Inspection on 08/11/05 for The Herons Care Home

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Herons Care Home 16/07/07

The Herons Care Home 26/07/06

The Herons Care Home 20/07/05

The Herons Care Home 08/03/05

The Herons Care Home 06/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Herons Care Home Swiney Way Toton Nottinghamshire NG9 6GY Lead Inspector Lee West Unannounced Inspection 8th November 2005 10:30 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 Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Herons Care Home Address Swiney Way Toton Nottinghamshire NG9 6GY 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) 0115 946 0007 0115 946 1363 Derwent Housing Association Limited (Supported Housing Section) Jennifer Cooper Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: The Herons, part of the Derwent Housing complex, is a purpose built home in a residential area of Toton, close to the Tesco superstore and opposite the Chetwynd Army Barracks. The home provides care for up to 38 older people, with rooms on two floors with a passenger lift between the levels. All the rooms are single and en-suite. The home is well maintained, pleasantly decorated and clean. The gardens are well maintained and are regularly used by the service users and there is a gate to the adjacent school where community links have been formed. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out using the Case Tracking method, Where 4 Service users were spoken with about their experiences and expectations of living at the home, with analysis of the records and talking with 3 members of staff to ensure that those living at the home have their needs met and their health and welfare maintained appropriately. There were a number of relatives and visitors present and they were also interviewed for their views. Belinda and Debbie assisted during the inspection. The inspection commenced at 2.30pm and it was noted that a number of service users were in the lounge area being served with tea, which was being offered to the visitors as well. The home was warm and had a homely atmosphere, even though the weather outside was cold and stormy. The home continues to provide a high standard of accommodation with a wide variety of activities arranged within an active social programme. What the service does well: What has improved since the last inspection? The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 6 The complaints procedure has been improved to an electronic system. The staff have up to date individual training records available and all staff are now permanently employed and not agency staff. 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 Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 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 Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Prospective service users, and their relatives, have the information needed to make an informed choice and also an opportunity to visit the home and stay on a trail basis. At the time of inspection there were no service users assessed for intermediate care within the home. EVIDENCE: Service users spoken with confirmed that they were given written and verbal information about the home and its services. They also confirmed that they were given the opportunity to stay in the home on a trial period. Written terms and conditions were seen and relatives spoken with also said the home provided much needed information to make choices. Assessments are carried out to ensure the home can meet the individual’s needs. One service user spoken with said “everyone has been really kind and this helped me to make up my mind to stay here.” The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 9 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): 7,8,9,10,11 Individual care plans are in place for each service user, whose needs are met. Medicines are stored and procedures correctly followed. Service users’ right to privacy is upheld and on the whole they are treated with respect. The wishes of service users upon death are followed. EVIDENCE: Medication was not fully inspected during this visit, however, Medicine Administration Records for the service users case tracked were correctly completed and given. All medication was stored appropriately and safely. Care plans are produced using the assessment of service user health, welfare and social needs. However, the paperwork for these has changed since the last visit and now do not show the actions required to address any identified needs. The day to day records show some inappropriate judgemental comments about the service users, but service users and visitors spoken with all were satisfied that they were treated with respect, that staff tried to preserve their dignity and always knocked on doors of private rooms. This was also observed by the inspector to be the case during the visit. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 10 Sadly, a service user has died since the last inspection and the staff followed the wishes set out in the care plan. The relatives of this service user sent a thank you card to all the staff which evidenced that the wishes were respected. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 11 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 Service users’ families and friends are made welcome and maintaining contact within the community is encouraged. Social, religious, cultural and recreational interests are met and the positive atmosphere within the home encourages service users, especially in exercising control over their lives. EVIDENCE: There is an activities organiser within the home who works towards meeting the preferences of the service users. Relatives and friends spoken with during this inspection, were satisfied that they are made to feel welcome, they are always invited to the evening activities and links with the local school provide opportunities for service users to attend events at the school. The back gate between the school and the home is well used to access the school. Service users are encouraged in all areas of interest, with some choosing the access the local college and university campus. The residents’ meeting which takes place every four weeks identifies possible future activities of interest to the service users. The service users spoken with all affirmed that they were always given choices over all areas of their lives. Service users and visitors were satisfied with the food, “excellent” “plenty of it”, “always willing to change something if I don’t like it” were some of the comments made to the inspector. The menus were varied and individual preferences were met. This was observed during this inspection when a The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 12 service user did not want sandwiches at teatime, these were changed for toast and marmalade requested by the service user. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 13 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 The home’s complaints procedure has been improved. The service users are protected from abuse, however, some inappropriate judgemental statements were written. EVIDENCE: Since the last inspection, the Home have installed a database “Comptrac” which takes the complaint through from first reporting to conclusion. The instructions for this were seen by the inspector and the administrator showed the inspector the database in action. The information remains confidential and, providing the information is put into the system, it produces accurate reporting and outcomes of complaints. This is accompanied by a new policy and information leaflet which has been given to all service users and are placed in the foyer of the building, which sets out all the stages of making a complaint and contains a card to make a complaint if needed. There is also a residents’ meeting every 4 weeks and records of the last meeting on the 28th October 2005 were seen. Complaints are aired during this meeting. All staff spoken with during the inspection are aware of the Protection of Vulnerable Adults procedures and their roles within those procedures. The daily records in the care plans though do show some inappropriate judgemental statements about service users, “rude” “doing stupid things” “uncouth” are examples. The staff, when spoken with about this, were unaware that their comments could be offensive if read by service users or their relatives, but were aware that if spoken the comments would be offensive. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 14 The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25,26 The home presents a well decorated, well maintained environment. The communal rooms are comfortable and clean as are the service users’ own rooms. All bedrooms have en-suite facilities and there are sufficient toilets and bathrooms for all. Specialist equipment is available. EVIDENCE: During the inspection, the lighting was being checked in the dining room. The communal rooms were observed to be clean, well decorated and warm on a very cold, stormy afternoon. The garden is accessible to service users, some of whom have potted plants on the patio area and is well maintained. The service users spoken with were highly satisfied with their rooms “I love it here the room is twice as big as my old place and I’ve got all my stuff I need around me.” They are encouraged to have their own possessions around them and the rooms inspected all reflected this to be the case. All areas of the home were safe and clean. The bathrooms and toilets for communal use were sufficient and hygienic. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 16 Specialist equipment of hoist and mobility equipment were seen during the inspection and service users said that they were used regularly. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 17 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 The home employs staff ensuring the needs of the service users are met and are in safe hands. The recruitment practices are thorough and protect the service users. Staff receive regular training. EVIDENCE: The home is now fully staffed with permanent staff and there is an appropriate mix of staff. The duty rota reflected this mix with sufficient staff on duty to meet the needs of the service users. The training records seen were up to date and staff records confirmed the recruitment policies and procedures were being followed correctly. Training programmes, including NVQs were evidenced to be carried out within the case tracked staff files. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 18 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): 31,32,33,36,37,38 The home is run by a Registered Manager whose leadership skills ensure the home is run in the best interests of the service users. The record keeping meets the requirements to safeguard the interests, health, safety and welfare of service users. Staff supervision is not being carried out formally at the time of the inspection. EVIDENCE: The home is managed by Jennifer Cooper, who is registered with the Commission. The staff team all focus on the needs and interests of the service users. The service users spoken with during the inspection said they were really happy with the way the staff help them to be as independent as possible, to maintain their safety where necessary and they said that they felt the home was run in their interests. “Nothing is too much trouble for the staff” “They are always willing to listen to my ideas” “things are done when I ask, in my last place it was when staff said. This place is lovely” are some of the comments made. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 19 Records were seen to be up to date and accurate at the time of the inspection and staff and service users confirmed that regular fire alarm testing was carried out. Staff supervision is still being organised. During the last inspection the manager said she was aware that a system was required. However, new paperwork is in the pipeline for this and the new system should be implemented by the beginning of the new year. Staff did say that they have received informal supervision. The Senior members of staff have received supervision and the management have concentrated efforts into continuing to build a strong senior care team, to ensure the continuation of the good care standards. The staff supervision is now essential to avoid the risk of reducing the care standards achieved and to monitor staff effectiveness and professional and personal development needs. The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 20 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 3 The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Prepare a written plan after consultation with the service user as to how the service user’s needs in respect of health and welfare are to be met. To keep the plan under review and after consultation with the service user or a representative, revise the service user’s plan at least once a month or when changing needs require the plan to be updated. Ensure that persons working at the care home are appropriately supervised and receive formal supervision at least 6 times a year Timescale for action 02/02/06 2 OP36 18(2) 02/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 22 The Herons Care Home DS0000008691.V259366.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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