Care Home: Heartly Green

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What the care home does well The home provides detailed information to people thinking about moving in. Assessments of peoples needs are carried out before people move in to make sure the home can meet their needs. Care plans are written in a person centred way and it is evident that people are involved in the planning of their care.Heartly GreenDS0000072939.V375387.R01.S.docVersion 5.2Recruitment is robust and makes sure that staff are safe to work with vulnerable residents. They have good working relationships with colleagues in the Primary Care Trust, community nurses and GP`s. They carry out quality audits both internally and externally. They have resident and relative meetings to make sure that people are involved in decision making within the home. Prospective residents who have an opportunity to visit the home and even a short stay in the home to make sure it is the right place for them. They carry out monthly audits to make sure systems are working correctly. They have a varied and balanced menu. This means that residents can choose from a range of meals. There is always food available through the night if needed. They have a structured activities programme, with a dedicated activities organiser. What has improved since the last inspection? This is the first inspection of this service. What the care home could do better: A recommendation was made that daily records be more detailed to show the actual care delivered by care staff. A recommendation is made that when transporting people in wheelchairs staff make sure both footrests are in place on the wheelchair. A recommendation is made that the manager arrange for a medication review for the person whose medication was prescribed `when required`. Key inspection report CARE HOMES FOR OLDER PEOPLE Heartly Green Cutnook Lane Irlam Manchester M44 6JX Lead Inspector Sue Jennings Key Unannounced Inspection 12th May 2009 09:30 DS0000072939.V375387.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heartly Green Address Cutnook Lane Irlam Manchester M44 6JX 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) 0161 777 7000 0161 777 7059 Inspirit Care Limited Jean Mann Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59) of places Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 59 Date of last inspection Brief Description of the Service: Heartly Green is a purpose built care home managed and registered in the name of Inspirit Care Limited a subsidiary of Community Integrated Care (“CIC”), a registered charity. Accommodation is offered over two floors and all bedrooms are en-suite with additional communal areas, which can be used for small and large group activities. The first floor offers accommodation to 29 people who require intermediate care. The ground floor offers accommodation to 30 people. The home is located in a residential area of Irlam in Salford and is close to shops, parks and transport routes and services. Parking facilities are available to the front of the building and the grounds offer secure well-maintained external areas for service users to access. The fees for the home range from £383.47 to £525.00 per week. Additional charges are made for hairdressing, newspapers and toiletries. Heartly Green DS0000072939.V375387.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 stars. This means the people who use this service experience good quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Care Quality Commission) in relation to this home prior to the site visit. The site visit was unannounced and took place over the course of 8 hours on Tuesday 12th May 2009. During the course of the site visit we spent time talking to people who live at the home, visitors the manager and care staff to find out their views of the home. We spent time looking at records. We looked at the care files of people living at the home and staff files. We also walked round the home and looked at communal areas and a sample of bedrooms. This visit was just one part of the inspection process. Other information received was also looked at. Some weeks before the visit the manager was asked to complete a questionnaire called an Annual Quality Assurance Assessment (AQAA) telling us what they thought they did well, what they needed to do better and to give us up to date information about the service provided. This helps us to determine if the management of the home see the service they provide in the same way we do and if our judgements are consistent with homeowners or managers. This service was recently re registered with us and therefore is classed as a new service with this being the first inspection, no references will be made to previous inspections of this home. References to we or us throughout this report represent the Care Quality Commission. What the service does well: The home provides detailed information to people thinking about moving in. Assessments of peoples needs are carried out before people move in to make sure the home can meet their needs. Care plans are written in a person centred way and it is evident that people are involved in the planning of their care. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 6 Recruitment is robust and makes sure that staff are safe to work with vulnerable residents. They have good working relationships with colleagues in the Primary Care Trust, community nurses and GP’s. They carry out quality audits both internally and externally. They have resident and relative meetings to make sure that people are involved in decision making within the home. Prospective residents who have an opportunity to visit the home and even a short stay in the home to make sure it is the right place for them. They carry out monthly audits to make sure systems are working correctly. They have a varied and balanced menu. This means that residents can choose from a range of meals. There is always food available through the night if needed. They have a structured activities programme, with a dedicated activities organiser. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Heartly Green DS0000072939.V375387.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 Heartly Green DS0000072939.V375387.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given enough information, and have their needs assessed before deciding to move into the home so they know that their needs can be met. EVIDENCE: They had a service user guide that gave detailed information about what they offered. This is given to prospective residents’ and gave enough information for people to make an informed decision about moving in. This document was under review to include the details of the newly appointed manager. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 10 We saw that assessments of people’s needs are carried out before admission. They told us that, before admission they receive a copy of the care manager’s or nursing needs assessment. This is done to make sure the staff at the home could meet the person’s needs. At the time of this visit the manger said she or a deputy carried out the pre admission assessments. A care plan was written using the information gathered during these assessments. We spoke to a visitor who told us that they were given an opportunity to visit the home before making a decision about their relative moving in. One person at the home told us “I used to work here on this site as an auxiliary before the new home was built I knew the area and wanted to come here”. The home provides 29 intermediate care places on the first floor. This is to provide rehabilitation for people following discharge from hospital in preparation for their return home. They also provide intermediate care to provide rehabilitation that prevents a hospital admission. Heartly Green DS0000072939.V375387.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans and risk assessments were detailed they addressed individual health, personal and social care needs and medication practices safeguarded residents. EVIDENCE: We saw that care plans were written in a person-centred way with statements like “I like to get up at 9am and go to bed about 10pm I like a hot drink before I go to sleep” and “I have difficulty with bathing and I need two staff to help me”. We saw that care plans gave information about a range of personal and health care needs. We saw risk assessments relating to nutrition, falls and pressure areas formed part of the care plan and were generally reviewed each month to show the changing needs of the residents. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 12 Daily records that were kept with the care plan were repetitive and did not reflect the actual care being given to people living at the home. The daily records should contain detailed information which can then be used to evaluate and review the care being provided. We recommended that daily records describe fully the care that was being delivered to people. Medication was dispensed in blister packs. We found that most medicines were usually administered and recorded correctly. Regular and detailed checks on medicines continued to be carried out. These checks helped to show that most medicines could be accounted for and had been given as prescribed. One person’s medication was prescribed ‘when required’. We saw that this was being administered at regular intervals three times a day. A recommendation is made that the manager arrange for a medication review for the person whose medication was prescribed ‘when required’. We spoke to the manager about risk assessments relating to pressure area care. We saw one care plan that identified a person to be at high risk of developing pressure areas. There was no mention in the care plan of a pressure relieving mattress or cushion. The manager told us that this is an area that had been identified in a recent audit of care plans. They told us that the person was using pressure relieving equipment and the recording in care plans was being addressed with staff. We saw in one person’s care plan direction to use ‘hip precautions’ but it was not clear in the care plan what these were. Where people are receiving intermediate care it should not be assumed that everyone knows what these precautions are. The care provided to people at the home is reviewed each month to make sure people’s needs are being met. They told us that a sample of care plans and the medication systems are audited on a monthly basis. They had records of the audits and of where shortfalls had been identified these were addressed with staff. We saw a person being taken to their bedroom in a wheelchair. There was only one footrest on the wheelchair. We saw a member of staff pulling the wheelchair backwards with the person’s feet dragging on the floor. A requirement is made that in order to ensure the health and safety of people footrests are used at all times. If the person cannot use footrests there should be a risk assessment in place identifying the reasons why. We saw some good care practice on all the units we visited. We saw that residents were relaxed and the atmosphere was calm and supportive. We saw staff generally offering assistance to people in a way that most suited the person. Staff chatted to people as they passed them in the corridor or Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 13 when they walked past people in the lounges. We saw staff chatting to people. Staff seemed kind, patient and friendly with everybody. We saw that people were treated with respect and dignity and their right to privacy was maintained during the visit. We saw staff knock on people’s bedroom doors before entering their rooms. We saw that staff clearly had a good relationship with the people living at the home. We saw people were spoken to in a respectful way. People living at the home and their visitors told us that staff were polite and treated them with respect. Comments included “they are very good” “we are always made to feel welcome” and “all very polite and helpful”. They told us that staff received trained in manual handling and satisfactory numbers of hoists are available. The slings are available in different sizes within each unit and these are kept clean. People who could express a view said they could get up in the morning when they wanted to and could have a lie in if they felt like it. Medication was dispensed into blister packs. We saw a sample of medication records and saw that medication was given as prescribed. Medicines were signed in as received and there was a system in place for the disposal of medication and samples of staff specimen signatures. One person who was having intermediate care at the home told us “they are very helpful and so kind”. Another person told us “they work hard and are very nice” “my stay has been very pleasant” and “it is a good idea”. We spoke to visitors who told us “the staff seemed nice” and “I am able to visit at any time they just ask that you avoid mealtimes but I am sure they would not mind if you visited then”. Another told us “the carers are good it is a hard job” and “if mum needs the GP or has a fall they let us know”. One person told us “I can make a cup of tea for mum when I get here and they don’t mind if I have one too”. Another told us “they keep me informed of anything that happens on the whole I am very happy”. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a good range of activities and a variety of home cooked food. EVIDENCE: People’s spiritual needs are recorded so they can be given the opportunity and any help they need to continue to follow their faith if they wish. The local Catholic Priest attends Heartly Green monthly to provide mass. Heartly Green also has contact with the local Church of England vicar, who is happy to provide services to service users who wish to receive them. We saw that people living at the home have monthly meetings with managers. This means that people can exercise their right to choice. Menus and meal times are regular agenda items discussed at these meetings. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 15 We saw the evening meal being served. The meal was Chicken casserole with vegetables or mixed sandwiches and for sweet five fruit jelly and cream or angel delight. The lunchtime meal was lamb chops or pork steaks with vegetables. The dining rooms were clean, bright and airy. Menus were displayed at the entry to the lounge/dining rooms. Menus gave a choice of meals. We saw that extra portions were offered and choices of meals were available. We saw that dining tables were set with tablecloths, cutlery and condiments. This created a pleasant and comfortable environment for the residents to enjoy their meal. They told us that Saturday is ‘residents’ choice’. This means that they ask people to plan the days-menu. They told us that people ask for things like Brunch. On the days when Brunch is the choice a light breakfast is served and then bacon, eggs, sausages, mushrooms, tomatoes, beans and toast are served around 11:30. The evening meal would be served at the usual time. Supper of hot drinks and biscuits, cake and sandwiches We spoke to people living at the home and they told us “the food is lovely” and “it’s great here the food is beautiful”. They had an activity organiser. We saw a rota informing people of the days the activity organiser was on each unit. They told us that they had various 1:1 activities, which included hand massage and manicures. They told us that they arrange arts and crafts such as card making. We spoke to people who told us they had a choice of whether they took part. One person told us “I don’t bother with the activities I prefer to sit and watch the TV” and “the staff are really nice”. There were a number of areas where people can meet with visitors. This can be in the lounges the foyer or in the person’s bedroom. There are no restrictions on visting times, although they do ask visitors to avoid meal times, where possible. We spoke to visitors who told us that they were always made to feel welcome by staff. A hairdressing room was provided. This was located on the first floor and looked like a hairdressing salon. This gave the impression of people going out to have their hair done. People are encouraged to manage their own finances, wherever possible. This can be at different levels. They told us that where this is not possible families or advocates provided support. They told us that people are encouraged to hold a small amount of change in their pocket or purse. This is to maintain people’s independence and empowerment. We saw a sample of people’s Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 16 financial records. These showed that receipts were in kept for purchases made on people’s behalf and an individual record was kept of these. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know how to complain and are confident that their concerns will be listened to. EVIDENCE: People living at the home are given a statement of purpose and service user guide. This includes a copy of the complaint procedure. Relatives and staff at the home are made aware of the complaints procedure. We saw copies of the service user guide in people’s bedroom that explains how to make a complaint. This information is also displayed in reception for visitors’ attention. The complaint log gave details about the complaint, the investigation and the outcome. We saw that complaints were dealt with appropriately. They told us that concerns and complaints were used to improve the service. We spoke to people living at the home and visitors who told us that they would speak to the manager if they had a concern. One visitor told us ‘if we have any concerns we would speak to the manager or the deputy’. They told us that care staff recieved training that teaches them how to recognise abuse and report poor practice. There is an organisational procedure for staff to follow in the event of any allegations being made. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 18 There was a copy of the Salford All Agency Policy on the Protection of Vulnerable Adults available for staff to reference. We spoke to staff that were aware of the action to be taken in the event of an allegation of abuse being made. There had been three safeguarding referrals. These had been reported using the Salford safeguarding policies and procedures. They had been appropriately reported and investigated. This means that staff working at the home are aware of the procedures in place to safeguard vulnerable people. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in suitably adapted, clean, comfortable and very pleasant surroundings. EVIDENCE: People cannot access the home without being admitted by staff. Visitors to the home press a door bell attached to an intercom system and a member of staff opens the door automatically. People are able to exit by pressing a button at the main door. This makes sure that no-one can enter the building without staff letting them in. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 20 We saw a visitors’ book in reception and saw visitors to Heartly Green being asked to sign in and out of the building. This is to in line with fire regulations and means that staff know who is in the building in case of an emergency situation so everyone can be accounted for. There was a bright and airy foyer furnished with sofas and easy chairs. There was a coffee vending machine with a small charge. People living at the home and their visitors were able to use this area to relax and chat. There are a number of parking spaces to the front of the building for visitors this includes several spaces for visitors with restricted mobility. There are secure garden and patio areas with a wooden fence that offers people who wish to sit in the gardens some level of privacy. The gardens are wellmaintained with a external open court yard at the centre of the building. People living at the home can access the courtyard from the reception area and ground floor lounges. This means that everyone living at the home can walk or sit in the gardens safely. We walked around the home we saw that the bedrooms, lounges and dining areas were clean and there were no unpleasant smells. There were sanitising gel dispensers around the home. Liquid soaps and paper towels were in use in toilets. This is to reduce the risks of infection and is good practice. We checked the gel dispensers and they were all full and we saw visitors using them. We saw infromation posters around the home providing infromation about infection control in relation to the recent swine flu health alerts. We saw that bedrooms had en-suite toilet, hand basin and shower facilities. Rooms were nicely decorated. Bedrooms had a wardobe, chest of drawers and an adjustable electric bed with a specialist pressure relieving mattress. All rooms have matching bedspreads and curtains. Some people had personalised their rooms with pictures and ornaments. People were seen relaxing after lunch in the small lounges either listening to music or watching television. There are small kitchens on each unit so that visitors can make a drink. We spoke to people living at the home who told us “I have a very nice room it is a bit smaller than my own but very nice”. Another told us “it is lovely here the rooms are very light I go in for a rest after dinner”. Another person told us “I like to sit and watch TV but the radio is very loud”. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff was sufficient to meet the needs of the residents accommodated and staff have access to a wide range of training. EVIDENCE: There were two carers on each unit and a team leader who moved from unit to unit on the ground floor. The first floor had a nurse manager and was staffed partly by physiotherapists and occupational therapists from the Primary Care Trust and staff from the home. The registered manager was responsible for the overall management of the home. We saw a sample of staff files. We saw that these were well maintained and contained all the necessary checks. We saw that Criminal Records Bureau (CRB) checks and checks had been made against the Protection of Vulnerable Adults list (POVA). All applicants have at least two references and, when possible, one from their last employer. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 22 We saw that all staff completed an induction period. We saw that supervision gave staff an opportunity to discuss their training needs and identify further training that would be of benefit to the people living at the home. We saw that all staff received a copy of their job description detailing their roles and responsibilities. The home keeps individual records of training and updates these after each supervision meeting. They told us that the organisation has a training programme that includes training such as Protection of Vulnerable Adults, Health and Safety, Manual Handling of people and loads, Basic Life Support, Skills for Care Common Induction, Dementia Training and Continence Care. We saw that staff had a structured induction and there were copies of training certificates on staff files. We spoke to staff. They told us that they had good access to training. We saw that training in relation to manual handling, medication, fire safety, first Aid, and Protection of Vulnerable Adults had been provided. We saw that there was a mix of male and female staff so that people can choose to have a male or female carer. We spoke to people living at the home. The told us “the staff are very good” another said “they work very hard and are really nice”. One person told us “it is great here the look after us really well”. Visitors to the home told us “the staff work really hard and sometimes they don’t seem to have enough people on”. Another told us “they do a brilliant job”. One visitor said “the staff are really helpful”. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed so that it is run in the best interest of the people who live there. EVIDENCE: The manager had the necessary skills qualifications and experience needed to manage a care home. The manager is supported by one full time and one part time deputy. They told us that the current manager will be leaving the home at the end of May 2009. The new manager was working along side the registered manager to familiarise herself with the policies and procedures. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 24 The organisation should make application to register the new manager with the Care Quality Commission as soon as the current registered manager leaves. We saw that policies and procedures were in place with regard to managing people’s finances. We saw a sample of financial records receipts were kept for all transaction made on behalf of people living at the home. These showed us that the people’s financial interests are safeguarded. We talked about the Deprivation of Liberty Safeguards. This is relevant where the home looks after finances or places restrictions on people’s activities. A recommendation is made that the home develop a formal agreement between people living at the home or their representatives, that staff can access people’s monies to purchase personal items. They should also consider a formal agreement where, for safety reasons, they hold people’s cigarettes and matches. This is in line with the Deprivation of Liberty Safeguards and the Mental Capacity Act. We saw that a health and safety policy was in place and risk assessments of the premises and safe working practices had been carried out. This was to make sure that people living at the home and staff had relevant information to enable them to live and work in a safe environment. We saw that there are procedures in place, such as weekly fire safety checks, safe systems of work, health and safety checklists and routine maintenance checks. Information given in the Annual Quality Assurance Assessment (AQAA) showed that fixed Gas and Electricty appliances had been regularly maintained. They also carried out a periodic test of portable appliences and lifting equipment. These checks mean that the safety of people living at the home, staff and visitors was given priority. They carried out a quality audit. This is to monitor the performance of the home in areas such as accident reports, medication storage and administration, staff training and Health and Safety. They told us they are planning to carry out quality surveys and will use the results to improve the service further. Monthly meetings are held with people living at the home. These covered the way the home is run and the quality of care provided. Feedback from relatives and friends was all very positive about the home. One person said “what would we do without places like this”. Another said “I am happy that my relative is safe and well cared for”. Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X 3 X X 3 Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? First 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. Standard Regulation Requirement Timescale for action Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 27 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 OP7 OP8 Good Practice Recommendations It was recommended that daily records describe fully the care that was being delivered to people. A recommendation is made that the manager arrange for a medication review for the person whose medication was prescribed ‘when required’. The organisation should make application to register the new manager with the Care Quality Commission once the registered manager leaves. A recommendation is made that the home develop a formal agreement between people living at the home or their representatives, that staff can access people’s monies to purchase personal items. They should also consider a formal agreement where, for safety reasons, they hold people’s cigarettes and matches. A recommendation is made that when transporting people in wheelchairs staff make sure both footrests are in place on the wheelchair. 3. OP31 4. OP35 5. OP38 Heartly Green DS0000072939.V375387.R01.S.doc Version 5.2 Page 28 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PQ National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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