Care Home: Healy House (Burnley)

What the care home does well This inspection visit showed the manager and staff had worked hard to improve the service for the people living at Healy House. House meetings were being held each week, so people were kept involved and could be asked about things which affected them. They also knew how to raise concerns, one person said "Oh yes, I know what to do if I need to make a complaint" Everyone was happy with the meals provided, people were involved with shopping, choosing menus and cooking. "We get some good food and I cook for myself every week" was one comment made. People living at Healy House were being were being encouraged to gain selfhelp skills, by helping out around the home. People were being involved with different activities and they were getting out into the community. "I`ve started playing basketball once a week" explained one person. People were being supported to take an interest in their appearance, hairdressing and clothing. Support was being given with healthcare needs and appointments. The staff team were keen to provide a good service; they worked very well with the people living in the home. "It`s a good team at Healy House" said one staff. To show staff were being properly recruited and checked out before starting work at the home, good recruitment records were available. To make sure they knew what to do, staff were being given regular training. Records were being kept available to show things in Healy House were being serviced and checked for the safety of people living in the home. What has improved since the last inspection? A manager had been registered with the Commission, to take legal responsibility for the day-to-day running of the home. There were good ways of finding out about peoples` abilities, needs, likes and dislikes before they moved into the home.To make sure people receive proper care and support, care plans provided clearer details and instructions for staff, about any diagnosed mental illness. Agreements in care plans were being managed better; to ensure support is provided in line with what has been agreed. More attention had been given to ensuring there is a good balance between people making their own choices, personal safety and acceptable risk taking. To ensure people live in a safe, comfortable and pleasant home, Healy House was being well kept and upgraded. "It`s much better now," said one person. What the care home could do better: This home still needs to show ongoing improvement and good practice, to ensure there are continued good outcomes for people using the service. To do this, management of Healy House must continue to be effective. To ensure people are well supported, staffing matters need to keep being properly managed. To show people using the service are being protected and properly supported, information on the recruitment of agency staff should be available in the home; records should also be kept to showing they have had training when they start. To show the home is being properly monitored, reports following unannounced inspection visits by the owner must be available in the home. CARE HOME ADULTS 18-65 Healy House (Burnley) 11 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector Mr Jeff Pearson Unannounced Inspection 25th February 2009 09:30 Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 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 Healy House (Burnley) DS0000009528.V374606.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Healy House (Burnley) Address 11 Ormerod Road Burnley Lancashire BB11 2RU 01282 838845 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) Mrs Bridget Mary Healy Miss Misbah Tabassum Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To Service Users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of Service Users who can be accommodated is: 5 Date of last inspection 14th August 2008 Brief Description of the Service: Healy House is part of Healy Care Burnley, which includes three separate terraced properties. The properties are situated on the same road, in what is primarily a residential area. The home is close to shops and local resources. The accommodation available is homely and domestic in style. The home has a dining kitchen and a communal lounge. A room is provided for people who smoke. Following internal alterations, there were four single bedrooms, two having an en-suite facility, this therefore reduced the number of people who could currently be accommodated. There is a large yard to the rear of the home. Staff are on duty to provide support 24 hours per day. At the time of this inspection visit, the range of fees charged were between £450.00 and £900.00 per week, there were voluntary optional charges for entertainment and transport. The home had a Statement of Purpose and Service User Guide providing information about the support and services available. Copies of these documents and the most recent inspection report, were available in the homes office; this information should help people make an informed choice about accepting placement at Healy House. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people using this service experience good quality outcomes. An unannounced inspection, which included a visit to the service, was conducted at Healy House on 25/02/09. The visit took 7½ hours and was carried out by one inspector. A random unannounced inspection had been carried out at the home on 14/08/08. Random inspections are short, targeted inspections which may focus on specific issues that have come up or check on improvements that should have been made. This random inspection had been carried out to look progress in addressing previously made recommendations. The findings were progress had been made, but a requirement was made in relation to the owner visiting the home and completing a report of the findings. A report following this inspection will be made available on request from the Commission, to members of the public or other enquirers. The people living at the home and staff were invited to complete surveys, to tell the Commission what they think about the care and service provided at Healy House, some were received at the Commission. Before the visit, the owner was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of two people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with people living at the home, the registered manager and staff. Various documents, including policies, procedures and records were looked at. Parts of the home were viewed. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A manager had been registered with the Commission, to take legal responsibility for the day-to-day running of the home. There were good ways of finding out about peoples’ abilities, needs, likes and dislikes before they moved into the home. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 7 To make sure people receive proper care and support, care plans provided clearer details and instructions for staff, about any diagnosed mental illness. Agreements in care plans were being managed better; to ensure support is provided in line with what has been agreed. More attention had been given to ensuring there is a good balance between people making their own choices, personal safety and acceptable risk taking. To ensure people live in a safe, comfortable and pleasant home, Healy House was being well kept and upgraded. “It’s much better now,” said one person. 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 Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs; abilities and choices were known and planned, for before they moved into the home. EVIDENCE: There was an indication within surveys, that people living at Healy House had been involved in choosing the home. Also, that they had received enough information about the home, to help them in their decision to move in. There had not been any new admissions to the home since the last inspection. However, an initial enquiry was currently being dealt with, this was discussed with the registered manager, who explained the action being taken to ensure persons’ needs are properly considered and planned for. Records showed that appropriate information had been obtained and the person had recently been visited. The registered manager explained that the as part of the admission process, new people would be enabled to visit the home, to see the accommodation, join in an activity and meet with current residents and staff. Their compatibility Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 11 to get along with the other residents would be considered at this time. Paperwork was available to help ensure good information is gathered. The AQAA (Annual Quality assurance Assessment) indicated that a pre assessment checklist was to be devised assist with the admission process; the manager had almost completed this. The AQAA also showed, that supporting further staff to receive Approaches to Mental Health training, was a plan for future improvement. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care planning process helped ensure peoples’ individual needs, abilities and choices were known and effectively responded to. EVIDENCE: Progress had continued in ensuring people using the service, have their needs identified and responded to in an individual plan of care. This had helped in ensuring a more consistent approach to providing support. People using the service indicated in surveys and discussion, an awareness and involvement with their individual plans. Care plans seen, included much relevant information about peoples’ needs, abilities and goals, including rehabilitation and skill development, also very specific plans in response to behavioural needs and relapses. It was encouraging, that the care planning process was being used to work with individuals more effectively by focusing on positive Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 13 outcomes. Wording the content of the plans in a more person centred way, was discussed with the manager. Systems were in place to regularly monitor peoples’ life and situation and reviews were being carried out on a regular basis. People living at Healy House were observed to be involved in many activities of daily living; for example, they were being consulted about day to day matters such as meals, drinks, TV programmes, outings, how they spent their time and other matters which affected them. Some care plans included separate agreements in relation to alcohol, smoking, community access and financial matters. Progress had been made in ensuring the staff team respond appropriately to any agreed limitations and other people, such as Care Coordinators and Community Psychiatric Nurses were being more effectively involved. Attention had been given to ensuring individual risk taking is properly considered and planned for, positive interventions had been devised to minimise harm to the person and potential harm to others. This approach aimed to ensure safety risks are assessed, balanced with effectively promoting independence, rights and choices. General risk assessments had been carried out and also more in-depth risk assessments specific to individuals, including accessing the community, using public transport and eating out. Systems had been introduced to review risk assessments, in response to changes in peoples’ needs, behaviours and circumstances. The AQAA (Annual Quality assurance Assessment) indicated that ensuring care plans continue to be updated in response to changing needs, as a plan for ongoing improvement. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service were being supported to engage in activities, use community resources and keep in touch with families and friends. EVIDENCE: Progress had been made in supporting people to engage in activities, which offer a more positive experience. People using the service spoke of the various individual and group activities they were currently involved with, including, voluntary work, cinema, gym, swimming, basketball, meals out and shopping. A resource file of suitable educational and fun/leisure activities was available and a weekly budget provided to fund such events. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that finding relevant and appropriate community resources for people to attend, as an area for further development. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 15 Records and discussion showed people’s relationship needs were being considered; people were being supported to keep in touch with families and others as appropriate. “I met with my family at Christmas” explained one person. House meetings were being held weekly to discuss choices and various opportunities, including, meals, menus, activities and outings. Independence living skills were being encouraged, people were responsible for keeping their rooms tidy, changing their beds and doing their own laundry. They could make drinks and snacks for themselves and were involved with shopping and cooking. People spoken with said they were happy with the food provided “The food is very good” was one comment made, they said that menus were being agreed with them each week. Mealtimes were flexible, depending on what was happening each day. Individual food likes and dislikes were known and catered for. Fresh produce, including vegetables and fruit was seen to be available. Records were being kept of meals and foods taken by each person, it was advised further details be noted, to enable a better monitoring of diets and choices. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Health and personal care practices and procedures were effective in ensuring people’s needs are properly and safely met. EVIDENCE: The care planning process included peoples’ agreed support needs in relation to personal hygiene. It was apparent from discussion and observation; people were generally being supported to take an interest in their appearance, hairdressing and clothing, individual choices were being encouraged. The home operates a ‘named carer’ system, which involves, following discussion with the service user, staff being linked with a particular person, to help provide continuity of support. Interactions observed between the people using the service and staff, appeared sensitive; staff were respectful and genuine in their approaches when providing support and guidance. Records showed people were being supported to keep hospital, and other health care appointments, also the monitoring of general well-being and ill health. Mental health care needs were identified and responded to within Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 17 individual care plans. Care plans also included a ‘health check’ assessment, with any matters being dealt with in consultation with appropriate health care professionals. Staff training had been provided in relation to specific health care matters such as epilepsy and schizophrenia. The AQAA (Annual Quality Assurance Assessment) indicated a lack of some health care related policies and guidance; this was discussed with the manager who agreed to address this matter. Medication policies and procedures were seen to be available, it was advised the Commissions website be accessed for further guidance. Medication storage facilities were satisfactory; clean and secure, temperatures were being monitored. Systems were in place to audit medication practices. Assessments had been carried as appropriate on peoples’ ability to manage their own medication; consent forms were seen agreeing to any staff support. Medication records seen were generally clear and accurate. Individual protocols were in place for giving ‘when required’ medication. The manager said all senior staff responsible for medication administration had received training. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good 22 and 23 This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices, provided safeguards for people using the service and supported the complaints process. EVIDENCE: People using the service who had completed surveys and those spoken with during the inspection, indicated they knew how to make a complaint. One person said, “I know what to do if I need to make a complaint”. Staff completing surveys indicated they were aware of how to respond to concerns or complaints made by people using the service and others. The complaints procedure was included within the service user guide and a summary was displayed in each person’s room. People were being encouraged to raise any issues within the weekly house meetings and the complaints procedures had been discussed. Records were being kept of any verbal complaints and the action taken. Systems were in place to manage more formal complaints; it was advised this should include devising investigation strategies, to assist the process and show how the complaint was dealt with. Safeguarding policies and procedures were available. The manager and staff spoken with expressed a good understanding of the action to be taken in relation to allegations, incidents and suspicions of abuse. Appropriate action had been taken to ensure support practices at Healy House provide effective safeguards for people using the service. Updated safeguarding information had been obtained from the local authority. POVA (Protection Of Vulnerable Adult) Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 19 training had been provided and arrangements had been made for another two staff to attend this. The manager said POVA training was to be ongoing. Some staff had received ‘conflict resolution’ training and further similar training was to be provided. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The accommodation at Healy House provided people using the service with a comfortable and clean place to live. EVIDENCE: People using the service expressed an appreciation of the accommodation provided; in particular their bedrooms and the general improvements made at the home, “Its much better now” said one person. The lounge provided a very comfortable and contemporarily furnished living space. Improvements had been made in the dining kitchen; new worktops and cupboard doors had been fitted. The front shared bedroom had been adapted to provide single accommodation and the ground floor bedroom had been upgraded to include an en-suite facility. People had recently been supported to choose new be linen. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 21 One bedroom currently did not have any proper curtains, just nets, it was advised alternative arrangements be made to better promote privacy in this room, the manager agreed to take action in response to this matter. Observations, records and discussion showed most repairs to the home were being identified and responded too more effectively. The home was found to be clean and suitable laundry equipment was available. Most staff had an NVQ (National Vocational Qualifications) level 1 in cleaning. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. For the benefit of the people using the service, Healy House should show continued good practice in relation to staff recruitment, staffing levels, training and development. EVIDENCE: Records and discussion showed staff training was being given appropriate attention at Healy House. The training matrix showed training had been provided, was ongoing or being planned for. All staff had attained NVQ (National Vocational Qualifications) levels 2 or 3. Courses such as First Aid, Fire Safety, Health and Safety and also more specialised training including ‘Approaches to Mental Health’, ‘Drug Awareness’ ‘Schizophrenia’ and ‘Epilepsy’ had been arranged and planned for. One member of staff spoken with confirmed training was ongoing at the home. People using the service made positive comments about the staff team they said, “The staff are alright, they do their best” and “They are all good”. The staff rota showed satisfactory staffing levels were in place and sufficient Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 23 numbers of staff were on duty on the day the home was visited. There was always a senior staff on duty, to provide leadership in the absence of the manager. Staff spoken with and those completing surveys, considered staffing levels were satisfactory in providing support for the people using the service. The manager said that additional staff could be provided for various activities and support needs. There was waking watch night staff and clear systems in place for on call support. Staff completing surveys indicated checks were carried out on them before they started work. Recruitment records showed that, appropriate checks and screening had been carried out, references sought and interviews held. People using the service had been involved in selecting staff to work in the home. There were no records or details on site, in relation to the agency staff working at the home; this meant there was nothing to confirm appropriate recruitment checks had been carried out for the protection of people using the service. The manager had requested this information from the homeowner. The induction training records of the new employee showed good systems were in place to provide information and instructions over a 12-week period. A staff mentor had been assigned to oversee induction training. Staff surveys indicated the induction training covered all necessary matters very well. There were no induction train records available for the agency staff; however, the manager said initial training had been given. This matter was discussed further, the manager agreed to implement a suitable training programme to use with agency staff. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that plans were in place to continue with staff training and development. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Healy House must continue to ensure effective leadership and good management practices, for the benefit and well being of the people using the service. EVIDENCE: The Commission has had ongoing concerns about the operation and management of Healy House. There has been evidence of historical erratic performance at the home, which lead to a lack of sustained good practice. This inspection showed much progress in the general management of the home, including addressing previously made recommendations. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 25 Since the last main inspection the manager had been successful in her application for registration with the Commission. She had suitable qualifications and had continued to develop her skills by accessing relevant training. This inspection visit showed the manager was enthusiastic, proactive and competent within her role. People using the service and staff made positive comments about the conduct and ability of the manager. One staff described her as “Fantastic, approachable, contactable”. Regular staff and residents meetings were being held and the manager said some policies were to be summarised to make them more accessible to people using the service. The manager said quality assurance surveys had recently been given to people using the service and relevant professionals. Feedback about the service had had previously been received from all concerned, responses had been reflected within the AQAA (Annual Quality Assurance Assessment) The manager said the home owner had carried out unannounced inspection visits to Healy House, but there were nor records of the reports available at the home and the manager had not received a copy. This meant it was still not clear that suitable arrangements were in place to show the home is being properly monitored, for the benefit of people using the service. Documentation was available to show that installations and equipment, such as electrical wiring and appliances had been serviced. General health and safety risk assessments had been carried out. Records showed fire drills and fire equipment tests were being carried out. Fire risk assessments were also available in the home. Arrangements were in place for staff to receive training in safe working practice subjects. The home did not have an accident procedure available, the manager therefore agreed to take action in response to this matter following the inspection. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 2 X X 3 X Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 27 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 YA39 Regulation 26 (5) Requirement To show the home is being properly monitored for the benefit of people using the service, reports following unannounced inspection visits by the registered person, must be available in the home. The registered manager must also be given a copy of the reports. (Not addressed from last inspection) Timescale for action 30/04/09 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. Refer to Standard YA32 YA34 Good Practice Recommendations To ensure people using the service are effectively, consistently and safely supported, staffing arrangements should continue to be appropriately managed. To show people using the service are being protected, written confirmation that agency staff have been appropriately checked and recruited, should be available in the home. To ensure people using the service benefit from living in a well run home, management practices and leadership, DS0000009528.V374606.R01.S.doc Version 5.2 Page 28 3. YA37 Healy House (Burnley) must continue to be efficient and effective. Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Healy House (Burnley) DS0000009528.V374606.R01.S.doc Version 5.2 Page 30 - 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!