Care Home: Heath House

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What the care home does well What has improved since the last inspection? Since the change of ownership there have been a number of improvements achieved within the first six months including:- redecoration of some bedrooms and the reception area and hallway have also been re carpeted and new lights fitted. One of the offices previously used by the manager has been re-designated the carer`s work base and provides a confidential area for handover meetings and care planning management. Some of the windows to the front and side of the premises have been replaced and the front door and two of the side exits have also been replaced, making the whole area lighter and brighter. Stair lifts on each of the flights of stairs have been installed and this makes it easier for residents to access the first floor. A new cooker and extractor fan have been installed in the main kitchen and the current food storage facilities are under review to improve available space. Training sessions including refresher courses have been put in place for staff to attend. Six care staff have registered to undertake NVQ 2 or above this year. A review of the office procedures has been made and some changes have been introduced, with better staff file management and audit systems for monitoring the record keeping and general administration of medication, care planning and day-to-day management. The Service Users Guide and the Statement of Purpose has been revised and updated. Relatives and residents are being kept up to date with news and views about the home through the regular publication of the homes newsletter. From the discussions with staff and relatives and residents it was said that the choice of meals and menus has improved with greater choices and attention to residents dietary needs and personal preferences. CARE HOMES FOR OLDER PEOPLE Heath House 152 Thorpe Road Norwich Norfolk NR1 1RH Lead Inspector Mrs Susan Golphin Unannounced Inspection 27th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heath House Address 152 Thorpe Road Norwich Norfolk NR1 1RH 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) 01603 618653 01603 629985 M and H Care Ltd Mrs Gunda Olga Read Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: 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: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 29 03 September 2007 2. Date of last inspection Brief Description of the Service: Heath House is a large converted Victorian building situated on the outskirts of the city of Norwich. The home can accommodate twenty nine older people in fifteen single and seven double rooms on the ground and first floor which can be accessed by a small passenger lift and also by stair lifts which have been fitted to the main stairs at the front and rear of the premises. There is a dining room and two other sitting rooms available for residents’ use. There is a small garden area and limited parking available to the front and side of the premises. Information about the service including inspection reports is available in the reception area and on request from the manager. The care costs range from £290 to £400 per week. Heath House DS0000071800.V370106.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*. This means the people who use this service experience good quality outcomes. This key unannounced inspection took place over one day, 7.5 hours in total, and all the standards were reviewed because the ownership of the home changed earlier this year. The home was purchased by a new provider in March 2008 and is now owned by Ms Nina Chaudhary through her company M&H Care Ltd.. Mrs Chaudhary has other business interests in the care of younger adults and in family care and with the acquisition of Heath House states that she is committed to providing quality care services to older people. A business plan for the premises and administration changes to the home has been drawn up and includes improvements to the exterior and interior of the building including replacement windows. Some immediate and cosmetic changes have already been made to the general décor in resident’s rooms and the hallway. Other changes have included re-arrangement of offices, providing a dedicated work area for the care staff and medication storage a review of meals, menus, and staff supervision and training. Everyone seen on the day said that the initial changes had been positive and beneficial to all. The manager was present throughout the inspection. The report contains information from the Annual Quality Assurance Assessment document the previous inspection report and from notifications received from the service since the last inspection. During the course of the day we were able to tour the premises, talk to residents, visiting relatives, staff on duty and observe care staff in practice. A small sample of records and care plans were also seen. Prior to the inspection the inspector received two out of five comment cards from relatives with two comment cards from residents. Overall the comments from residents and relatives about the service are very positive and complimentary. Two out of ten staff comment cards were returned and all were positive and complimentary about the service provided and the good support and supervision from the manager and senior staff. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the change of ownership there have been a number of improvements achieved within the first six months including:- redecoration of some bedrooms and the reception area and hallway have also been re carpeted and new lights fitted. One of the offices previously used by the manager has been re-designated the carer’s work base and provides a confidential area for handover meetings and care planning management. Some of the windows to the front and side of the premises have been replaced and the front door and two of the side exits have also been replaced, making the whole area lighter and brighter. Stair lifts on each of the flights of stairs Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 7 have been installed and this makes it easier for residents to access the first floor. A new cooker and extractor fan have been installed in the main kitchen and the current food storage facilities are under review to improve available space. Training sessions including refresher courses have been put in place for staff to attend. Six care staff have registered to undertake NVQ 2 or above this year. A review of the office procedures has been made and some changes have been introduced, with better staff file management and audit systems for monitoring the record keeping and general administration of medication, care planning and day-to-day management. The Service Users Guide and the Statement of Purpose has been revised and updated. Relatives and residents are being kept up to date with news and views about the home through the regular publication of the homes newsletter. From the discussions with staff and relatives and residents it was said that the choice of meals and menus has improved with greater choices and attention to residents dietary needs and personal preferences. What they could do better: As previously stated the new provider has established a business plan for the service to improve and upgrade the overall standards. Provisional plans are in place to replace a new shaft lift and to redecorate and refurbish throughout the communal sitting room / dining areas and conservatory over the next eighteen months. There are also plans in place to carpet and redecorate the corridors to the rear of the premises. However, the access corridors and stairs and some of the resident’s rooms on the first floor would benefit from early redecoration and minor refurbishment especially the main shower room and second bathroom. There is to be better staff access to NVQ courses and MUST training which helps carers to have a good understanding and monitoring of the nutritional needs of older people and palliative care training which staff will attend this year. The Service Users Guide and the Statement of Purpose has been revised and some of the updated information shared with others through the newsletter. The documents need to be published in a user- friendly format and made available to prospective residents and commissioners of the service. Some of the care planning files and staff recruitment and evidence of learning files have been reviewed and are being updated into a new filing system which Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 8 gives a clearer chronological list of events and activities and is easier to reference. The client group is predominantly people with some level of mental frailty and the staffing levels need to be flexible and appropriate to meet specialist need especially at crucial times of the day and also to support and promote personal interests and social stimulation on an individual basis. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 9 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 Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1- 6 Quality in this outcome area is good There is comprehensive information about the service provision and what people may expect should they choose to live in the home. There is a clear assessment process in place that includes consultation with residents and their relatives about their healthcare needs and lifestyle. There is no designated intermediate or rehabilitation service available in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s files seen on the day showed that all prospective residents healthcare needs are assessed prior to admission. They are encouraged to visit Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 11 the service with their relatives before making any final decisions about where they wish to live. One resident said that she had ‘visited other places but felt this was the right choice’. One of the visitors said that he felt the place was homely and offered ‘the nearest thing to peoples’ own homes and what they would expect’. The updated brochure for the service including the Statement of Purpose and the Service Users Guide have been revised but not yet issued to residents or relatives. One of the relatives said that the information available about the service and the pre admission visit had been helpful and reassuring. There is no designated intermediate or rehabilitation service available in this home. However, prospective residents can access short term or respite care as part of the decision making process about long- term care. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7-11 Quality in this outcome area is (good). Residents receive good personal and healthcare support, based on a comprehensive plan of care. Residents personal care is delivered by person centred carers in a respectful and dignified. There is an good medication policy in place supported by clear procedures guidance and training for staff, including supporting residents who may wish to manage their own medication. Staff in the home have a good understanding of death and bereavement and a sensitive approach when dealing with residents and relatives. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 13 EVIDENCE: Support care plans seen on the day show that regular reviews are in place with good support from GPs and other health care professionals. Specialist equipment is in place where necessary to promote good healthcare practice. The care planning process and each of the care files are being updated as part of the administrative changes. The manager is also looking at different formats for assessing the needs of those people with dementia to improve the depth and of information especially social and emotional details. Storage and record keeping of medication seen on the day is clear, well maintained and up to date. It is well located in the same are that the carers and senior staff use as a working base and provides a good location for auditing the records and managing the system effectively. Medication stock is checked weekly and an audit is carried out each month. There is a separate record for creams lotions and eye drops that are also stored in a lockable fridge. The manager confirmed that there is a medication risk assessment policy in place, but currently there are no residents managing their own medication. There is one dedicated senior member of staff with responsibility for managing medication and also for ensuring that all staff have completed the current training. Palliative Care training will be completed by staff at the end of September 2008. The staff were observed throughout the day delivering care and support confidently and competently. Residents said that the staff are always helpful. During the interviews the carers were able to demonstrate their understanding and knowledge about caring for older people, dealing with those who have short- term memory loss as well as those who need end of life care. They were able to give good examples of care practice and how they ensure that residents dignity and privacy is respected and upheld. Heath House DS0000071800.V370106.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15 Quality in this outcome area is ( good). Residents can access social activities and interests and encouraged and supported to be involved in their own decision- making and life choices. Residents and relatives maintain social and family links with friends and the local community. There are positive processes in place to deter stereotyping and to support and promote residents equality and diversity needs. Residents are offered a well -balanced diet that caters for individual needs and choices. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 15 Since the change of ownership there is a regular newsletter about the service that tells residents and relatives whats on and what is happening in and around the home. There is also an information board that is updated regularly and because it is so well used is proving to be an important information tool. The home has an activity organiser who maintains a record of peoples interests and popular events, and from the comments received residents said that the staff are very good at keeping them up to date on what is happening. Some of the recent activities have included massage sessions, entertainers /singers and clothes parties and a fete. The management and staff seek information about peoples cultural and religious needs as well as identifying some of the diverse needs of older people, they do this as part of the assessment process or after admission as part of the care planning review. One member of staff said that that they try to ‘get to know as much as possible’ about resident’s social history and beliefs to ensure their diverse needs are known. Residents seen on the day said that the meals ‘are nice’ and the lunchtime meal looked appetising and well presented. The daily menu is displayed on each of the dining tables and resident’s dietary or special needs are well known by the cooks and carers. Snacks and drinks and fresh fruit are available between the standard meal times. One relative said that they thought ‘the overall quality of the food has improved lately, and the home seem able to cater easily for everyone’. The manager said that they are looking at completing the MUST training that enables staff to gain good insight into the nutritional needs of older people, their diet and eating patterns and especially when people are ill or at the end of their lives. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16-18 Quality in this outcome area is ( good). There is a good complaints procedure in place. Resident’s and relatives have a clear understanding of how to complain. There are good procedures and practices in place that promote the safeguarding of adults and enable staff to report concerns and complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no formal complaints made to the Commission about this service. A complaints and compliments file is maintained and a written record of any incidents. The manager also records every level of concern or any enquiry however small and reviews the information on a regular basis. This helps to identify any recurring incidents or communication problems. Staff seen on the day were able to confirm that they have received training and guidance in safeguarding adults and have a good understanding of how to respond to bad practice or concerns they might have about the service. Training and the sharing of expertise in managing challenging behaviour will be included in the training programme this year. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19-26 Quality in this outcome area is (good). The home provides a good environment that is clean, safe and well maintained. Resident’s rooms reflect their personal choices and are comfortably furnished. Appropriate aids and adaptations are in place to promote resident’s personal dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located in a closely built residential area, near to the city and local amenities. The house is Victorian and there is a listed building restriction on Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 18 some of the development. There is a small garden area with limited off street parking. Since the change of ownership all the stairs to the first floor levels have been fitted with stair lifts which has helped to promote resident’s independence and safety. There is a passenger lift but it has limited use and is still subject to review regarding its upgrade that will be more suitable and appropriate for the client group. Resident’s have a choice of communal rooms to use and all are appropriately and comfortably furnished and decorated. There are plans in place to refurbish all the communal areas including the dining room and conservatory over the next eighteen months. A short tour of the premise was undertaken and all the areas were clean and pleasantly arranged and offered a homely and comfortable environment. Some of the resident’s rooms and corridors on the first floor would benefit from redecoration and refurbishment to compliment the replacement windows and replacement carpets completed recently. There are two shower facilities on the first floor both are suitable for the client group but again would benefit from minor refurbishment and redecoration to provide a warmer and more homely environment. It was explained that the home is without a maintenance / handy person at the moment and some minor repairs and fixtures and fittings are awaiting attention. Relatives and residents spoken to on the day said that they had noticed positive improvements to the reception area and hall and it had made a made a big difference to the home. One resident said that ‘the home is nice and clean’ and ‘I like my room’, another said ‘they look after my laundry and I don’t have to worry about it’. Other major changes have included new lighting in the hallway, replacement carpeting in the hall and stairs and corridors to the rear of the building. A new front door and side doors have been fitted to improve security and easier access. The kitchen area has been upgraded in part with a new cooker and extractor fan. A review of the food storage facilities is also being carried out to try and improve the overall space and working area. The manager’s office has been re-located to the centre of the home and this has provided a separate office for the senior staff. Having a separate workspace for staff ensures resident’s privacy and confidentiality is promoted. The office is also used by staff for handover meetings and storage of care records and has improved the access to the medication and medical storage area. There is a clear infection policy in place for the home and staff were observed using protective clothing appropriately to promote good standards of cleanliness and hygiene. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27-30 Quality in this outcome area is (good). There is a sound recruitment and selection process in place. Appropriate training is offered on a regular basis that focuses on good delivery of care and support to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were seen on the day, and are up to date and in good order. Each contains appropriate details of recruitment selection including checks through the Criminal Records Bureau and relevant references. They also contain evidence of learning and certificates indicating attendance at training sessions such as health and safety and lifting and handling and first aid. During the discussions with staff and from the comments received they confirmed that their recruitment and induction training provided a clear indication of what is expected of them and their responsibilities to each resident. The staff files are being filleted and updated by the manager and the structure improved for ease of reference. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 20 Twelve out of the fourteen carers employed have achieved or are working towards the NVQ 2 or above this year. Other training undertaken has included food hygiene, administration of medication, Moving and Handling First Aid and Continence Management. Observing the care staff at work it is evident that they are confident and caring and both liked and respected by each other, residents and relatives. Regular supervision and appraisals are in place and staff said that they feel ‘well supported by the management’. Staff meeting are also arranged at regular intervals and staff seen on the day said that there is ample opportunity to raise matters or concerns with the management. From the staff rota and from the quality assurance information submitted prior to the inspection there are sufficient numbers of staff to meet resident’s needs in the main. The manager stated that she has identified times where additional staff would improve the service for residents especially those who are mentally frail. It was acknowledged that more time with residents who have some degree of dementia or challenging behaviour would help to promote better knowledge and interpretation of needs. The manager is reviewing the specialist dementia training opportunities for senior staff and carers both at local and national levels. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31-38 Quality in this outcome area is ( good). There is a good administration and business planning procedure in place that safeguards the financial and health and safety and well being of the residents. The home is well managed and run in the best interests of the residents and staff. Structured supervision and appraisal sessions for staff are in place. There is a good system in place for seeking the views of those who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 22 The registered provider plays a key part in the management of the home and since its acquisition visits on a regular basis sometimes unannounced and conducts the regulation 26 reviews. Copies are signed off by the provider and manager and maintained so that they can be accessed as part of the inspection process. The manager confirmed that there is a provisional initial business plan in place for the service that is dealing with immediate changes and improvements. It is anticipated that a longer term plan with workable timescales will be implemented over the next twelve months, to show continuing growth and improvements to the premises and the service generally. The registered manager is supported by senior staff team but there is no designated deputy manager to share some of the administrative and managerial tasks and also have accountability for the service in the manager’s absence. The home has an inclusive and homely atmosphere and this can be seen in the relationships with staff, residents and visitors. Relatives and residents commented positively about the manager and the staff and said that ‘they are always about and helpful’ Residents seen on the day said that they have been asked about ‘activities and meals and what they would like to do’ and there is a ‘newspaper to read with things about the home in it’. Formal supervision and appraisals for staff are in place and documented. Staff confirmed that they receive an annual appraisal to review their personal and professional development. Care staff seen on the day said ‘it was an opportunity to discuss their work and their practice. All the health and safety aspects for the service including monitoring of water temperature and maintenance of equipment and mechanical aids are in place with good systems for recording and supervising practice. A record of maintenance and repairs and safety checks are in place, a small sample was seen on the day and was up to date and well maintained. The staff group have received training in moving and handling and first aid and infection control . Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 23 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 3 9 3 10 3 11 3 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 3 18 3 3 3 2 2 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 3 3 3 3 3 Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP1 Good Practice Recommendations It is recommended that the management complete the revision and update of the Statement of Purpose and Service users Guide and brochure for the service and make it available to residents and relatives. It is recommended that the management complete the review and update of the resident’s files. It is recommended that the management review the staffing levels to ensure the social and emotional needs of those who are mentally and physically frail are being met especially at crucial times of the day. It is recommended that the redecoration and minor refurbishment of the shower and bathrooms on the first floor be completed as soon as possible. It is recommended that the plans to upgrade and improve the shaft lift be continued and completed, to promote the independence and mobility of the residents It is recommended that the management review the DS0000071800.V370106.R01.S.doc Version 5.2 Page 25 2 3 OP7 OP8 OP27 4 5 6 OP21 OP22 OP27 Heath House 7 8 9 OP34 OP37 OP24 appointment of a deputy manager, to support and maintain the service in the absence of the manager. It is recommended that the management implement a business plan for the continued development and progress of the service. It is recommended that the review and revision of staff files be completed to improve the file structure and ease of access for inspection purposes. It is recommended that the management continue and complete the redecoration and refurbishment of the premises as planned. Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Heath House DS0000071800.V370106.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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