Inspection on 28/09/05 for Harleston House

This inspection was carried out on 28th September 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 16/05/05

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 Announced Inspection 28th September 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 Harleston House DS0000058556.V257887.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. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Harleston House Address 115 Park Road Lowestoft Suffolk NR32 4HX 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) 01502 574889 01502 516638 harleston@greensleeves.org Greensleeves Homes Trust Mr Scott Andrew Delf Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 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 organisation to extend the service and to upgrade the existing premises. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection of Harleston House, a twenty-five bedded residential care home for older people situated in the coastal town of Lowestoft. This was the second scheduled inspection in the inspection year 2005/2006. The inspection was carried out on 28 September 2005 over a period of five and three quarter hours. The inspection was facilitated by Mr. Scott Delf, the registered manager and the Inspector also had discussions with Mr. Andrew Moore, the architect employed by the owning organisation to produce plans for the proposed extension and refurbishment of the existing building. During the inspection, previous requirements were discussed and standards not covered at the last inspection were assessed. Information contained within this report is collated from the submitted pre-inspection questionnaire, discussions with the registered manager, staff members and residents, required records, policies and procedures and direct observation. What the service does well: What has improved since the last inspection? Since the previous inspection, the home has employed an activities coordinator. This appointment has ensured that residents are offered a daily programme of meaningful activity. Feedback gained from residents was extremely positive about this new appointment. The activities co-ordinator was obviously a popular member of staff and it was evident that residents had been motivated to take up such hobbies as knitting. The home is now ensuring that Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 6 all residents are provided with a general risk assessment and has also ensured that risk assessments have been completed in relation to the hazard posed by uncovered radiators. 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. Harleston House DS0000058556.V257887.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 Harleston House DS0000058556.V257887.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): 2, 3 and 6 Prospective service users can expect to have their care needs assessed and therefore be assured that following admission, the home will be able to meet their individual needs. Residents can be assured that they will be issued with a placement contract which sets out the financial contributions of each party. EVIDENCE: As part of the inspection process, the pre-admission information in relation to the most recently admitted resident was examined. The home was clearly able to evidence that in this case of this resident a detailed pre-admission assessment of need was carried out using the pro-forma issued by the Greensleeves Homes Trust. The home was able to evidence that the service user had been issued with a placement contract. The home does not offer an intermediate care service. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 9 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 On admission to the home all residents can expect to be provided with a detailed care plan, which includes the assessment of any potential risks. On the day of the inspection, practices in use did not ensure that residents were protected by the policies and procedures in relation to the administration of medication. Service users can expect to be treated with respect by staff and for their right to privacy to be upheld. EVIDENCE: During the inspection, the care plan of the most recently admitted resident was examined. The care plan gave a detailed breakdown of assessed need and set out the interventions required by staff to ensure that these needs are met. A general risk assessment had been completed and included as part of the care planning process as had a moving and handling assessment. The system used for the administration and safe storage of medication was examined. Medication is provided from the local pharmacy in blister packs which are stored in a medication trolley from which they are dispensed directly to residents. The pharmacy carries out a three monthly medication audit at the Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 10 home, the most recent taking place on 27 September 2005. Medication is administered by senior staff all of whom have completed the Boots advanced medication course. On the day of the inspection, the member of senior care staff was observed administering medication to residents. Medication was administered during the mid day meal served in the dining room. As the dining room is limited in space, the medication trolley is left outside the dining room. It was noted that: * The medication is left unlocked outside the dining room whilst the member of care staff goes inside to administer medication to each resident. * The member of care staff signed the MARS sheet before she administered the medication and did not wait to observe the resident taking it. The home was able to evidence that all personal care provided is done so in the privacy of residents’ own rooms. Bedrooms have appropriate privacy locks as do communal bathrooms throughout the building. During the inspection, staff members were observed to knock on resident’s doors before entering. Residents spoken to at the time of the inspection were smartly dressed and were able to express preferences with regard to the style of clothes they wore. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 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 the following standard(s): 12, 14 and 15 Residents living at the home can expect to be offered a programme of varied activities which are appropriate to their needs and abilities. Residents can expect to be provided with a menu of meals which are varied in their content and nutritious. Additionally residents can expect to be enabled to make choices around their daily lives. EVIDENCE: Since the previous inspection, the home has employed an activities coordinator who is present at the home for ten hours per week. A programme of activities available to residents was displayed on the home’s notice board. On the day of the inspection, the activities co-ordinator was on duty and had been providing a hairdressing service to residents. Later in the day residents enjoyed a quiz session. One resident showed the inspector a necklace that she had made in a previous activities session. Two residents spoken to reported that there was plenty of activity in the home and that they never got bored. Another resident reported that they felt the level of activity provided was just right, although another resident felt that they spent long periods sitting doing nothing. Residents were clearly encouraged to take up such activities as knitting if they wanted to and several residents were knitting squares which the activity organiser was going to make up into a blanket. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 12 The provision of meals for residents was examined on the day of the inspection. A weekly menu was examined which evidenced that residents were provided with a varied and nutritious diet. Three cooked choices were available for the lunch time meal and kitchen staff ensured that residents were provided with a minimum of one portion of fresh vegetables a day. The evening meals consisted of sandwiches and cakes and on a Sunday residents were provided with a “Parlour Tea” which was served in the form of a buffet. Vegetables were served in dishes placed on each table enabling residents to take as much or a little as they wished. It was noted that a chilled fruit juice dispenser was available in the dining room. On the day of the inspection several residents enjoyed a meal of gammon and pineapple and one reported that meals were consistently of a good standard and that meal options offered made a nice change from “meat and gravy”. Another resident reported that their 99th birthday had been celebrated with a “party tea”. One resident reported that very often lunch was not served until 1.30pm which they felt made the morning very long. The home’s cook reported that she did not get much feedback from residents in relation to the popularity of the meals provided. It was therefore suggested that she might like to consider talking to residents in the dining room after the lunch time meal. Alternatively residents might like to consider whether they would like the cook to attend their monthly meeting. Daily routine sheets which form part of the resident care plan indicated that residents are able to make choices around how they wished to spend their time ie what time they wished to get up or retire to bed. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 13 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 Residents can expect the homes policies and procedures to offer them protection from abuse. EVIDENCE: The home was able to evidence that it has a copy of the Suffolk local joint procedure on the Protection of Vulnerable Adults. However the copy retained by the home had not been revised and contact details were provided on how the home could obtain a copy of the revised procedure. The home was able to evidence that all staff received abuse awareness training from the owning organisation. Staff personnel records evidenced that prior to the commencement of duties all prospective staff are subject to a POVA check. Additionally all staff are subject to an Enhanced Disclosure via the Criminal Records Bureau. Since the previous inspection, the Commission has received two written complaints in relation to this home. Both complaints were anonymous and were investigated by the Commission. The first complaint received by the Commission on 04 May 2005, contained 6 elements. Following investigation, two elements were partly upheld, three were not upheld and one was unresolved. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 14 The second complaint received by the Commission on 5 and 6 September 2005 respectively (two separate letters) contained 5 elements. Two elements of the complaint were upheld and three were not upheld. Harleston House DS0000058556.V257887.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 -26 Residents can expect to be provided with communal and private accommodation which is spacious, well maintained and homely. EVIDENCE: Accommodation is sited in a Victorian House which over the years has been extended to provide additional facilities. Greensleeves Homes Trust plans to extend the current building to provide an additional 15 beds and to refurbish the existing building. A copy of the proposed plans has been submitted to the Commission for Social Care Inspection for consideration and comment. Current accommodation is sited on three floors and all floors are accessible by either stairway or shaft lift. The twenty-four bedrooms are all offered for single occupancy and whilst none of the current rooms have the advantage of ensuite facilities there are an adequate number of communal bathroom facilities to meet the needs of the resident group. One bathroom on the first floor of the home is due to be re-fitted and refurbished to allow easier access and the use of a hoist for assisted bathing. A selection of resident bedrooms were viewed on the day of the inspection. The home is aware that some of these bedrooms Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 16 require redecoration and refurbishment and evidence was available to show that old bedroom furniture was being replaced on a gradual basis. It is the intention of the owning organisation to refurbish all bedrooms as part of the extension and renewal plans. Residents had obviously been encouraged to make their rooms as homely as possible with the addition of personal belongings and all rooms are provided with a telephone and television point. There are two communal lounges sited to the front of the property which were pleasantly furnished and maintained to a good standard of decorative order and repair. In addition there is a chapel area with lounge seating where residents can spend time and where daily worship is held. During the previous inspection, it was noted that corridor areas around and along the main staircase were maintained to a poor state of decorative order and a requirement was made for this to be addressed. It was noted during this most recent inspection that this outstanding work had not been attended to. Appropriate aids and adaptations had been provided around the home. All areas of the home were maintained to a satisfactory standard of cleanliness and hygiene and no unpleasant odours were detected. Harleston House DS0000058556.V257887.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 Residents can expect to be cared for by staff members who receive appropriate training relevant to the work they perform. Residents can also expect to be protected by the home’s recruitment policies and procedures. EVIDENCE: Information contained within the pre-inspection questionnaire and examination of training records confirmed that 42 of care staff working at the home have achieved an NVQ qualification at Level 2 and above. The Manager advised that another 6 staff are now working towards NVQ Level 3. The home is therefore on target to achieve a figure of 50 NVQ qualified staff by the end of the year. As part of the inspection the personnel files of the two most recently employed staff members were examined. These confirmed that prior to any prospective staff member commencing duties, all were subject to a POVA check and two satisfactory written references were secured. Training records evidenced that staff are provided with a structured Induction training package which complies with TOPPS standards. Records also evidenced that staff were provided with areas of mandatory training such as moving and handling. During the inspection, the Inspector attended a staff handover and spoke to the three staff members involved. Those staff spoken to had no concerns about the way in which the home was administered or staffed, although one felt that a larger pool of staff would be beneficial for covering sickness or Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 18 annual leave, although it was confirmed that no staff worked additional hours unless they wished to. Another staff member reported that they felt standards at the home had improved since being taken over by the Greensleeves Homes Trust and that more training was now available. Staff observed during the inspection, interacted with residents in a professional but warm manner. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 19 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): 31, 33 and 38 Residents can be assured that the home is managed by a person who has appropriate qualifications. Residents can expect to be provided with regular opportunities to express their concerns, views and expectations in relation to the day-to-day running of the home. In general residents can feel assured that they are provided with an environment which is safe and poses little risk, although one health and safety issue needs to be addressed. EVIDENCE: The current manager has been in post for approximately one year and has an NVQ Level 4 in Management and a degree in Behavioural Science. In November 2005 he will commence an NVQ Level 4 in Care which when successfully completed will provide him with the Registered Manager’s Award. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 20 Visits by a representative of the Registered Provider are carried out on a monthly basis in compliance with Regulation 26 of the Care Homes Regulations 2001 for the purposes of quality assurance. A written report of the findings of these visits is provided to the Commission for Social Care Inspectio (CSCI). Monthly resident meetings are held to provide a forum for them to express any concerns or ideas they may have in relation to activities and the way in which the home is run. Standards in relation to the health and safety of service users were examined as part of the inspection process. Records seen evidenced that fire alarms were tested on a weekly basis and secondary emergency lighting monthly. All accidents occurring in the home are recorded in detail and filed within the resident’s own personal. There is an outstanding requirement from previous inspections that the requested person ensure that all radiators are either covered or replaced with the low surface temperature variety. The Inspector has been assured that this will be addressed as part of the forthcoming refurbishment. Assessments have been carried out in relation to the risk posed to each service user by unguarded radiators. It was identified that one radiator in room 22 poses a high risk to the occupant. The radiator is sited in front of a window thus forcing the occupant to lean over the radiator when attempting to open the window. It has therefore been agreed that this radiator will be provided with a cover on an urgent basis. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 3 3 3 3 3 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 3 X 3 X X X X 2 Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13(2) Requirement The Registered Persons must ensure that the medication trolley is not left unlocked and unattended at any time. The Registered Persons must ensure that the record used for the recording of the administration of individual resident medication is not singed until the prescribed medication is administered to the individual concerned. 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 the radiator in Room 22 which poses a risk to the occupant is either provided with a cover or replaced by a radiator of the low-surface temperature variety. Timescale for action 28/09/05 2 OP9 13(2) 28/09/05 3 OP19 23(2)(d) 28/11/05 4 OP38OP25 13(4)(a)& (c) 28/11/05 Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 23 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 OP15 Good Practice Recommendations The Registered Persons should ensure that the home’s chef actively seeks feedback from residents in relation to the quality and popularity of the meals provided. Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk 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. Extracts may not be used or reproduced without the express permission of CSCI Harleston House DS0000058556.V257887.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!