individual needs. The inspectors were concerned about the recent admissions of two younger adults, both had complex needs and required specialist support. Staff are not trained at present to meet these needs. Three service users recently admitted clearly said they did not want to stay at the home on a long-term basis. There was only a minimum amount of information about two service users who had moved into the home. The management team expressed concerns that the placing agencies had not provided full details about medical histories. In addition, there was some uncertainty about whether the placements were permanent or temporary. Daily records showed that one service user had been getting upset about staying at the home. Management were advised to arrange immediate reviews with social workers. In addition, they must be more thorough when carrying out assessments and more demanding in asking for specialist support. Due to these concerns the home must contact the inspector to discuss details of needs before agreeing to further admissions. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7-9,11 Care plans need further work so that individual needs are recorded and staff know how to meet them. The effective procedures for staff administering medication means that service users are kept safe. Staff are confident in dealing with service users who are dying. EVIDENCE: The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 11 Four sets of care documentation were checked. Care plans and risk assessments continue to improve with good information recorded about individual needs. In some cases more detail is required. For example, one care plan identified concerns about weight loss and said that staff should monitor diet and weigh the individual weekly. There were no details about how to monitor diet nor was weighing carried out. The manager explained that this had ceased to be a concern. In this case, the record should reflect this and the care plan should be updated. A care plan had been completed for one service user who had recently moved into the home but only three areas of need had been identified, two of these related to weight. The manager and staff talked about care needs that were not included in the care plan. This showed a good understanding of the individual’s needs but records must be kept. One care plan had very good information about how a service user’s needs should be met in four key areas. This included specific guidance for staff on how to deal with some sensitive issues. However, other key areas of need had not been identified in the care plan. One service user had been involved in reading their care plan and had also contributed to a past history record. The district nurse was visiting one service user with a pressure wound. The care plan included a record of the special mattress and cushion used including the name of the equipment. This could be better if the required pressure of the mattress was recorded. Although the district nurse maintains a plan of care the home also needs one so that staff are aware of any action necessary if dressings become loose. Service users said that they were well looked after. The district nurse said that the care staff were doing well and that they followed advice about care. The home administers medication via a Monitored Dosage System (MDS). Documentation and storage was checked and discussions held with the senior staff undertaking the drug round. Records were satisfactorily kept. Administration was also good. Records are kept of medication returned to the pharmacist. The manager was advised to talk to the pharmacist about him/her inspecting the system periodically as part of the contract with the home. Senior staff administer medication and all have received training. The senior staff displayed a good understanding about service user’s individual needs and medication. For example liquid medication had been requested as one service user had difficulty with tablets. Staff spoke about looking after service users who are terminally ill. They talked about involving healthcare professionals and seeking guidance when necessary. They were able to describe how they ensured service users were comfortable. Several staff have attended palliative care training, this covers how to look after people that are dying. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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, 14. The home has not planned how it can meet the needs of the wide age range of people living at the home. This has resulted in some service users not receiving enough stimulation and other service users getting upset. Proper consultation does not take place before decisions are made on behalf of service users. EVIDENCE: During the inspection it was noted that a few individuals left the home independently to follow their own pursuits and interests. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 13 The home is now registered to provide care to older people and people under 65 years. The current age range is early forties to late nineties. Staff were asked specifically about how the home meets the needs of the different age groups. Staff said it was sometimes difficult and they acknowledged this area should be developed. They confirmed the behaviour of some of the younger service users had upset other service users. A younger person’s daily records were looked at. In the last two months, one outing had been recorded but no other activities. The manager said various activities had been provided including trips out. These had been to the local cinema, shopping, bowling and church. These were not recorded. The manager has had meetings with service users. Service users said their relatives were welcomed in the home by staff. One said that he is a member of the local church. Decisions had been made on behalf of one service user. A family member had been consulted but there was no evidence that consultation with the service user or any healthcare professional or social worker had taken place. A record of the decisions was not available. Discussions with staff showed these decisions had been made in good faith. But multi-agency meetings including the service user and/or their representatives must take place before any decisions are made and detailed records kept about agreements. Discussions were held about service users holding keys to their bedrooms. This is a right and should be assessed as part of the admission process. Risk assessments should be undertaken on each individual to check if they have the capacity to hold and use a key. Reasons for the decision not to provide a key must be clearly recorded. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17. Service users and staff have confidence in management to resolve any concerns. Management must obtain written information from placing authorities about agreed limitations of service user’s rights. EVIDENCE: The complaint procedure is displayed prominently. The acting manager advised that no complaints have been made to the home. A current complaint received by the CSCI is being investigated by the home although this has not been done within the 28 days timescale. Service users and staff said they would discuss concerns or complaints with the manager or other agencies if they thought it was appropriate. The manager said that placing social workers had verbally agreed to restrictions placed on some service users. The restrictions included bringing a service user back into the home if they walked away and restricting telephone calls. Although done with the best of intentions and with the agreement of other agencies, this is a restriction of individual rights with no documentation to reinforce the legality of the action. The managers were advised to arrange immediate reviews with social workers to establish if mental health The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 15 assessments had been held and what the results were. In addition the managers must attend training on individual rights. This would help them to question information given to them about prospective admissions. It is acknowledged that the managers did not knowingly seek to limit the service users’ freedom and choice but there is a naivety in dealing with other agencies. There is a too ready acceptance about information given prior to admission. Further training would equip managers to robustly challenge and question when undertaking pre-admission assessments. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Areas of the home that have been renovated provide very comfortable accommodation of a good standard. The providers fail to recognise that some bedrooms are of a very poor standard and are not comfortable. Regular automatic renewal of linen and furniture would improve the service to residents. Service users and staff’s health must be protected in the smoking lounge. The provision of a second sluice room would enable staff to be more effective in infection control. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 17 The provision of a dryer would enable staff to return laundry to service users quicker. EVIDENCE: All parts of the home were inspected. Three communal rooms provide adequate sitting and dining facilities although in the National Minimum Standards for Younger Adults it is required they have separate communal rooms. The provider confirmed this would be provided in the second and final phase of renovation. The lounge and lounge/dining room are decorated and furnished to a good standard. The smoking lounge has been painted and a new carpet fitted. The provider was again told about the poor quality of the armchairs. Although some have been replaced these are poor quality with cushions that are ill fitting. These are a source of concern for those service users who may be at risk of developing pressure ulcers. Additional ventilation has been provided in this room but was not effective in clearing the smoke. There are a high number of smokers who sit in the smoking room continuously. The health needs of these people and staff must be considered. Advice about this should be sought from an environmental health officer. The provider has converted part of the top floor of the home to provide five additional bedrooms and a communal bathroom. This has recently been registered as a separate unit called The Loft. The second and final part of this phase has still to be carried out. An application has been sent to the provider. This needs to be returned with detailed plans. This proposed work would include a lounge/dining room specifically for the younger adults accommodated. The work carried out is to a high standard. All the new bedrooms have ensuite facilities and decoration and carpeting is to a good standard. All the former triple bedrooms located on the first floor have been reduced to two people sharing. These rooms have not been renovated, as there will be some further alterations that affect them. The provider was advised to apply in writing outlining plans to alter one shared room located on the first floor into two single rooms that may be smaller than the required 12 metres. Some bedrooms were personalised and homely, but there are still some that are in a poor state of repair and require urgent attention. One had a particular malodour, which must be dealt with either by more thorough cleaning or replacement of the carpet or bed. The providers are failing to ensure that all service users live in comfortable bedrooms. One bedroom identified to the provider required urgent attention. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 18 Some items of furniture were shabby and worn and need replacing. Some beds have been replaced. Some faded thin bedding was seen and also pillows that were misshapen. The provider was advised to carry out an audit of bedding, pillows, towels and beds and replace where required. All toilets and bathrooms were not seen. At the last inspection, many of these facilities apart from the second floor bathroom were poor quality and need upgrading. Not all of these were checked at this visit. A number are due for alteration as they are included in proposed building works. At the time of the inspection new flooring was being laid in a WC. At the last inspection it was required that the chair on the fixed hoist in the first floor bathroom was replaced. This has been sent for industrial cleaning. A radiator must be installed in the 2nd floor bathroom, as there is currently no heating in this room. In addition the landing and corridors in this area are not heated. The manager was advised to provide room thermometers and monitor the temperature to check if additional radiators are required. The heating was satisfactory in other parts of the home. The laundry is located in the basement and has separate areas for washing and drying. Staff said drying laundry in the home was a problem when it is not possible to hang them outside. Examples were given of service users running short of clothing and underwear. There was some uncertainty about whether the dryer was in working condition. The owner was told he must provide a working dryer. Due to the size of the home and number of floors that staff have to negotiate to access the laundry, it is required that as part of the developmental works a second separate sluice room is provided at a more central location in the home. This room should include a wash hand basin, paper towels and dispensed soap, sluice disinfector machine and clinical waste bin. The provider was advised to contact an infection control advisor for specialist advice. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Staffing levels are enough to meet the numbers of service users but their needs vary therefore the manager must have the flexibility to increase staff in order to meet individual needs. Recruitment procedures are in the majority good and safeguard service users. All staff who have substantial access to service users must be recruited in the same way. Staff training is varied and ongoing. Alcohol related training is required urgently. EVIDENCE: Copies of the staff rota were not submitted with the pre inspection questionnaire. It was agreed that these would be sent later. The acting manager advised that she ensures that there are four care staff working each shift throughout the day and two working each night. Staffing levels were recently increased to meet the needs of one individual. This flexibility must be The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 20 maintained so that the manager can increase staffing according to individual needs. Staff confirmed that NVQ training is ongoing although only three of the existing staff have a NVQ qualification to level two or above. This means that only 16 of care staff have this qualification. The requirement is for 50 in 2005. It is acknowledged that there has been a turnover of the staff with these qualifications. Three sets of recruitment files were reviewed for the latest recruits. For one person this should have had more details about education and employment history. There was evidence of thorough identification checks. POVA (Protection of Vulnerable Adults) First and CRB (Criminal Record Bureau) checks had been completed before employment. The provider was informed that the same recruitment procedures must be carried out for the occupational therapist. All staff employed in the home must be subject to the same robust recruitment procedures to make sure that the service users are protected and staff are suitable. Staff said that training opportunities had improved greatly and they have opportunities to attend various training courses, which includes distance learning, in-house training, and external courses. In the pre-inspection assessment the manager provided details about the various courses that have been organised in 2005. Many relate to health care such as oral hygiene, eye care and blood glucose training. A visiting district nurse confirmed that talks have been given to care staff. Other courses relate to health and safety such as first aid and basic food hygiene. Future courses are to be arranged to give staff the training they require to meet the specialist needs of service users who have a history of alcohol abuse and related needs. This training must be given priority as feedback from staff showed that they are struggling to meet the specialist needs of some of the recently admitted service users. Therefore it was agreed that this type of admission must be discussed with the inspector until all staff have received the necessary training. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Some very important information had not been recorded. This does not enable anyone to monitor service users’ health or welfare or what is happening in the home. EVIDENCE: The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 22 Staff and management talked about a number of situations that had occurred in the home. This included cigarettes going missing, incidents with residents, and discussions with healthcare professionals. None of this information had been recorded. The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 2 3 2 4 1 5 X 6 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 1 18 X ENVIRONMENT Standard No Score 19 2 20 2 21 2 22 3 23 2 24 1 25 2 26 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X 37 1 38 X The Heathers DS0000001162.V252896.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement A statement of purpose and service user guide must be given to prospective service users and/or their representatives. Written contracts must be given to service users. When transferring rooms new contracts must be issued The admission process must improve. Service users with specialist needs must not be admitted until staff have the skills and training to meet their needs. Care plans must provide more detail about how needs are to be met and must include social life and activities. A tumble dryer must be provided in the laundry. Any decisions taken to limit service users’ choice must be made in consultation with all parties including the service user, their representative and any other agencies involved. Restrictions must be clearly recorded within an agreed framework. DS0000001162.V252896.R01.S.doc Timescale for action 31/12/05 31/12/05 2 OP2 5 3 OP4 12, 14 15/11/05 4 OP7 15 31/12/05 5 6 OP10 OP14 16 12 31/12/05 15/11/05 The Heathers Version 5.0 Page 25 7 12 8 OP24 16, 23 9 OP25 23 10 OP26 16 11 12 13 YA28 OP29 OP30 23 19 18 14 OP37 17 15 16 OP38 *RQN 13 39 (h) Any decisions taken to limit service users’ rights must be made in consultation with all parties including the service user, their representative and any other agencies involved. Restrictions must be clearly recorded within an agreed framework. The registered providers must ensure that all bedrooms are comfortable and suitable. All old and worn bedding, pillows, towels, furniture and beds must be replaced. A radiator must be provided in the 2nd floor bathroom. The temperature of the landing areas on 2nd floor must be monitored. The malodour in one bedroom must be eradicated either by more thorough cleaning or replacing the carpet and bed if necessary. Separate communal space must be provided in the last phase of the 2nd floor building work. All staff working in the home must be subject to the same robust recruitment procedures. Staff must receive specialist training in order to meet the needs of those with alcoholism and related needs. All information including incidents and discussions must be recorded in care documentation. Ventilation in the smoking room must be improved. Detailed plans of the proposed alterations to the 2nd floor must be submitted to the CSCI and these must include all proposed changes and upgrading of facilities throughout the home including the additional sluice DS0000001162.V252896.R01.S.doc 15/11/05 31/12/05 15/11/05 15/11/05 30/03/05 31/12/05 31/01/06 15/11/05 31/12/05 31/12/05 The Heathers Version 5.0 Page 26 room identified in the report. 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.V252896.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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