Inspection on 29/08/07 for The Heathers Nursing Home

This inspection was carried out on 29th August 2007.

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

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

Other inspections for this house

The Heathers Nursing Home 06/02/08

The Heathers Nursing Home 16/08/06

The Heathers Nursing Home 13/12/05

The Heathers Nursing Home 24/05/05

The Heathers Nursing Home 22/12/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Heathers Nursing Home Bowling Hill Chipping Sodbury South Glos BS37 6AX Lead Inspector Andrew Pollard Unannounced Inspection 29th August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Heathers Nursing Home Address Bowling Hill Chipping Sodbury South Glos BS37 6AX 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) 01454 312726 01454 315614 theheathers@acaciacare.wanadoo.co.uk Mr Hitan A Patel Mr Roger Tippings Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 4 persons aged 50 years and over who are receiving nursing care May accommodate up to 3 persons (aged 65 years and over) who are receiving personal care Manager must be a RN on parts 1 or 12 of the NMC Register Staffing notice dated 10/06/99 applies. Date of last inspection 16th August 2006 Brief Description of the Service: The Heathers is a Grade II listed Georgian manor house situated in Chipping Sodbury close to the town centre of Yate. There is access to public transport for surrounding areas and the centre of Bristol and the home is close to the Avon Ring Road and motorway system. It is a care home with nursing and offers accommodation in single and shared rooms. The accommodation for residents is on two levels and there is a passenger lift between floors. There are several lounges and a small courtyard to the front of the building for use in good weather. The home operates a No Smoking Policy, staff and service users who smoke must do so outside of the building. Fees start from £505 per week. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A number of residents were spoken with and surveys were received. Eight surveys were returned from relatives. Three comment cards were received from GP’s. All survey responses were positive. The inspector spoke to the provider, manager and deputy manager and other care assistants and ancillary staff about their roles and responsibilities. The building, rooms and facilities were inspected. A range of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were reviewed. Tour of premises was conducted. General feedback was given to the manager on the day of inspection. Residents and staff interaction were seen to be positive and caring upholding the dignity of the residents. The residents and relatives spoken with on the two days of inspection praised the staff and quality of care no complaints were made. What the service does well: The home was found to be clean, warm and free from unpleasant odour. Staff were cheerful and interacting with residents in a positive, caring and sensitive manner. Residents were calm relaxed and looked well cared for. The home continues to provide quality and effective care by ensuring that prospective residents are appropriately assessed before admission to determine that their needs can be met The home provides meaningful activities for all the residents based on individual capabilities. Residents are protected by a robust complaints procedure and the home would ensure that any complaints are thoroughly investigated and all required action (if any) implemented. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 6 The home ensures that there are adequate numbers of staff to meet the residents’ needs. The home ensures that aids and equipment are provided in sufficient quantity to assist staff with meeting the needs of residents. What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is well managed and a thorough assessment of prospective residents needs is carried out. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 9 . EVIDENCE: A statement of purpose and a home guide plus additional helpful information is made available at the initial stage of enquiry to prospective residents/families. This provides good information about the services and facilities available and includes the terms and conditions. The manager is due to carry out a review of the service user guide in the coming weeks following a revision of the conditions of registration. All the residents’ surveys returned stated that they had received adequate information to help them decide if The Heathers was somewhere they would like to live. They also confirmed that they or family member had received a contract on admission to the home. The home has an admission procedure and pre-admission assessments are covering activities of daily living, health needs and personal history. All residents have Waterlow, handling and continence assessments. Each person has a handling assessment, as the competent person the manager countersigns and dates these documents. Resident’s assessment records showed assessment of the person’s physical and mental needs had been carried out. Progress has been made in developing thumbnail biographies and social care assessment assisted by the recent appointment of an activities organiser. The prospective resident/relatives are involved in the assessment and all information is used to determine the suitability of the placement. Where possible the manager or deputy carry out assessments and obtain information and care plans from other professionals for example, social workers, district nurses and hospital staff. Staff spoken with demonstrated understanding of the needs of the resident. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good core care plans are in place but the scope and personalisation could be improved. The staff provide a high standard of personal and nursing care to maintains residents’ health and well-being and dignity. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Storage of drugs for disposal needs to be improved. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 11 EVIDENCE: Core care plans are used but would benefit the residents if they were more personalised. In general the case files give detailed information stating how best to meet the residents needs and demonstrating that health care needs were being monitored and kept under review. Annual reviews are planned to take place and if possible will coincide with social services reviews. The night staff are going to be delegated responsibility for writing detailed night care plans. There was discussion about the possibility of senior care and key workers being delegated responsibility for writing the personal care elements of care plans signed off by the named RN who complete the clinical elements of care planning. Regular evaluation of resident’s care plans were taking place. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, the correct use of bed rails and how to reduce the risk of falls. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, the correct use of bed rails and how to reduce the risk of falls. Residents spoken with stated that they are well cared for and that “staff are excellent”, and “staff help me when I ask them”. The resident survey asked “Do you receive the care and support you need?” Of the 8 responses received all said, always. Comments included, “I am happy with the care I get”. The deputy manager has attended symptom control training at the Hospice. As yet formal end of life plans have not been written, however it is intended to seek advice from the hospice and write such in the near future. Observation of staff showed that they have a good awareness of how to respect residents’ privacy and dignity Residents spoken with said the staff were helpful and attentive to their wishes The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 12 Each resident was referred to a GP on admission to the home and an initial first visit was then set up. The majority of residents are registered with a local surgery and one of the doctors carries out weekly visits. Evidence from the care files and discussions with residents and staff showed that residents have visits from their GPs, physiotherapists, dentist, opticians and other health professionals. General Practitioner (GP) and Para-medical visits and their outcomes were well documented. Three GP’s who responded to the survey indicated they felt the overall standard of care in the home was good. One GP said that,” The manager and deputy are well informed and the home is well managed. Medication procedures and practices in the Home were reviewed, and the Home operates a safe system of storage, administration and recording of medication. Disposal arrangements are in line with current legislation, however the disposal bin does not provide secure storage of drugs awaiting disposal as the lid cannot be put on until the bin is full. The home has drug fridge drug fridge and suction equipment. None of the current residents wish to or are able to self medicate at the present time. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14.15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard and provides a balanced diet for residents. EVIDENCE: Another resident spoken with on the day stated that there are no restrictions to time of visiting One relative’s comment card stated that they are satisfied with the home and the services provided, “staff are very welcoming”. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 14 The home provides meaningful and fun activities for the residents. There is more effort being made to offer social engagement with some residents on a one to one basis if they do not enjoy group activities. At present there are no residents with particular cultural needs. The home has a new activities person that has been allocated 12-14 hours a week to provide activities for the residents. The stroke Association quiz book is in use and reminiscence products. Residents are assessed on an individual basis to enable the home to plan suitable activities after consultation with the resident/relatives on admission. Information on the activities preferences is regularly reviewed to ensure it remains up to date. The activities programme was displayed in the lounges and the hallway. There is a record of activities that residents participated in. Activities noted planned include trips and outings musical entertainment, bingo, exercise classes and aromatherapy. A recent resident/relative meeting was held but was poorly attended. The manager stated that the residents benefit from services run by the local church including Holy Communion for residents each monthly. A residents spoken with very much enjoys the service. The menu offers two choices for the main meal or an individual choice can be catered for. The menu is nutritionally well balanced and on the day the food was well cooked and nicely presented. Residents are asked their wishes in the afternoon for the following day. On the day of inspection there were two choices of meals in the menu cottage pie or Quiche. Residents spoken with stated that they enjoyed their meals. The kitchen looked clean and there is a cleaning schedule in place. The home was inspected by the South Gloucestershire Council Environmental Services and has started implementing a new food safety risk assessment and recording schedule. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints. Proper arrangements and policies are in place to protect residents from abuse. There are good arrangements in place for staff training and awareness of Protection Of Vulnerable Adults matters. EVIDENCE: The Home has appropriate procedures in place for the management of complaints. The complaints procedure was on display in the hallway at the entrance. The document contains contact details for the Commission for Social Care Inspection There had been no recorded complaints since the last inspection. The Manager stated that the home has an open door policy and has resolved any concerns before they became a complaint. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 16 All residents who completed a survey indicated that they knew who to talk if they were not happy and how to make a complaint. Comments included, “I’ve never had cause to complain “. Residents also said they would speak to their key workers or the manager to discuss any concerns they may have. Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. All staff are instructed in adult protection and prevention of abuse as part of their induction. There have been no allegations of abuse. There is evidence of ongoing staff training in relation to Protection of Vulnerable Adults. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the home to ensure that the home is aware of the protocol to be followed if incidents of abuse should occur. The home does not handle residents’ money. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of furnishing and décor in bedrooms and communal areas is good. The Home is safe, well maintained, and suitable for the needs of residents both internally and externally. The standard of cleanliness is high. EVIDENCE: The residents sitting in the communal areas and playing bingo appeared relaxed in their homely environment. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 18 Suitable dining room seating and table facilities are provided so that residents can enjoy their meal times comfortably and in a congenial setting. The home was found clean, warm, well lit and free from unpleasant odours. There is ongoing redecoration of rooms and replacement of bedroom furniture, including profiling beds. Replacement of flooring in specified corridors and carpets in some residents’ bedrooms. Suitable screening has been provided in bedrooms, which respects the privacy and dignity of the residents. Resident areas are fitted with appropriate aids such as grab rails, well equipped bathrooms with fixed and mobile hoists. All rooms have a nurse call system with audible alarm facility. New pressure relieving equipment has recently been purchased. Mobile and fixed hoists and stand aids are provided. There is a shaft lift, which give level access to all parts of the home. When surveyed residents said the home was always clean and fresh and one person said it was usually so. All verbal comments were in praise of the cleanliness of the environment and its upkeep. Sluice areas included one washer disinfector although there is a need to manage the odour in the sluice. The laundry has sufficient washing machines and tumble dryers. Two residents praised the quality of the laundry service. There are appropriate infection control, policy and procedures in place. Housekeeping staff have attended courses on Control of Substances Hazardous to Health (COSHH). There is an infection control policy in place. The clinical waste is correctly disposed of to prevent the spread of infections. The home’s maintenance book was up to date and a full time handy man employed to ensure that the home remains in a state of good repair. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in good order. The home is well staffed with appropriately trained and experienced staff for the number of residents. Good progress is being made training care staff for the benefit of residents. EVIDENCE: The staffing levels are in accord with or exceed the staffing notice for the residents. The staffing levels are indicative of the needs and level of care required by the residents. Surveys agreed that staff were always available when they needed and always listened and acted upon what the residents had to say. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 20 At present there are no Nurse or carer vacancies. The home has a small bank of staff and agency use is minimal. The domestic, catering, admin and laundry staffing levels are satisfactory. The induction programme is comprehensive and based on the Skills for Care standards. After completion of the commence foundation training care staff enrol on the National Vocational Qualification (NVQ) programme level 2 A robust recruitment policy and procedure is in place. The staff files inspected showed all the appropriate documents and checks were in evidence. In future CRB’s will be retained until the inspector has signed them off. Registered Nurse verification of registrations has been validated with the Nursing and Midwifery Council (NMC). A check of the NMC list of struck off or suspended staff is carried out. Surveys stated that, “the staff work hard to please the residents”. Other comments included, “The whole team are of a caring nature” and “Staff are friendly, approachable and respectful”. Residents spoken with stated that staff attended to them promptly when they rang the bells. The Home operates a named nurse and key working system to enhance the resident/staff relationships. Staff have received comprehensive induction training prior to attending to residents’ personal care independently. Training records show that all mandatory training including fire safety, food hygiene, first aid, load handling and adult protection was undertaken and course dates had been organised for staff. The manager has done additional training to train staff in load handling and Ms Harding in general Health and Safety matters. Registered nurse training records will be reviewed on the next inspection. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33.34.35.36.37.38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run taking into account the views and wishes of the relatives and residents and as they are able. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Responsible individual does not write Regulation 26 reports. Staff supervision is taking place. The Home protects the health and safety of residents and staff. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager and deputy are registered nurses who was able to demonstrate an understanding of the needs of the individuals living in the home and have a good team who work with them to ensure that high standards of care are achieved and maintained. The atmosphere in the home was positive and calm. Staff were noted interacting with residents in a caring and friendly manner. There was a scrapbook containing many thank you and commendation letters. Survey documents from GPs and relatives praised the manager and deputy for their attentiveness and skills. This is evidence of the Manager’s management style. People spoken with were complimentary about the management of the home. The manager is well supported by the deputy manager and Mr Hitan Patel (RI) to carry out his leadership responsibilities. Staff appraisal and supervision was reviewed. Some staff had received supervision on a one to one basis, however it has been ad-hoc and some nurses may require training to feel confident in delivering the process before it can be properly established. It was agreed that due to the size of the home that there would be a combination of supervision and appraisal for nursing and care staff four times a year. There was a high degree of satisfaction expressed by all of the residents spoken with. Based on the comments received from residents and visitors surveys and through observation it is evident that people feel the home is run in the residents best interests and their needs are being met. The manager conducts an annual audit to assess the satisfaction of residents with regards to the service and care that the home provides. This information is obtained through questionnaires and completed by residents and relatives. A survey has recently been carries out and when collated will be sent to the commission. Other quality review include care plan reviews; resident and staff meetings; daily visit to residents by the Manager and deputy; comment cards from visitors, home newsletter. In addition there are ‘back to work’ interviews with staff after illness and a health and safety audit. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 23 The manager has in the past written regulation 26 reports; Mr Patel confirms that in future he will write the reports. The home employs a maintenance man who works full time. Records showed that relevant inspections and maintenance has been carried out at the required intervals for the fire alarms and equipment, gas and electrical services, hoists and lift. Baths have thermostatic mixer valves and the monitoring hot water temperatures take place, however the temperatures recorded widely varying outlet temperatures. The manager made immediate arrangements to have the maintenance man attend to check all the outlet temperatures and adjust as required to provide comfortably hot but safe water. The fire logbook was up to date and in order. Staff fire safety drills and training are taking place at the required intervals. Accidents were noted to be properly recorded and reviewed as required. Discussion relating to the use of informing the Commission for Social Care Inspection through the Reg 37’s forms were discussed and the managers freedom to use judgement about what was serious enough to warrant notification to the Commission. All residents have risk assessments including tools for assessing falls and falls prevention The home has appropriate moving and handling and pressure relieving equipment and that staff have attended updates on handling residents. The Heathers Nursing Home DS0000062576.V344819.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 2 2 The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP37 OP9 Regulation 26 13.3 Requirement Timescale for action 30/10/07 Reg 26 to be written by the provider. The disposal bin for discarded 30/09/07 drugs should have a tamperproof lid to ensure the content are secure. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP38 OP25 Good Practice Recommendations Extend care plans to include end of life and night care plans. Submit a copy of the landlord gas safety certificate. Hot water temperatures need to be monitored at the outlet to ensure they are hot but do not exceed 45 degrees. The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI The Heathers Nursing Home DS0000062576.V344819.R01.S.doc Version 5.2 Page 27 - 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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