Inspection on 16/06/06 for The Heathers

This inspection was carried out on 16th June 2006.

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 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 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 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE The Heathers 1 St Pauls Road Manningham Bradford West Yorkshire BD8 7LU Lead Inspector Paul Newman Key Unannounced Inspection 16th June 2006 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.V300292.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 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.V300292.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 theheathersbrd@fsmail.net 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 Maraj Bibi Care Home 29 Category(ies) of Past or present alcohol dependence (7), 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 (12), Physical disability over 65 years of age (5) The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To provide a lounge located on the second floor when completing the final phase of the refurbishment To review staffing levels when the final phase is completed. Date of last inspection 15th November 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. A number may have mental health and/or physical needs; are younger than retirement age; have alcohol dependency. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by the assessed quality rating of the home. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a visit to the home. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people living at the home. All core National Minimum Standards are assessed and this provides the evidence for the outcomes experienced by residents. At times it may be necessary to carry out additional visits, which might focus on specific areas like health care or nutrition and are known as random inspections. The last inspection was an additional visit on 3 May 2006. At that time the home’s quality rating was poor but some progress had been made from the inspection in March 2006 when eight requirements had been made. This visit was unannounced and carried out by two inspectors over one day. Both inspectors had also been involved in the inspection in May 2006. The inspection started at 9.30am and finished at 4.00pm. Verbal feedback was given to the owners and management team at the end of the inspection. The purpose of the visit was to make sure the home is being managed for the benefit and well being of the residents and to see what progress had been made in meeting requirements from the last inspection. Information to support the findings in this report was obtained by looking at the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Records in the home were looked at such as care plans, staff files, and complaints and accidents records. Residents, their relatives and visitors were spoken to as well as members of staff and the management team. CSCI comment cards and post-paid envelopes were left at the home to be given to residents and their relatives as well as comment cards for health care professionals who visit the home. Eight residents took time during the visit to complete these. Across the range of responses to questions there was a large degree of satisfaction with the services, care and support provided. Conversations were held with individual members of staff and the Joint Care Management Team Care Home Educator who was providing training to staff on the day of the inspection visit. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 6 The general trend for the home is moving forward and progress is being made. This is sufficient enough to warrant reassessing the home’s quality rating from poor to adequate. What the service does well: Residents are properly assessed before they agree to live in the home. The care plans that are made up are clear, regularly reviewed and address health, personal and social care needs, wishes and preferences. There was good evidence in the care plans seen of promoting independence and choice. Staff practices make sure that residents are treated with respect and dignity and the care plans identify ways of doing this that are specific and helpful to the individual resident. Staff have a good knowledge of the individual residents’ needs. There was a large degree of satisfaction expressed by residents both in conversations during the visit and in the survey questionnaires that were completed. Some of these were: • • • • • ‘Staff have a heart of gold’ ‘Staff are fabulous’ ‘The new owners have made changes for the better’ ‘The home is pleasant and most of the time there is somebody to talk to’ ‘This is a very happy home’ Residents’ social needs are assessed and documented and activities are arranged that are geared to stimulate and interest them that include getting out into the local community. What has improved since the last inspection? Following the last inspection in May 2006, the owners were required to provide an improvement plan. This was done within the timescales set. The major issues that have been a problem are to do with the building and the improvement plan should set out the priorities. The plan that was sent identified some of the issues that had been discussed and itemised in the previous report. Some improvements have been made to the building like the redecoration of the smoking lounge and provision of an extractor fan. Monthly reports on the conduct of the home are now done regularly and copies sent to the CSCI. The manager has introduced monitoring and checking systems for things like care plans and medication and questionnaires have been sent out to see what relatives and professional visitors to the home think of the way the home operates. Domestic staff hours have been increased and the manager thought this had really helped, particularly over the weekend. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 7 What they could do better: The service is improving and the owners have shown genuine commitment to maintain this. The requirements that remain outstanding are to do with the building and some recommendations were made about one policy, the way complaints are recorded and the development of activities. • The owners provided an improvement plan following the last inspection. This did not address all of the requirements for that inspection and only indicated work to be carried out up to September 2006. A new action plan must now be provided that addresses all of the requirements and recommendations of this visit and plans for ongoing maintenance, redecoration and refurbishment. This includes – installation of a sluice cycle washing machine on first floor, routine maintenance, replacement of furnishings, redecoration, renewal of draughty windows, replacement of a bath hoist, renovation of bathrooms, fitting of a radiator on the top floor landing, completion of work raised by the environmental health officer, flaking paint in the laundry area, storage of combustible materials in the cellar area, incomplete works to bedrooms; inadequate radiator covers; lockable facilities in bedrooms and repair of sash windows. Any training programmes or general developments should also be included. The registration of the home has conditions attached that are to do with the completion of the development of the top floor of the home (provision of a lounge) and review of the staffing levels when the lounge has been completed. This must be included in the improvement plan and the CSCI are keen to see this completed because it is an important development for the more independent residents who live at the home. An internal policy that links to the Bradford Adult Protection Procedures should be developed. This should give advice on the immediate actions that should be taken when abuse is alleged or suspected, who should be notified and the procedure should have contact telephone numbers for the Bradford Adult Protection Team, the out of hours emergency duty social work team, the police and CSCI. The way that complaints are recorded was discussed and advice given about the way this could be improved. A new document for recording complaints is to be devised so that it can be placed on any resident’s individual file. The home has a wide range of residents (see registration categories) and the owners should consider employing an activity organiser to particularly address the needs of younger adults living in the home. • • • • 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.V300292.R01.S.doc Version 5.2 Page 8 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.V300292.R01.S.doc Version 5.2 Page 9 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 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and/or their relatives have the information that is needed before they choose a home. Assessments are made before people move in to the home, that give staff sufficient information about the individual’s care needs. EVIDENCE: The home has a statement of purpose and a service user guide and copies of these have been made available to the Commission. From the manager’s description, no resident is admitted to the home without first being assessed The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 10 and where possible, visiting the home. If that is not possible, then relatives always visit on the resident’s behalf. The manager wants prospective residents and their relatives to be as sure as possible that the home is suitable, that they know what room they will be living in and generally how the home operates. The service user guide is given at the introductory visit. All of the survey questionnaires that were returned said that the individual felt they had received enough information about the home before they moved in so that they could decide if it was the right place for them. Some residents spoken with said that they had visited the home before they made a decision. As part of the evidence gathering, one inspector case tracked three residents. This meant detailed checking of their files, speaking to the residents, observing the individual care provided to make sure that their care needs were being met, and speaking to the staff who deliver the care to make sure that they had a clear understanding of each individual’s needs. Key standard 3 requires that the home carries out a comprehensive assessment of each resident’s needs before they are admitted to the home. The home’s registration categories include younger adults and older people with past or present alcohol misuse, residents with old age some of whom may have dementia and disabled older people. Residents from different categories were chosen for case tracking, one of these being a recent admission to the home. The pre-admission documentation that was seen was adequate being like a checklist of needs that identified where assistance or support was needed. At a recent inspection of another home owned by these providers, different preadmission documentation had been seen that gave far more detailed and useful information and it was suggested that the same system be adopted at The Heathers. Despite this assessments had been carried out in all three cases that provided sufficient information to formulate a care plan. It was noted that new files are in line with the single assessment process. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 11 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, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are agreed with residents or their relatives and give a clear picture of the person, their needs, wishes and preferences. The plans address health, personal and social care needs. Staff practices make sure that residents are treated with respect and dignity and the care plans identify ways of doing this that are specific and helpful to the individual resident. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 12 EVIDENCE: The three residents who were case tracked each had differing needs. These were clearly identified in each care plan. The plans were easy to follow and reviewed each month as required. Each plan was positive and identified specific needs, personal strengths, preferences and wishes. Having read the plan the reader has a good picture of the person and their needs. Specific health care needs were well documented and audit trails of staff observations and concerns that they document about an individual’s health problem, subsequent referral to the GP or other health care professional and the advice and treatment that followed could be made from the files. There was evidence of regular and routine optical, dental and foot care from the records that included optical prescriptions and appointment dates and treatment. The personal profiles that were completed were useful and once again identified issues and prompted staff to manage residents with sensitivity, in particular one resident whose sense of missing home and his daughter. The plans also covered the residents’ palliative care wishes that included specific religious needs. Risk assessments were up to date and covered moving and handling, falls and nutrition. The advice to staff on reducing risk was clear. Each of the residents had their weight checked monthly or more regularly if there were concerns about nutrition. There was a record of falls. Where necessary risk assessments were completed for specific issues like smoking. The details of medication and of GP visits and treatments that were in the care plan were checked against the medication administration charts and medication held. The manager had implemented medication audits in March 2006 and these have been carried out monthly. The checks made during the visit evidenced sound record keeping and observations made of staff practice with medication indicate that systems and procedures are safe. The more able residents were involved in their reviews and those spoken with gave the clear impression that they talked to staff about what they wanted and needed. Resident’s said that they were settled and comfortable living in the home. They said that staff were kind and caring and respected their privacy. The observations of the staff as they interacted with residents supported these comments and in particular the work they did with the three residents that were case tracked during the inspection. Throughout the day staff were seen knocking on doors before entering and where they were providing personal care to residents in their rooms, they made sure the door was closed. Similarly residents’ privacy was protected when bathing and toileting was taking place in communal facilities. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 13 The home operates a key worker system that is being developed. The staff spoken with had a clear picture of the needs and lifestyle wishes and preferences of the three residents who were the focus of the inspection. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good ideas to develop the range of activities that are provided that will more fully meet the age and peer needs of younger adults. The employment of an activity organiser would help this aim. Nevertheless, residents exercise choice and control over their lifestyles and are generally satisfied. Residents are satisfied with the food provided and there are ideas to extend the range of meals and experiences for younger adults. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 15 EVIDENCE: In the conversations with the manager it was clear that she is encouraging staff to develop the range of activities that are provided. It is not easy to provided a full range to meet the varying needs of this mixed category home. There was evidence from the care plans and conversations with the residents who were case tracked, that they are encouraged to join in things that are arranged. Around the home there were paintings displayed of St. George’s day celebrations and the soccer world cup flag in the lounge. One resident talked about going to church regularly and receiving communion. He joins in activities within the home like painting, music and movement. He goes to the shop each day and this was identified in his care plan to maintain his mobility. Another talked about seeing the ‘Race for Life’ in the local park and about how he enjoyed listening to a live music concert that had taken place at the home through a church. In recognising the therapeutic value of gardening for some residents the manager wants to develop this activity including establishing a greenhouse. A trip to Blackpool is also planned. Of the eight survey questionnaires that were returned, six felt that there were ‘usually’ activities arranged that the resident can take part in. Two felt that there were ‘always’ activities. The manager’s efforts to extend the range of activities will no doubt be welcomed by residents. Conversations with the residents indicate that they make decisions about what they wear, when they get up and when they go to bed. They are free to spend time in communal areas or in their own rooms if they wish. The home’s service user guide makes it clear that contact with family and friends is encouraged and seen as an important part of resident care. The residents spoken with talked about visitors and this extended in some cases to going out with family on a regular basis. The menus that were checked show traditional English meals that will provide good balanced nutritional value. Six of the survey questionnaires that were returned said that they ‘usually’ liked the meals provided and one of these qualified the comment by saying that ‘if there is something you don’t like, they provide an alternative’. There has been recent consultation with residents about the food provided and there are now plans to introduce cultural evenings that will appeal to younger people living at the home. This type of consultation and approach is encouraged. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel safe living in the home. There are appropriate procedures in place for responding to and dealing with complaints. EVIDENCE: The pre inspection information that was provided by the home showed that there had been three complaints and one had been substantiated. Records seen and discussions with the manager during the visit showed that these had been properly dealt with and there were satisfactory outcomes. One complaint was properly referred through adult protection procedures. This was not substantiated but was thoroughly investigated with all the appropriate agencies that should have been notified and involved. Complaints procedures were seen on notice boards around the building and the procedure is also included in the Service User Guide. The residents spoken with said that they feel comfortable in raising concerns. This was reinforced by the survey questionnaires that were returned. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 17 Bradford adult protection procedures are available to staff at the home but there was not a suitable internal policy that linked to the Bradford procedures. This was discussed and advice given on the immediate actions that should be outlined, who should be notified and, the procedure should have contact telephone numbers for the Bradford Adult Protection Team, the out of hours emergency duty social work team, the police and CSCI. In practice however, the referral mentioned above was properly managed. Staff said they would not hesitate to report abuse to the person in charge. Residents said they felt safe. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 18 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 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a significant amount of work and investment required to bring the environment to acceptable standards. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 19 EVIDENCE: Following the random inspection made in April 2006 the owners were asked to provide an action/improvement plan. The intention was for the CSCI to be happy with the timescales for work to be carried out to meet outstanding requirements and to give the owners the opportunity to demonstrate how they intend to approach ongoing maintenance, redecoration and refurbishment. A plan was forwarded that outlined work to be carried out up to the end of September 2006. It did not however cover all of the issues that had been identified in the report. It has been the approach of the two inspectors to encourage the owners and management team to take responsibility, and be proactive in the development of the plan. To have completed a thorough check of the building would have taken a large proportion of the time allocated to the inspection and to have published a report with a long list of requirements in relation to the building would not have reflected the otherwise good efforts made by the manager and staff at the home and the generally positive responses from residents. It is therefore vital that the next improvement plan accurately reflects and prioritises the work that the owners intend to complete and the timescales they intend to take. The last inspection report noted the following: • • • • • • • • • • • • • • • Installation of a sluice cycle washing machine on first floor, Routine maintenance, Replacement of furnishings, Redecoration, Renewal of draughty windows, Replacement of a bath hoist, Renovation of bathrooms, Fitting of a radiator on the top floor landing, Completion of work raised by the environmental health officer, Flaking paint in the laundry area, Storage of combustible materials in the cellar area, Incomplete works to bedrooms, Inadequate radiator covers, Lockable facilities in bedrooms and repair of sash windows, Completion of the development of the top floor. While some of this work has been done, the owners and management team were advised to carry out a room by room assessment of what exactly needed to be done and then to make a priority list that could form the basis of the improvement plan. It is only this approach that will satisfy the CSCI that things will get done in a systematic way. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 20 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, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the care they receive and enjoy good relationships with staff. The staff are committed to training and there is an ongoing training programme that uses external trainers. Sound procedures are followed to recruit staff and to make sure they are vetted and checked. EVIDENCE: The pre inspection information provided by the home outlined the training that has taken place over the last year. This included safe working practice training as well as some more specialised sessions like dementia care, alcohol dependency, palliative care and diabetes. Progress is being made in the numbers of staff achieving National Vocational Qualifications with six staff having completed level 2 or an equivalent. A further four staff are enrolled for NVQ’s. Three staff files were checked to make sure the home carries out The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 21 proper recruitment and vetting procedures. These had all the necessary documentary evidence and included the induction training records for each member of staff. Three members of staff spoken with confirmed that they also had followed induction training and spoke about safe working practice training that they had completed. The manager has conducted an audit of training needs and has identified where updates are required and these will be built into the training programme. The duty rotas provided for the inspection showed sufficient staff on duty at all times and at the time of inspection there were four carers on duty supported by ancillary staff. All the staff spoken with said that there was a good team spirit. They talked about regular staff meetings and about the shift handover arrangements that appeared sound, with written handover sheets and all residents discussed. They appreciated that the manager was encouraging them to be more involved in care planning and this had helped motivation. They also felt that the improvements in the activities that are arranged had made a significant difference to morale in the home. Staff confirmed that a supervision system had started (one to one sessions with the manager). Although this is in its infancy, the manager is encouraged to keep this form of support and oversight going. Issues raised in the last inspection report about the number of domestic lours have been addressed with cleaning hours now provided on the weekend that the manager said had improved matters. The manager said that she had monitored staffing levels generally (also raised in the last inspection report) and said that she was in a position to bring in additional staff if needed, but felt that the current staffing levels met residents’ needs. Nothing was observed during the inspection to suggest this was not the case. The residents said that they felt the staff were caring and terms like ‘they can’t do enough for you’ and ‘staff are fabulous’ were typical of the comments made. The observations made during the visit showed relationships to be good and there was a happy and jovial atmosphere in the home. It felt a good place to be. The staff were supportive and watchful of the residents and their manner with them was friendly, warm, personable but also professional. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and the best interests of the residents are at the heart of staff practice and checking systems that have been developed. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has been registered since the last major inspection. She is experienced in the care sector and although having a degree in management is currently undertaking relevant management qualifications for the care sector. Looking back over previous requirements and the improvements made since her appointment, it is clear from the evidence of this inspection that the manager has made a significant impact on morale, internal record keeping and has introduced auditing and monitoring systems to make sure that things do not slip (e.g. care plans and medication). The staff spoken with said that they felt the manager was good and had introduced new systems and was encouraging them to be more involved. Regular staff meetings have been held and a supervision system has begun. Residents meetings have been held so that they can express their views about home life and make suggestions about activities and food. Quality satisfaction surveys have been used with residents, relatives and professional visitors to the home. The views expressed by residents were generally good about all aspects of home life, particularly the staff. Oversight of the home by the owners in regulatory terms has improved and monthly reports on the conduct of the home are now forwarded to the CSCI each month. There is an operations manager who is the interface between the home and the owners, and staff said that the owners were regular visitors to the home and took an active interest in the residents and what was going on. One resident who has lived at the home for a long time said that things had improved since these owners took over. The owners provided an improvement plan following the last inspection. This did not address all of the requirements for that inspection and only indicated work to be carried out up to September 2006. A new action plan must now be provided that addresses all of the requirements and recommendations of this visit and plans for ongoing maintenance, redecoration and refurbishment. Any training programmes or general developments should also be included. There is one resident who manages his own finances including his own bank account. Money is held for safekeeping for some residents. Records are kept for these and two were chosen and checked and reconciliation made with the cash held. There were no problems and all was accurate and clearly recorded. From the pre inspection information provided by the home it could be established that regular and routine safety checks are made of equipment and facilities, things like fire safety equipment, gas installation, electricity installation, hoists and lifts. To be doubly sure of fire safety, the records were checked during the visit and staff confirmed that they had been involved in fire drills. Accident records were also checked. Observations during the visit showed that staff were properly equipped and wearing protective clothing to reduce the risk of cross infection. During the tour of the building some rolls of The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 24 new carpet were seen that was in a position to cause a health and safety hazard but this was immediately rectified. The Heathers DS0000001162.V300292.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 3 2 X 3 X 4 3 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 ENVIRONMENT Standard No Score 19 1 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 X 35 3 36 X 37 X 38 3 The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 24 Timescale for action The registered persons must 30/11/06 provide an improvement plan that outlines areas that are to be developed and improved, how this will be done, who is responsible for the work and the target timescale for completion. The plan must include issues raised in the section referring to environment. These are: • • • • • • • • • • • The Heathers Requirement Installation of a sluice cycle washing machine on first floor, Routine maintenance, Replacement of furnishings, Redecoration, Renewal of draughty windows, Replacement of bath hoist, Renovation of bathrooms, Fitting of radiator on top floor landing, Completion of work raised by the environmental health officer, Flaking paint in the laundry area, Storage of combustible Version 5.2 Page 27 DS0000001162.V300292.R01.S.doc • • • • • materials in the cellar area, Incomplete works to bedrooms, Inadequate radiator covers, Lockable facilities in bedrooms Repair of sash windows, Completion of the development of the top floor. 31/05/06 Previous timescale partially met. 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 OP16 Good Practice Recommendations The way that complaints are recorded was discussed and advice given about the way this could be improved. A new document for recording complaints should be devised so that can be placed on any resident’s individual file. An internal policy that links to the Bradford Adult Protection Procedures should be developed. This should give advice on the immediate actions that should be taken when abuse is alleged or suspected, who should be notified and, the procedure should have contact telephone numbers for the Bradford Adult Protection Team, the out of hours emergency duty social work team, the police and CSCI. The home has a wide range of residents (see registration categories) and the owners should consider employing an activity organiser to particularly address the needs of younger adults living in the home. 2 OP18 3 OP27 The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI. The Heathers DS0000001162.V300292.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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