Inspection on 17/07/06 for The Heathway

This inspection was carried out on 17th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Heathway 30/11/05

The Heathway 08/07/05

The Heathway 02/12/04

The Heathway 03/08/04

The Heathway 22/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Heathway, The 70 Reddicap Heath Road Sutton Coldfield West Midlands B75 7EN Lead Inspector Jill Brown Key Unannounced Inspection 17th July 2006 08:45 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 Heathway, The DS0000033584.V304613.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. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathway, The Address 70 Reddicap Heath Road Sutton Coldfield West Midlands B75 7EN 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) 0121 329 2222 0121 378 1878 Birmingham City Council (N) Indira L Surju Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the home is registered to accommodate 26 adults over the age of 65 who are in need of care for reasons of old age and may include mild dementia That minimum staffing levels are maintained at 4 care assistants plus a senior member of staff throughout the waking day of 14.5 hours Additionally to the above minimum staffing levels, there must be 2 waking night care staff and a senior on waking or sleeping-in duty Care manager hours and ancillary staff should be provided in addition to care staff Registration category will be 26 (OP) Date of last inspection 30th November 2005 Brief Description of the Service: The Heathway is a large, purpose built Local Authority care home for 26 elderly people. The home is located in Sutton Coldfield in a mainly residential area close to the Falcon Lodge estate. Sutton Coldfield centre is approximately one mile away where numerous community facilities are located. Public transport is available from outside the home. The building comprises of three floors but living accommodation for the residents is provided on the first and second floors. The ground floor provides office space for the management of the home together with an age concern coordinator, community psychiatric nurses and a day centre. Also on the ground floor is the main kitchen and laundry. The two upper floors are a mirror image of each other in design and comprise of two lounges, a dining room, bedrooms and small kitchenettes. There are bathing and toilet facilities throughout. The residential accommodation for the residents was generally well decorated and comfortable. A sensitivity garden with ramped access, smooth brick surfaces and raised flowerbeds is at the rear of the home and provides residents with a pleasant, sheltered environment in which they and day centre users can enjoy the warmer weather. There is parking to the front and side of the home. The current full fees for the home are £472.00 per week. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place over 10 hours on a day in July. For this inspection the inspection 18 comment cards from residents and 8 from relatives. The inspector talked to 1 relative and 8 residents during the inspection. The inspector looked at a variety of records looking at three residents care files, three staff files, and accident and medication records. A tour of the building was undertaken and records such as fire, building and food safety were look at. The manager and assistant managers on duty were spoken to. The home completed a pre-inspection questionnaire before this visit and information from notifications about accidents and so on were taken into account. What the service does well: The home has detailed assessments, which give information about residents’ health conditions and daily routines. This information helps the home develop care plans called Individual Service Statements (ISS) in this home that respond to the residents’ difficulties and abilities. Residents and relatives are happy with the care provided in the home and said ‘ The care and support is excellent and first class,’ ‘I feel I can discuss anything with them about my health and family.’ ‘Staff act and listen’ ‘I like everyone.’ A relative thought that ‘the kindness and standard of care by all staff at the Heathway was excellent.’ The home showed that they could respond to cultural and religious needs; there were expectations that residents be assisted to meet their religious needs and menus showed that the catering staff would respond to being asked for cultural preferences. The home had ensured that staff received training in conditions such as dementia and diabetes and skills such as communication. The home had developed daily records that showed when individual residents were involved in activities and when anyone health caused concern. The staff ensured that concerns about health were followed up. The home had good staff records and this showed that staff undergo rigorous checks before being employed. Staff files showed supervision of staff and monitoring of staff performance was done. Staff were receiving appropriate Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 6 training however it was not possible to see if all the staff had all the appropriate training on this visit. The home has regular staff and resident meetings and this can ensure that the home continues to improve. The manager has the experience and qualifications to run the home well. What has improved since the last inspection? What they could do better: The home should provide simple information about services they can offer like use of wheelchairs, and their expectations from relatives such as personal allowances reviews and so on. A copy of the resident’s contract was not always completed on the care file and this means there was no way of checking who had received it and whether the contract had been updated. A number of potential needs had not been risk assessed. These needs were about whether residents were at risk of developing pressure areas, or likely develop health conditions because of their weight and nutrition. These issues had remained outstanding from the previous inspection. Residents weights showed that some residents were gaining and a number were losing and there were no clear plans for ensuring residents health in this area. One resident’s file showed an identified mental health condition that deteriorated in the past. There were no clear recordings of signs that may show that this individual’s mental health was deteriorating again. The home had a fairly roust medication process however this was let down by lack of assessment of residents that self- administer medication. Although the environment appeared to improving key issues remain outstanding. The unit kitchens’ fridge and the medication fridge temperatures were too high and this could lead to contamination. The residents could not alter bedroom radiators to respond to changes in temperature and the lighting Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 7 was fluorescent in some areas and this is not seen as promoting a homely atmosphere. At the time of the inspection bath hot water outlet was not restricting the temperature adequately and this was made an immediate requirement. However the home manager ensured that this was rectified on that evening. A whole staff team record of training was not updated so that the inspector could see the whether this was sufficient to ensure that training remain in date for all staff. The home did not have records available of the insurers inspection of the passenger lift or the gas landlords certificate on the premises and these must be sent to the Commission. 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. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do not move into the home without an assessment. Information given to residents and their representatives could be improved to ensure that relatives have clear expectations and rights. Residents have staff that are able to meet their needs and arrangements are made to meet any cultural and religious needs. EVIDENCE: The homes contract remained the same format as previous inspections room numbers had been added to ensure that residents knew that the bedroom they were paying for. Details about charges for the home had not been updated on the contract however residents receive information from accommodation charges about their fees. All comment cards received said that they had received a contract and were given enough information and support prior to admission to the home. One care file did not have a copy of a completed contract. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 10 The home had no new admissions therefore the admission process could not be assessed fully so a previous requirement about ensuring there is an assessment on the preadmission visit was brought forward. Whilst comment cards said that admission to the home were good one family commented that it would be helpful if they were informed of what to expect especially things like whether wheelchairs were available if they take their relative out. Assessment information on the files selected was detailed and gave information about resident’s preferred daily routines as well as their health needs. This helps to make sure that care is given in a way and at a time to suit the resident. The home has access to community psychiatric nurses for residents that have mental health needs and a number of these are based on the site. Residents have access to their GP, nurses, chiropody dental and ophthalmic services and records of these visits are kept. Residents can have Holy Communion visits from the local church if they wish and arrangements can be made for other faiths if needed. Menus clearly state that alternative menus are available to meet health and cultural needs on request. A number of staff have completed courses on dementia awareness and communication skills. This ensures that residents that have needs beyond the usual population of the home can be planned for. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home produces a number of good plans for some need there are gaps, which could lead to health care needs not being met. Systems for administration were generally satisfactory but risk assessments for residents that self-administer medication needed to be I place to ensure that residents were safe to do so. Residents felt and were treated with respect. EVIDENCE: Residents have care plans produced by the home called Individual Service Statements (ISS). ISS contain good information such as the name residents prefer to be called by, personal routines such as time to get up and going to bed, activities and management of health conditions. There was evidence of risk assessments being undertaken for moving and handling, but not for nutrition, keeping skin healthy or relapse triggers for Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 12 people with mental health problems. These risk assessments are important because they help determine ways to keep people well and safe. Behaviour such as refusal to accept personal care or medication did not result in a plan on the ISS. ISS and risk assessments were not kept near to the staff giving the care. Key information such as moving and handling assessments must be kept near to staff to ensure that they check these before moving the resident. Resident’s weights were collected and from these records residents with low weight were either stable or increasing in weight. However there were residents that were gaining large amounts of weight and of low weight that did not have adequate nutritional plans. Residents appeared well cared for with their personal hygiene needs such as hair care nails and so on being met. The home manages medication well with senior staff taking responsibility for ensuring that the medication received into the home is the same as prescribed. Controlled drugs were accounted for appropriately. There were clear photographs of residents with the Medication Administration Record (MAR) and on the drug cassette and copies of the prescription from the doctor. These checks to ensure that the right medication is given resident are good practice. Not all residents that self-administer medications had a risk assessment and reviews to ensure they were safe to do so and this was outstanding from a previous inspection. Medications stored in the fridge were dated when opened but the fridge temperature was registering above 8 degrees centigrade, which means some medications were being stored outside what the medication is registered for. A mistake in carrying over the number of medications left from the previous MAR on the day of the inspection meant that a number of boxed medications appeared to have the wrong amount of tablets however a check on the previous MAR showed the count of tablets was correct. Not all homely medications given were individually checked with the prescribing GP and this must be done to ensure that the homely medications do not react with prescribed medications. A couple of residents said on comment cards that they found the medication difficult either they said there was too many tablets or they were too big and these comments could be usefully discussed with the prescriber. Residents said of the care they received: - ‘ The care and support is excellent and first class,’ ‘I feel I can discuss anything with them about my health and family.’ ‘Staff act and listen’ ‘I like everyone.’ A relative thought that ‘the kindness and standard of care by all staff at the Heathway was excellent.’ Staff showed a kind and considerate attitude to individual residents on the day of the inspection. The home has yet to improve residents’ access to a private telephone line. However the inspector was informed that the telephone system the home was changing shortly and this would be looked at this point. Heathway, The DS0000033584.V304613.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be involved in activities and have choices about how they live their life in the home, meals and visitors and this enhances resident lives. EVIDENCE: Daily records show that residents have activities on a regular basis such as dominoes, exercises, bingo, painting, theatre, and time in the homes garden as well as watching TV. Residents said they joined in activities when they wanted to one said ‘There are activities but I like my own company,’ ‘I spend most of my time reading or watching the TV.’ Residents were seen in the garden with relatives, enjoying a board game with staff, and watching the television during the inspection. Residents that have difficulty in joining group activities need an individual plan in their ISS to ensure they get one to one time with staff. Comment cards suggested that relatives felt welcome in the home. Residents felt that they could have visitors when they wanted. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 14 There were no undue restraints on residents in the home. However it was clear that residents had a number of restrictions on the day of the inspection due to the decoration of the corridors. A number of residents spent time in their rooms watching their own televisions. Comment cards all say the food is good except for 5 of the 18 who stated it was usually good. Food stocks were good and the kitchen rotated the stocks they had to ensure food was used within the ‘best before’ dates. The menu showed a good variety of food on offer. There was a choice of foods at breakfast, lunch, tea and supper. The residents could have a cooked breakfast at the weekend if they wished. The menus indicated that further choices were available to meet health and cultural needs. One resident had a risk assessment for thickener that was needed in drinks. One residents’ meeting asked for crumpets on the menu and this was seen as option for an evening snack. This showed the home was responding to needs and wishes identified for meals. Heathway, The DS0000033584.V304613.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 inspected at least once during a 12 month period. 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. The home has good procedures in both adult protection and complaints and residents show a confidence that their concerns will be dealt with appropriately. EVIDENCE: The home had one complaint in the last 12 months and this was under investigation. The home has appropriate complaint procedures that consistent with all the homes run by the city council. The majority of residents knew how to complain and were clear whom they would speak to if they were unhappy. Comments made were ‘I normally say if I’m unhappy’ ‘ If I have any comment to make I tell the staff the next day.’ The Commission have received no complaints about this home since the last inspection. The home has copies of the Birmingham multi-agency guidelines on adult protection. There have been no referrals of an adult protection nature since the last inspection. A number of staff have received adult protection training in the last year. The staff and residents have opportunities to state any concerns and this keeps residents safe. The home keeps an inventory of resident’s belongings on admission to the home and keeps good records of residents’ money and this keeps residents belongings safe. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the homes’ environment was being improved it was not possible to see the full impact of the changes being made. A number of issues such as residents being able to control the heat and their rooms and water temperatures prevented the environment being good. EVIDENCE: The environment was undergoing some work at the time of the inspection and these improvements should make the environment good. Residents stated in the comment cards that the home was always clean and fresh. The home was clean throughout. The home had a nice enclosed garden area and this was being used during the hot weather. Bathrooms were also being refurbished and this made inspection of a number of them difficult. The home had a good number of bathrooms for the number of residents. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 17 The bedrooms in the home come in two sizes the larger bedrooms are at a premium and existing residents put their names down for the larger bedrooms when they become vacant. Residents’ rooms were individual in style. Residents were able to bring in small bits of furniture and ornaments to decorate and furnish their room and on occasion this includes a double bed. Residents have keys to their bedrooms where appropriate and if this is not possible the reasons are noted in their care plan. Residents are not able to determine the heat in their bedroom as radiators are centrally controlled and do not have access to thermostatic valves. A number of the resident rooms viewed had fans to assist in keeping the room cool during the hot weather. The hot water temperature in a bathroom was hot and the thermostatic valve did not appear to moderate the temperature. An immediate requirement was left about this. The manager immediately contacted the maintenance firm to arrive at the home that day. The homes small kitchens showed that the fridges were kept at above the 8 degrees centigrade required and the 5 degrees recommended this could mean that food becomes contaminated. The main kitchen of the home had an inspection from the Food Safety Department in May 2006 that reported that at the time of their inspection the home’s food hygiene standard was very good. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home showed that they had a robust recruitment and training methods. They showed that staff are skilled, they had clear expectations about how staff were to perform and checked this. This means residents can be assured that they are in safe hands. EVIDENCE: The home has had some residents’ places not being used until staffing levels can be recruited to. The manager reports that although these vacancies have been advertised there has been a poor response and a number of hours remain vacant. Staffing rotas showed the home has managed to keep the home appropriately staffed with the use of agency staff. A relative felt that the staffing levels had been short on occasions. Residents however thought that staff were available both to give care and listen to them. Over 50 of the care staff have at least an NVQ2 in care, which means staff are clear what is good care for residents. The home keeps records on the staff that work at the home and these are quite robust. There is a clear process from the home advertising a job, to application form to the appointment of a person. Health checks were undertaken, references applied for and Criminal Records Bureau checks applied Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 19 for. One staff member’s file did not show that further checks had been undertaken on the limited stay granted in the UK. Files recorded supervision and detailed occasions where performance of staff fell short or was better than expected and this showed that staff performance was monitored. It was clear that staff received training on mandatory subjects such as moving and handling, health and safety and so on shortly after starting work. Induction is starting to match the Skills for Care organisation guidelines and this is good practice and enables staff to give care for residents appropriately. Staff employed by the City council are subject of a probationary period and this is good practice. The full staff team training matrix needed updating at the inspection and the home were to send in a copy of this subsequent to the inspection. It was clear that staff were having training but it was difficult to assess whether the home had met the targets for the full staff team. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run with the interest of the residents being promoted. A number of inspection records for services such as gas were not in the home and this is the job of a central department at the City Council. EVIDENCE: The Registered Manager has worked in care of older people for a number of years and has completed the Registered Managers Award. She has a diploma in management of care. These mean that she has the qualifications and the experience to manage the home effectively. The homes last independent quality assurance took place at the beginning of 2005 the home did well in this audit and also showed that they had taken action on areas identified as weaknesses subsequent to that inspection. The Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 21 home holds resident meetings on a regular basis averaging one every 2 months. Outcomes of concerns raised in these meetings need to be recorded so residents are clear about how their concerns are responded to. Residents’ money was managed appropriately with the amount kept in the home matching the accounts on the records sampled. The home does not check the accounting on a routine basis and it is recommended that this is done at least once a month. Residents that are able are encouraged to manage their own money. Care staff routinely had supervision from a member of the senior staff. This was planned for monthly; whilst this was not always achieved the home still met the standard of six times a year. This ensures that staff have an opportunity to discuss areas of the home’s working that they are concerned about and allows managers to check staffs training ad performance. The home ensures that the maintenance and inspection of services in the home for example wheelchairs are checked monthly, the nurse call system, water quality and fire safety checks were completed. The passenger lift inspection by the insurer was outstanding. A gas landlord certificate was seen to be out of date. Whilst these checks may have been done the certificates were not in the home and the home had no record of the checks being carried out. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 3 X X 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4(1)Sch 1 Requirement The registered person must ensure that the statement of purpose is accurate and all appendices are available. A copy of the updated statement of purpose must be forwarded to the CSCI. (Previous timescales of 18/01/04 and 01/09/05 not met Not inspected on this occasion.) The registered person must ensure that the service users are given a contract reflecting their status in the home. (Previous timescales of 01/10/04 and 01/08/05 and 01/01/06 not met) The registered person must ensure that a recorded assessment is carried out at the pre-admission visit. (Previous timescales of 01/03/05 and 01/08/05 not met. Not inspected on this occasion) The registered person must ensure that ISS’s cover all the DS0000033584.V304613.R01.S.doc Timescale for action 30/11/06 2 OP2 5(1) 30/09/06 3 OP5 14(1) 30/09/06 4 OP7 15(1) 30/09/06 Heathway, The Version 5.2 Page 24 5 OP7 12(1)(a) 6 OP7 15(1) 7 OP8 12(1)(a) 8 OP9 13(2) identified needs of service users and state how care staff will meet these. (Previous timescales of 01/10/04 01/09/05 and 01/02/06 not met) The registered person must ensure that the service user assessment covers nutritional needs and tissue viability. (Previous timescales of 18/01/04 01/09/05 and 01/02/06 not met) Residents that have diagnosed mental health needs must have a plan in the ISS to show how these needs are to be met including behaviour, relapse triggers where appropriate. Any unexplained amounts of gain or loss in weight must result in action including a nutritional plan. The home must ensure that residents that self-administer medications are assessed as safe to do so and their abilities routinely reviewed. All homely medications must be checked with the prescribing GP. All medicinal fridges must have their maximum current and minimum temperatures record and must not register outside 28 degrees centigrade. The home must look at ways in which residents can be enabled to make telephone calls in private. (Previous timescale of 01/10/05 and 01/04/06 not met) Individual residents that are unable to join group activities must have an activity plan to ensure one to one time with staff. Flooring in the corridors should be replaced. DS0000033584.V304613.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 9 OP10 12(4)(a) 30/11/06 10 OP12 16(2)(n) 30/09/06 11 OP19 23(2)(b) 30/11/06 Page 25 Heathway, The Version 5.2 12 OP25 23(2)(p) (Previous timescale of 18/03/04 01/10/05 and 01/06/06 were not met and the home was undertaking work) Lighting throughout the home 30/11/06 should be domestic in character. (Previous timescales of 01/05/04 01/10/05 and 01/06/06 not met) The registered person must ensure that service users are able to control the temperature of radiators in their bedrooms. (Previous timescales of 01/10/04 and 01/10/05 not met) Bath hot water outlet temperatures must always be restricted to safe temperatures. Immediate action to be taken on the bath identified. (Subject of an immediate requirement) Unit fridge temperatures must not exceed 5 degrees centigrade. The home must ensure that it has a method of checking that time limited visas are checked at approaching the renewal date. The home must send an updated version of the homes training matrix. (Outstanding since 01/02/06) The registered person must ensure that reports of the monthly team managers visits are available for inspection. (Partially met). This standard was not inspected on this occasion. A copy of the certificate for the insurers passenger lift inspection must be sent to the Commission. A copy of the Landlords Gas Certificate must be sent to the Commission. 13 OP25 13(4)(c) 18/07/06 14 15 OP26 OP29 13(3) 19 30/09/06 30/09/06 16 OP30 18(1)(c) (i) 26(5) 30/09/06 17 OP37 30/11/06 18 OP38 23(2)(b) 30/09/06 Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 26 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 OP1 OP9 OP35 Good Practice Recommendations It is recommended that the home add to their information what the home expects of relatives and what they can expect from the home. It is recommended that where there is a difficulty with medication for the resident this be discussed with the prescribing GP. It is recommended that the home check the calculations in the records of residents’ money as well as the balance at least once a month. Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Heathway, The DS0000033584.V304613.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!