Inspection on 16/05/05 for Harleston House

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Harleston House 25/03/09

Harleston House 11/05/07

Harleston House 24/05/06

Harleston House 28/09/05

Harleston House 11/10/04

Harleston House 07/04/04

Harleston House 25/02/04

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

CARE HOMES FOR OLDER PEOPLE Harleston House 115 Park Road Lowestoft Suffolk NR32 4HX Lead Inspector Jane Higham Unannounced 16 May 2005 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 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. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Harleston House Address 115 Park Road Lowestoft Suffolk NR32 4HX 01502 574889 01502 516638 None Greensleeves Homes Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Scott Delf CRH Care Home 25 Category(ies) of OP Old age (25) registration, with number of places Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11 October 2004 Brief Description of the Service: Harleston House is a 25 bedded residential home for older people situated in a residential area of Lowestoft. The home was first registered in 1950 and has over the years been extended to provide additional accommodation. All resident rooms are offered for single occupancy . At the end of January 2004, the ownership of the home transferred from the Church Army to the Greensleeves Homes Trust, a national organisation which owns two other residential homes within East Anglia. It is the intention of the new owners to upgrade existing premises and renew furnishings etc. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of Harleston House, a twenty-five bedded residential care home for older people situated in the coastal town of Lowestoft. The was the first scheduled inspection in the inspection year 2005/2006 The inspection was carried out on 16 May 2005 over a period of 5 hours and included the investigation of an anonymous complaint, a report of which has been produced by the Commission for Social Care Inspection. During the inspection an environmental tour of the building was carried out and the views of residents as to the quality of the service was sought. What the service does well: What has improved since the last inspection? What they could do better: Through a detailed pre-admission assessment process, the home needs to ensure that no prospective residents are admitted who fall outside the stated category of registration. Discussions with residents identified that there was a general feeling that the home did not provide an adequate amount of activities, although the Manager was able to state that this was being addressed. As part of the current refurbishment process, the home must continue with its programme of ensuring that all radiators which are accessible by residents are either covered or replaced with those of the low temperature variety. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 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. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 Up until recently, not all prospective residents being admitted to the home could be assured that their individual care needs would be met. However, it is now agreed that no admissions to the home will take place without a needs assessment being completed either by the placing authority, or in the case of privately placed residents, by a member of senior staff from the home. The home must not continue to offer care to residents who come outside their category of registration. EVIDENCE: Pre-admission documentation in relation to two residents was examined as part of the inspection process. It was highlighted that in both cases an assessment of need had not been carried out either by the management of the home or the placing authority prior to admission taking place. This shortfall was also highlighted as part of the previous inspection and it has been agreed with the Commission that no new residents will be accepted for admission by the home without a full assessment of need taking place. On the day of the inspection it was identified that two residents had been diagnosed as suffering from dementia. Both had been assessed by a psycho-geriatrician and in the case of one of the two residents an alternative more appropriate placement was being sought. As the home is not registered to provide care to older Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 9 people with a diagnosis of dementia it was agreed with the service provider that an alternative specialist resource must be identified for the second of the two residents. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 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 standard(s) 7 and 8 Residents accommodated at the home can expect to have an individual plan of care which details their assessed needs, preferences and interests. The emotional and physical health of residents is monitored and residents are enabled to access community health services where appropriate. EVIDENCE: Two resident care plans were examined as part of the inspection process. Both care plans gave a clear breakdown of the individual needs of each resident and the interventions required by staff to meet those needs. Documentation seen confirmed that resident care plans were reviewed on a regular basis and amended where necessary. As part of the care planning process risk assessments are completed in the case of each resident. In the case of one resident a recently updated risk assessment had been produced to evidence a marked deterioration in both mental state and behaviour. In the case of another resident, although a risk assessment had been produced this was incomplete, did not stipulate any agreed interventions and was not signed or dated by the author. Resident care plans did however evidence that residents were enabled to access community health facilities and in the case of the two residents selected for the purposes of care tracking evidence was available to confirm that they had both received an assessment from a psycho geriatrician. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12 and 13 Whilst the home has experienced difficulty in recruiting to the post of activities co-ordinator, residents can now expect to be provided with a programme activities which are appropriate to their interests and preferences. EVIDENCE: In March of this year, the home employed an activities co-ordinator for ten hours per week. Unfortunately this appointment did not continue, culminating in a resignation after two weeks. However, a new activities co-ordinator has been employed on the same basis and was commencing duties during the week beginning 16 May 2005. The Manager confirmed that this person will have complete responsibility for the provision of a programme of activity for residents. This will include a variety of outings throughout the year. The home does have a musical entertainer who visits every Friday. Residents spoken to at the time of the inspection confirmed that there was currently very little planned activity within the home and that they often felt bored as there was nothing to do. One resident spoken with felt that it was important for resident so be offered a weekly light exercise class. The home has an open visiting policy and residents were being visited by family members on the day of the inspection. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 Residents living at the home can expect to have their concerns and complaints listened to and acted upon using the home’s complaints procedure. Residents can also expect to be provided with the appropriate contact information should they wish to pass their concerns and complaints on to other statutory agencies, such as the Commission for Social Care Inspection. EVIDENCE: The home was able to evidence during the inspection that it has a robust complaints procedure, a copy of which is available to all residents, families and visitors to the home in the form of a Complaints information leaflet. The complaints procedure is also contained within the Service User Guide which is provided to all residents. The home was able to evidence that it maintains a log of all complaints received which contains details of the action taken and outcomes reached. Prior to the inspection an anonymous complaint had been received by the Commission which contained six elements for investigation. A report has been produced by the Commission for Social Care Inspection which details the findings of this complaint and actions required. Three elements of the complaint were not upheld, one was unresolved and two were partly upheld. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 21,22,23, 24, 25 and 26 Residents who live at the home can expect to be provided with both private and communal accommodation which is furnished comfortably and maintained to a good standard of decorative order and repair. Residents have free reign to make their rooms as personal and as homely as they would like and to express their personal tastes and preferences. Whilst none of the bedrooms have ensuite facilities, residents can be assured that there are an adequate number of communal bathing and toilet facilities which are provided with specialist equipment for residents who may have a disability. EVIDENCE: Accommodation is sited in a Victorian House which over the years has been extended to provide additional facilities. Accommodation is sited on three floors and all floors are accessible by both stairway and passenger lift. Whilst the home can accommodate twenty-five residents, the twenty-four bedrooms are all offered for single occupancy and although there are no ensuite facilities, the home has sufficient communal bathrooms and toilets to meet the needs of the resident group. The home has two separate lounges with a dividing door which Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 14 can be opened to provide one large room suitable for functions etc. An additional living space has been created in the chapel area which is also used for twice weekly services. On the day of the inspection, the home was maintained to a good standard of decorative order and repair, although some corridor areas required redecoration. Residents’ rooms were attractively decorated, comfortably furnished and many had been made to look very homely with the addition of personal belongings such as photographs and ornaments. Several bedrooms were equipped with televisions and personal telephones. Residents have a choice of communal areas in which to spend time, all of which were comfortably furnished. The home has five communal bathrooms, although one can only be accessed via a small flight of stairs. A quote has been secured for this bathroom to be refitted and revamped to allow easy access and to allow enough room for a hoist to be used. On the day of the inspection, the home was maintained to a good standard of cleanliness and hygiene. The home continues with its plan of refurbishment and renewal. As part of this process, the home must continue to replace or provide covers to the existing radiators in all areas accessible by residents. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents living at the home can expect to have their needs met by staff in such numbers as will meet their needs and ensure both their health and welfare. EVIDENCE: On the day of the inspection, the home was staffed by the Manager, Deputy Manager and four care staff. The number of care staff had been increased from the usual three, due to the increased complex care needs of one resident who was due to be transferred to an alternative residential resource. During the night period, residents are attended by two members of care staff, present in the home on an awake basis. Residents spoken with at the time of the inspection were very complimentary in their feedback about staff and gave the impression that staff were attentive and as one resident reported “nothing is to much trouble for them” Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36, 37 and 38 Residents are provided with care and accommodation in a registered care home that is appropriately managed and which has clear administrative procedures. Two areas in relation to health and safety need to be addressed to ensure that residents are not placed at risk. EVIDENCE: The current manager has been in post for just under a year and at the time of the inspection an application was being processed culminating in his registration with the CSCI. The Manager has an NVQ Level 4 in Management a degree in behavioural science and has worked in the care industry since 1997. Since the previous inspection, Greensleeves Homes Trust has produced a detailed procedure for the safekeeping and management of residents finances. Evidence was available to confirm that all staff are now provided with formal supervision by the Manager on a five weekly basis. Throughout the inspection, Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 17 required records and policies and procedures were referred to and found to be in place. Records in relation to fire safety were examined. The home was able to evidence that fire alarms were tested on a weekly basis and secondary emergency lighting and the siting of fire extinguishers were checked in accordance with guidance issued by the Suffolk Fire and Rescue Service. It was noted during the inspection that when staff were transferring residents in wheelchairs, lap straps were not used. Additionally it was also noted that toilet cleaner was stored in the sluice facility which was not locked. Both these issues would constitute a health and safety risk to residents. Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x 3 3 3 2 Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last 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. 1. Standard 3 Regulation 14(1) Requirement The Registered Persons must ensure that no service users are admitted to the home prior to a full needs assessment being completed either by the placing authority or a senior member of the homes staff. This is a repeat requirement. The Registered Persons must ensure that the home does not offer accommodation to any resident whose care needs fall outside the conditions of registration detailed on the certificate of registration. Timescale for action Immediate 2. 4 3. 7 4. 12 8(2)(a) of the National Care Standards Commissi on (Registrat ration) Regulation s 2001 7 The Registered Persons must ensure that a risk assessment is produced for each resident as part of the care planning process. Risk assessments should be signed by the author and reviewed on a regular basis. 16(2)(n) The Registered Persons must ensure that residents are provided with a programme of activities appropriate to their interests and abilities. This is a I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Immediate 15/08/05 04/07/05 Harleston House Version 1.30 Page 20 repeat requirement. 5. 19 23(2)(d) The Registered Persons must ensure that corridor areas within the building are maintained to a satisfactory standard of decorative order. The Registered Persons must ensure that all wheelchairs used within the home are provided with lapstraps. The Registered Persons must ensure that hazardous substances are stored in a lockable cupboard. The Registered Persons must ensure that all radiators in areas accessible by residents are either provided with covers or replaced with those of a low surface temperature. This is a repeat requirement. 08/08/05 6. 38 13(5) Immediate 7. 38 13(4)(a)& (c) 13(4)(a) Immediate 8. 20 For review on 28/09/05 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 None Good Practice Recommendations Harleston House I54-I04 S58556 Harleston House V230396 050516 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection St Vincents House Cutler Street Ipswich IP1 1UQ 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. 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