Care Home: Heathvale

What the care home does well The home is well decorated and furnished to a good standard. Each bedroom is of a good size and easily meets the standards required. The furnishing of the home has been thoughtfully considered with appropriate equipment provided throughout the unit and overall it has a homely, comfortable feel. What has improved since the last inspection? N/A. What the care home could do better: The registered person is required to produce an up-to-date Statement of Purpose and Service User`s Guide as per Regulation 4 and 5 respectively. It is also recommended that a review date is included on both documents. The medication policy must include procedures for receipt of medicines by staff in the home. The registered person needs to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times as a number of health and safety issues were identified during the course of this inspection. CARE HOME ADULTS 18-65 Heathvale 95 Brigstock Road Thornton Heath Croydon Surrey CR7 7JL Lead Inspector Mohammad Peerbux Key Unannounced Inspection 20th March 2007 2:30pm Heathvale DS0000059084.V332730.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 Heathvale DS0000059084.V332730.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. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathvale Address 95 Brigstock Road Thornton Heath Croydon Surrey CR7 7JL 08706003636 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) chris.tinson@glencare.com Gordon Henry Phillips Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Heathvale is a nine bedded home registered with the Commission for Social Care Inspection to provide residential care for adults with learning disabilities. There is currently no service user residing at the home. The home is a large detached property situated on a busy street close to the centre of Thornton Heath and well placed for accessing local shops and public transport links. The home is in keeping with neighbouring properties. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this inspection no service users were living in the home and no service users have lived in this home since it was registered with the Commission for Social Care Inspection last year. The acting manager from another care home within the same group was present on the day of the inspection and is thanked for her support over the course of this inspection. As a result of the home not yet having any service users in placement some of the Key Standards could not be inspected or inspected fully and only limited evaluation was possible of the outcomes because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person is required to produce an up-to-date Statement of Purpose and Service User’s Guide as per Regulation 4 and 5 respectively. It is also recommended that a review date is included on both documents. The medication policy must include procedures for receipt of medicines by staff in the home. The registered person needs to ensure so far as is reasonably practicable the health, safety and welfare of service users and staff are promoted and protected at all times as a number of health and safety issues were identified during the course of this inspection. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 6 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. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 7 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 Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 8 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): 1,2 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users should receive sufficient and appropriate information, which they need to make an informed choice about living at Heathvale. The proposed assessment framework should ensure that prospective service users needs are assessed. The proposed process and documentation in place now should ensure that prospective service users get the opportunity to test drive the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide, however both documents must be reviewed to include all information as per regulations 4 and 5 respectively. It is also recommended that a review date is included on both documents. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 9 Standard 2 refers to the assessment of service users needs. Since there are no service users living at Heathvale the usual inspection of service users’ files was not possible. However the acting manager was able to show blank assessment form that the staff would use to assess their prospective service users needs. The format proposed covers the range of needs likely to be relevant to a prospective service user and from that point of view is “fit for purpose”. In addition that staff would ensure that they get the referring professionals assessment of the individuals needs, which will be used as a part of the assessment process. The acting manager informed that prospective service users would visit the home on an introductory basis before making a decision to move, and unplanned admissions would be avoided. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 10 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): Standard 9. Only limited evaluation was possible of the outcomes for the standard outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Quality in this outcome area has not been rated as there was only evidence available relating to how the system could be used, no actual examples of risk assessments have yet been undertaken. Outcomes for the key standards 6 & 7 were not assessed on this occasion. EVIDENCE: Given that there were no service users in place at the home it was not possible to fully inspect the home’s provision in meeting the requirements of this Standard. However the acting manager showed the proposed risk assessment framework, which would be used. The proposed document should be useful and should assist service users to be supported to take appropriate risks as a part of developing a more independent lifestyle. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 11 The registered provider is reminded that risk assessments should be included in the admission procedure and should be reviewed together with the service user’s care plan every 6 months or sooner if circumstances dictate. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 12 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): Standard 12,13 & 15. Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users would be encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. EVIDENCE: The acting manager stated that staff would help service users to find and keep appropriate jobs, continue their education or training, and/or take part in valued and fulfilling activities. Service users would be able to continue to take part in activities engaged in prior to entering the home, if they wish, or reestablish activities if they change localities. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 13 Staff would support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. Staff would also support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual plan and contract. Outcomes for the key standards 16 & 17 were not assessed on this occasion. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 14 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): Standards 19 & 20 Quality in this outcome area is good. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. Prospective service users physical and healthcare needs should be able to be met by the home and that they should be protected by the home’s policies and procedures with regards to medication. EVIDENCE: Outcome for the key standards 18 was not assessed on this occasion. The acting manager advised that healthcare needs would be a part of the needs assessment and care planning process. Service users would be supported and enabled to have access to a dentist, optician, chiropodist and community nurse and any other healthcare professional as and when they need it. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 15 The home’s policy on medication was checked. The policy covers all the main areas required and provides appropriate guidance for support staff to carry out their duties in this area of work to a satisfactory standard. However the policy must also include procedures for receipt of medicines by staff in the home. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 16 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): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. The home has appropriate complaints procedure in place. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The current complaints procedure is a good and gives clear step-by-step guide of how to make a complaint. The home has a copy of London Borough of Croydon adult protection procedures. It is recommended that a copy of the home own adult protection procedure is also made available in the home at all times. The registered provider must also ensure that staff have training on abuse. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 17 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): Standards 24 & 30. Quality in this outcome area is adequate. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. The home is generally hygienic, clean, homely and comfortable however some health and safety issues need to be addressed as these potentially place service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. It is accessible, would meet service users’ individual and collective needs in a comfortable and homely way. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. However there are a number of health and safety concerns (see standard 42). Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 18 The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 19 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): N/a EVIDENCE: None of the above standards were assessed at this inspection, as there are no staff in post at present. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 20 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): Standards 37,39 and 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Only limited evaluation was possible of the outcomes for the standards outlined above on this occasion because the home has been dormant for some months and consequently the decision was taken to carry out a ‘reduced’ inspection. The quality assurance system will help ensure that their views underpin monitoring and review of the homes developments. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 21 EVIDENCE: Presently the home does not have a registered manager in post. However the registered provider is in the process of recruiting a manager to ensure that the home meets its stated purpose, aims and objectives. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, would be in place to measure success in achieving the aims, objectives and statement of purpose of the home. A number of health and safety issues arose during this inspection and they are as follows: -There was no risk assessment for the home. The registered provider must ensure that risk assessments are carried out for all safe working practice topics covered in Standards 42.2 and 42.3, and that significant findings of the risk assessment are recorded. -No fire risk assessment was in place. The registered provider is required to undertake and record a Fire Risk assessment in accordance with the Fire Precautions (Workplace) Regulations. - It was noted that the gas certificate was out of date. The registered provider must ensure that all certificates regarding health and safety are kept up to date and that there is a system in place to monitor this. -One of the dining room doors is also a fire exit, which has a key operated lock. The registered manager is required to ensure that all emergency fire exit doors are openable without the use of a key whenever the premises are occupied. Certificates relating to health and safety were checked. These included electrical wiring and installation, gas safety, call system and fire safety. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 2 X 3 X X 1 X Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 4 and 5 Requirement The home has a Statement of Purpose and Service User Guide, however both documents must be reviewed to include all information as per regulations 4 and 5 respectively. The medication policy must include procedures for receipt of medicines by staff in the home. The registered provider must ensure that risk assessments are carried out for all safe working practice topics covered in Standards 42.2 and 42.3, and that significant findings of the risk assessment are recorded. The registered manager is required to ensure that all emergency fire exit doors are openable without the use of a key whenever the premises are occupied. The registered provider is required to undertake and record a Fire Risk assessment in accordance with the Fire Precautions (Workplace) Regulations. The registered provider must ensure that all certificates regarding health and safety are kept up to date and that there is a system in place to monitor this. Timescale for action 20/05/07 2 3 YA20 YA42 13(2) 13(4) 30/04/07 30/04/07 4 YA42 13(4) 20/04/07 5 YA42 13(4) 30/04/07 6 YA42 13(4) 15/04/07 Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 24 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 YA1 YA23 Good Practice Recommendations It is recommended that a review date is included on the Statement of Purpose and Service User Guide. It is recommended that a copy of the home own adult protection procedure is also made available in the home at all times. Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Heathvale DS0000059084.V332730.R01.S.doc Version 5.2 Page 26 - 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. 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