Inspection on 17/02/06 for Harrias House

This inspection was carried out on 17th February 2006.

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

Harrias House 03/07/08

Harrias House 04/07/07

Harrias House 02/02/07

Harrias House 07/11/05

Harrias House 29/03/05

Harrias House 06/12/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Harrias House Hedgerley Lane Beaconsfield Bucks HP9 2SD Lead Inspector Christine Sidwell Unannounced Inspection 17th February 2006 14:00 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 Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Harrias House Address Hedgerley Lane Beaconsfield Bucks HP9 2SD 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) 01494 674204 hh.manager@ukonline.co.uk Beaconsfield Housing Society Limited Elinasi Bailey Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Harrias House provides care for 17 service users. It is situated on the edge of Old Beaconsfield and is an elegant building with extensive grounds. It provides welcoming and homely care for the older person. The rooms are spacious and can be personalised. There is an experienced care team. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of an unannounced inspection, which took place on the 17th February 2006. The purpose of the inspection was to inspect the remaining key standards, which were not assessed at the announced inspection undertaken on the 7th November 2005, and to assess progress towards achievement of the requirements made at that inspection. Records were examined and a short tour of the building undertaken. The deputy manager was spoken to. The residents and family members who were in the home at the time of the inspection were spoken to. A follow up visit was undertaken on the 3rd March 2006 to speak with the manager. What the service does well: What has improved since the last inspection? What they could do better: The improvement in the care plans should be continued by integrating risk assessments into the care plans and by reviewing them on a monthly basis. The recruitment files must be updated to ensure that they contain the required documentation and staff must not commence work until a Criminal Records Bureau (CRB) check and two satisfactory references have been received. If it is necessary for them to start work before the Criminal Records Bureau Disclosure is received a POVA first check must be sought. A Health and Safety policy must be written and agreed. Risk assessments for safe working practices should be undertaken. A systematic quality assurance programme should be implemented. Please contact the provider for advice of actions taken in response to this Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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 Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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): none These standards were not assessed on this occasion but were met at the inspection undertaken on the 7th November 2005. EVIDENCE: Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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 The care plans have improved and contain much of the information necessary to guide carers in meeting resident’s needs. EVIDENCE: The home uses the standex system of care planning and has worked hard to improve the written care plans. Four records were examined at random and found to contain demographic data and an initial assessment of care. Short and long-term care plans had been agreed. The daily entries had been signed and dated. There was documented evidence of medical and other healthcare professional input. Some of the risk assessments were held in another file and it is recommended that these be integrated with the main system of care planning. The care plans are continuing to improve. It is recommended that the next phase in the care plan development should be incorporating individual risk assessments and setting up systems to ensure that plans are reviewed on a monthly basis. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 10 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, 13, 14 and 15 The atmosphere in the home is relaxed and residents and their families are encouraged to remain in contact. There are planned activities, which bring variety and stimulus to the resident’s day. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The routines in the home are flexible and the residents confirmed that they had a choice as to when they got up and when they went to bed. Relatives and friend are welcome at any time and the visitors spoken to confirmed this. On the day of the unannounced inspection a group of residents was playing scrabble with the activities organiser. She said that she visited at least twice weekly and undertook individual and small group activities. The activity plan for the week was posted in the hall. Visitors confirmed that they can see their relatives in private and several residents said that they went out frequently with their families. Representatives from the local church visit the home. The manger said that residents or their families manage their monies. All residents are on the electoral roll. Residents are encouraged to bring their personal belongings and all rooms were personalised and homely. The residents said that they enjoyed their meals and that they had a choice of main meal. The home has appointed a new chef and he has introduced a four week suggested menu, which he said was flexible and could be changed to meet the needs of residents. The menu seen was varied and predominately Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 11 home cooked. Soft diets are available as are special diets. Drinks and snacks are available and a hot drink and biscuits are served at night. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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 the following standard(s): none These standards were not assessed on this occasion but were met at the inspection undertaken on the 7th November 2005. EVIDENCE: Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 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 the following standard(s): none These standards were not assessed on this occasion but were met at the inspection undertaken on the 7th November 2005. EVIDENCE: Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 14 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 Although the carers are supervised and many are very experienced, the formal training programmes necessary to ensure that they have the skills to care for residents and not to put either residents or themselves at risk are not in place. The necessary checks on staff suitability must be undertaken before they commence work to protect residents from unsuitable carers. EVIDENCE: At present there are 14 carers working full and part time shifts. Currently none hold the National Vocational Qualifications in Care although three have completed the foundation course and will be starting the course in March 2006. No staff have been recruited since the last inspection and it was not possible to assess whether the requirements regarding recruitment made at the last inspection have been put into place. This will be assessed at the next inspection. New staff have an orientation to the home and work alongside experienced carers until they are confident to care for residents alone. None have as yet completed an accredited induction programme although there are plans in place for staff to do this. Not all staff have had the basic mandatory training, including manual handling training. This must be addressed as a matter of urgency. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 15 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): 33, 35 and 38 There is a committed management team. There is a need to introduce a systematic quality assurance programme if the residents and trustees are to be assured that the quality of care is of a consistently high standard. The Trustees should also agree a health and safety policy and ensure that it is implemented to protect both residents and staff. EVIDENCE: The Beaconsfield Housing Trust, which manages the home, has an active board of trustees who take an interest in the home. The chairman and three of the trustees visit the home regularly. They do not as yet provide the Commission for Social Care Inspection with reports of their quality assurance visits but are willing to do so and the inspector has agreed to send the Commission’s guidance on this. Resident’s views are sought informally on a daily basis and a questionnaire is undertaken periodically. A newsletter is published which keeps residents up to date with changes in the home. There remains a need to introduce a more systematic quality assurance programme to ensure that all aspects of the home’s care and management are reviewed on a regular basis. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 16 The home does not manage resident’s money. Residents have locked storage in their rooms if they wish to keep valuables with them and all residents have a key to their room door, which can be locked if they wish. At the last inspection a requirement was made that a health and safety policy be written and agreed. This has not yet been completed and the requirement has been repeated in this report and a new timescale has been set. Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 17 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 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x X STAFFING Standard No Score 27 X 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 18 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 15 Requirement The improvement in care plans should be maintained. Risk assessments should be incorporated into the care plans and they should be reviewed on a monthly basis. The recruitment files should contain the information specified in Regulation 19, schedules 2 and 4 of the Care Homes Regulations 2001. Staff must not start work until a Criminal Records Bureau (CRB) check has been received. If necessary a POVA first check must be undertaken and the staff supervised until a full CRB check is received. All staff must complete an induction programme This is an unmet requirement of previous inspections and a new timescale has been set. All staff must have foundation training with annual updates of mandatory topics. This is an unmet requirement of previous reports and a new timescale has been set. DS0000022976.V285102.R01.S.doc Timescale for action 30/06/06 2. OP29 19 30/04/06 3. OP29 19 30/04/06 4. OP30 18 30/06/06 5. OP30 18 30/06/06 Harrias House Version 5.1 Page 19 6. OP38 13 7. OP33 24 A health and safety policy must be agreed and risk assessments should be undertaken to ensure safe working practices. This is an unmet requirement of previous inspections and a new timescale has been set. A systematic quality assurance programme should be implemented. 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Harrias House DS0000022976.V285102.R01.S.doc Version 5.1 Page 21 - 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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