Inspection on 09/12/05 for Harecombe Manor

This inspection was carried out on 9th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Harecombe Manor 02/09/08

Harecombe Manor 16/10/06

Harecombe Manor 13/01/05

Harecombe Manor 08/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Harecombe Manor Southview Road Crowborough East Sussex TN6 1HG Lead Inspector Niki Palmer Unannounced Inspection 9th December 2005 10:00 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 Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Harecombe Manor Address Southview Road Crowborough East Sussex TN6 1HG 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) 01892-652114 Mr Alexandre Ollivier Mrs Evelyn Ollivier Mrs Mohamed Biby Gulamaideen Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (51) of places Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of ten (10) places can accommodate service users in receipt of personal care only at any given time. Service users may have a physical disability. That the maximum number of service users to be accommodated is fifty one (51). Service users must be aged sixty five (65) years or over on admission. Date of last inspection 24th June 2005 Brief Description of the Service: Harecombe Manor is a privately owned care home that is registered to accommodate up to 51 residents. Nursing care is provided at this establishment. A maximum of 10 places can accommodate residents in receipt of personal care only at any given time. The home is located opposite Crowborough Hospital and has car-parking facilities available. It is on the outskirts of town and there are some local amenities within walking distance of the home. The home is spread out over two floors. Two passenger shaft lifts provide access between the floors. There is a pleasant garden area at the rear of the home that all residents can access if they choose. Harecombe Manor was first approved for registration on 23rd March 1989. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Harecombe Manor will be referred to as ‘residents’. This unannounced inspection took place on Friday 9th December 2005 between 10.00am and 3:00pm and was carried out by two Inspectors. The inspection began with discussions with the Registered Manager of the home in respect of progress made since the last report, followed by an inspection of the premises and its facilities. In order to gather evidence on how the home is performing, individual discussions took place with eight residents, whilst others commented on their care during lunchtime, the Inspectors having been invited to join them for a meal. In addition three nursing staff, one care assistant, and five visiting relatives were spoken with throughout the day. 40 residents were accommodated at the time of the inspection. Other records and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, pre-admission assessment procedures, two individual care records, medication procedures, the provision of activities, the systems in place for protecting residents from harm and three staff recruitment files. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 24th June 2005. What the service does well: Harecombe Manor provides all prospective residents and their relatives with comprehensive written literature in respect of the facilities and care that can be offered by the home. Residents and relatives said that they found this very useful. The provision of food is managed well. All residents spoke positively of the chef, one resident commented ‘he never fails to feed us well’. The Registered Manager is approachable and actively listens to any concerns that are raised. Other comments used included ‘Its nice, like home’ and ‘staff are very good indeed’. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Residents are provided with sufficient information to help them judge if the home is appropriate for them. The pre-admission assessment process is improved; this ensures that no one is admitted to the home whose needs cannot be met. EVIDENCE: The home has a combined Statement of Purpose and Service Users’ Guide in place. It contains details of the home’s philosophy of care and core values, residents’ charter, room sizes, staffing arrangements, the provision of activities and food, the complaints procedure, fee structure and a copy of the home’s terms and conditions of contract. In addition it was particularly pleasing to note that a smaller information leaflet has been compiled titled ‘from enquiry to admission’. This informs residents of what to expect in relation to informal visits and the pre-admission assessment process. Residents and relatives spoken with confirmed that they found the homes written information to be informative and helpful in supporting their decision of where to live. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 9 Concerns were raised during the last inspection regarding the home’s preadmission assessment procedures. The Registered Manager said that since this time she personally carries out all assessments prior to admission, liaises with family members and individual’s General Practitioners. Five new residents have recently been admitted to the home. Those spoken with confirmed that the Registered Manager had met with them at their previous place of residency in order to carry out an assessment of their needs. Records were found to contain significant and thorough information regarding personal and social care needs. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10. Residents’ healthcare needs are met well by the home. All residents are treated with kindness, dignity and respect. EVIDENCE: All residents are provided with individual plans of care, which are kept in their own bedrooms. They are clear, concise and reasonably detailed. Risk assessments are in place for the prevention of falls, manual handling and pressure area care management. The home is required to ensure that pressure area care assessments detail the action that is to be taken by staff in order to maintain tissue viability. The home’s medication administration systems and records were viewed. The home uses a pre-packed system, which can be easily monitored. Storage and records were satisfactory, however it was unclear in one person’s records, whether or not one or two tablets had been administered as per the ‘as and when required’ criteria. A requirement has been made in respect of this. Controlled drugs were checked and found to be in order. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 11 Residents spoken with confirmed that staff treat them at all times with dignity and respect. Each of the residents are addressed by their preferred term and have all personal care needs carried out in the privacy of their own rooms or bathrooms. Throughout the course of the inspection all staff were observed to treat residents appropriately, from nurses and care assistants to housekeepers and administration staff. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15. A planned programme of activities needs to be in place to ensure that residents leisure and social care needs are met. The provision of food is managed well. EVIDENCE: An activities person is employed to work for 25 hours per week. Residents confirmed that the variety of activities has improved since the last inspection. In the mornings the activities coordinator spends one to one time with residents in the privacy of their own rooms, whilst group activities take place in communal areas in the afternoons. Although records of activities that have already taken place are kept, there is no planned programme in place, so residents are not aware of what is happening from day to day. This is an outstanding requirement of the previous inspection report. All of the residents spoken with, without exception were looking forward to the home’s Christmas party, which was due to take place the following day. Relatives and friends had been invited and raffle tickets were on sale for a number of donated prizes. A great deal of effort had been made by the home to ensure that the festive party was well planned and the home was nicely decorated. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 13 Residents spoken with said that they had been consulted regarding the Christmas party, and are in general in relation to the daily routines, for example they can get up and go to bed when they wish, decide on their clothing each day and choose their meals and activities. Preferred routines and choices are recorded within individual plans of care. Both of the Inspectors enjoyed a meal in each of the dining areas. Every Friday, three fish dishes are offered to residents; battered, grilled and steamed. It was pleasing to note that on the day of inspection, residents ate a variety of alternatives on offer during the lunchtime period including salad, egg on toast and omelettes. All residents spoke very highly of the chef’s consistency of the provision of food. Comments included ‘food is very nice’, ‘the food is very good’ and ‘he never fails to feed us well’. A variety of condiments were available. Discreet support was provided to those who needed it whilst specialist diets such as pureed food were presented well and looked appetising. Despite the majority of the residents spoken with saying that they enjoy the surprise of each lunchtime meal, a recommendation has been made for the home to make the daily or weekly menu available to residents in advance. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. The home has good systems in place to prevent residents from harm, neglect and abuse. EVIDENCE: Whilst the home’s complaints procedure was not inspected on this occasion, on the day of inspection a complaint was made to the Registered Manager in respect of additional charges for hairdressing and chiropody. It was pleasing to note that their concerns were actively listened to and documented. The Registered Manager assured the relatives that this would be followed up with the Registered Provider of the home. The relatives said that they always feel able to approach the Registered Manager regarding any concerns that they may have. Since the last inspection the home has simplified and condensed it’s procedures for the protection of vulnerable adults. There is now a clear flowchart in place in accordance with local multi-agency guidelines. Staff spoken with were able to demonstrate a clear understanding of the recognition and signs of abuse and the home’s reporting procedures. No alerts have been raised since the last inspection. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26. Whilst some progress has been made to certain areas of the home, other parts remain poor. A rolling programme of renewal needs to be prioritised and actioned in order for the home to present as attractive throughout. EVIDENCE: On the whole the home was found to be clean, tidy and reasonably wellmaintained on the day of inspection, with the exception of a broken window in one of the bedrooms. Excess clutter has been removed from the home and grounds and unrestricted windows have been risk assessed and appropriate action taken. Two bathroom floors have been replaced with non-slip flooring, which has made a vast difference to the overall appearance of the rooms. The Registered Manager confirmed that all remaining bathroom floors will be replaced in due course. It was pleasing to note that all call bells were accessible to residents on the day of inspection and were detailed within individual plans of care. A small number of bedrooms have been redecorated since the last inspection and new furniture and carpets purchased. It remains Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 16 an outstanding requirement for the home to produce a programme of renewal to replace old and tatty furniture and carpets. This was discussed with one of the administrative staff. The laundry area is situated in the basement of the property. A designated person is employed to launder all clothes and bedding etc… It was noted that the flooring in the laundry needs treating to make it impermeable. This will help to reduce the risks of the spread of infection. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. Since the last inspection significant improvements have been made in the way in which care staff are employed. This helps to ensure and protect the safety of residents. EVIDENCE: Harecombe Manor is approved to employ two adaptation nurses from overseas by the University of Brighton. The Registered Manager has compiled a specific induction course for this purpose as recommended by the University, which is based on TOPSS and the modules of the University programme. A lot of the focus is placed on introducing them to English culture, which most of them will experience for the first time. In addition the Registered Manager has recently been asked to facilitate supernumerary first year student nurses. Of the 14 care assistants employed four have achieved at least NVQ level 2,whilst four are currently working towards this. Two of the most recently employed staff recruitment files were checked for compliance with the Regulations. It was pleasing to note that both files contained proof of a POVA First and Criminal Record Bureau check (CRB), written references, proof of identification and a full history of employment. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38. Harecombe Manor is adequately managed. EVIDENCE: Small amounts of residents’ money are kept securely in the home, for purchases such as hairdressing, toiletries and outings. The Registered Provider keeps written records for each transaction including receipts. Accident forms are kept within the home and all serious incidents are notified to the CSCI. Concerns were raised during the inspection in respect of footrests missing from several wheelchairs. This has the potential to place residents at risk. This was discussed with the Registered Manager and a requirement made. A sample of the home’s health and safety records were examined. Emergency lighting and fire equipment checks were carried out in September 2005. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 19 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X 2 X X 1 X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17(1)(a) Sch3 (k)(p) 17(1)(a) Sch3(k) 16(2)(m) (n) Requirement That pressure area care assessments detail the action that is to be taken by staff in order to maintain tissue viability. That clear medicine records are kept of the actual dose administered as per the ‘as and when required’ criteria. The variety of activities offered by the home need to be planned in advance in consultation with residents [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT]. That the broken window in room 32 is replaced. That an action plan is forwarded to the CSCI with timescales for the replacement of old and worn furniture, flooring in each of the bathrooms and the replacement of poor quality carpets [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION]. That footrests are used at all times when transferring residents in wheelchairs. Timescale for action 31/01/06 2. OP9 09/12/05 3. OP12 31/03/06 4. 5. OP19 OP21OP24 23(1)(b) 13(4) 16(2) 23(1)(d) 31/12/05 31/03/06 6. OP38 12(1)(a) 09/12/05 Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 21 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 OP1 OP15 Good Practice Recommendations That the Statement of Purpose and Service Users’ Guide is dated to evidence that it is current. That daily menus and alternatives are displayed within the dining area and other areas of the home. Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Harecombe Manor DS0000013993.V270002.R01.S.doc Version 5.0 Page 23 - 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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