Inspection on 06/03/06 for Havelock Court Nursing Home

This inspection was carried out on 6th March 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Havelock Court Nursing Home 20/07/09

Havelock Court Nursing Home 01/08/08

Havelock Court Nursing Home 06/08/07

Havelock Court Nursing Home 05/09/06

Havelock Court Nursing Home 18/08/05

Havelock Court Nursing Home 24/03/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Havelock Court Nursing Home Havelock Court 6-10 Wynne Road Stockwell London SW9 0BB Lead Inspector Sonia McKay Unannounced Inspection 6th March 2006 08:15 Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 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 Havelock Court Nursing Home DS0000007024.V284678.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Havelock Court Nursing Home Address Havelock Court 6-10 Wynne Road Stockwell London SW9 0BB 020 7924 9236 020 7738 6914 enquiries@havelock.ansple.co.uk 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) ANS Homes Limited John Cunningham Care Home 60 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental disorder, excluding learning of places disability or dementia (0), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0), Physical disability (0), Physical disability over 65 years of age (0) Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. MD(E) up to 5 services in this category PD(E) and DE(E) when the current service users in this category vacate there are to no further admissions into these categories service users who are liable to be detained under the Mental Health Act l983, including Sections 2 and 3, must not be admitted until the relevant Sections are discharged if the number of service users in the category of MD rise above 30, staffing ratios for each shift should be maintained in accordance with the Staffing Notice dated 15 March 2002 for the top floor of the home 18th August 2005 4. Date of last inspection Brief Description of the Service: Havelock Court is a nursing home owned and managed by a care provider called ANS. ANS became a subsidiary of BUPA in August 2005. The home provides nursing care for 60 residents in a purpose built home in the middle of a mixed business and residential area, a few minutes walk from a major shopping centre that has full transport and community facilities. It is set in a no-through road in its own grounds, with a gate entrance and its own parking facilities. The ground floor has the reception area, offices and communal facilities and the first and second floors have the service user bedrooms. The ground floor has an activities room, 2 separate lounges, 2 conservatories, one of which is for smoking, 2 dining rooms, and a back garden. There is a lift to all floors, and a keypad system for all communal doors to ensure the safety of service users with dementia who wander. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over ten hours by one inspector. It involved talking with five of the service users, both managers, nursing staff, care staff, maintenance staff, laundry staff and kitchen staff. Records of care, staff records and records relating to the home environment were examined and there was a full tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Staff must be better trained to meet the individual needs of service users accommodated. For example, meeting the needs of individuals with a learning disability. Care staff must assess the safety of aids and adaptations, such as wheelchairs, on a daily basis and swift action must be taken when faults are identified. The storage of confidential service user information must be improved. A plan must be developed for how the home will meet the standard for a maximum of 10 service users to share a staff team and each communal facility, due to come into effect in April 2007. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 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. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective service users individual aspirations and needs are assessed before moving to the home. EVIDENCE: A member of the nursing team completes a comprehensive pre- admission assessment of the care needs of any referred person before they are admitted to the home. Pre-admission assessment documents for one service user were examined. A member of the nursing team completed the detailed assessment whilst the service user was still hospital. A continuing care assessment was also obtained. The home develops an individual service user plan with each prospective service user. The care plans are based on the care management assessment and the homes own needs assessment. The suitability of the placement was reviewed with the placing authority after six weeks. Recommendations made as a result of this review have been addressed. For example, referrals have been made for the service user to attend appointments with audiology, chiropody, a specialist diabetic eye clinic and a visiting dentist. The service users ability to mobilise using a zimmer frame decreased significantly shortly after admission to the home and the service user is Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 9 currently using one of the homes communal portering wheelchairs to access the communal areas on the ground floor, pending an assessment for a personal wheelchair. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10 Service users assessed and changing needs are reflected in their individual plans although more must be done to ensure that service users with a learning disability are able to understand and contribute to their care plans. EVIDENCE: During the previous inspection it was noted that a number of service users had not had an annual statutory placement review. Discussion with the home manager during this inspection indicated that the majority of placing teams have since conducted an annual review. Six service users have not had a statutory annual review and the home manager has written to the placing authorities concerned to request the reviews. Three care plans were examined. Care plans are produced from a standard format and include a full assessment of the service user’s needs, including the use of recognised nursing assessment tools and risk assessments. Each element of the care plan is regularly reviewed, dated and signed. One of the service users has a severe learning disability and challenging behaviour at times. There is a need to develop the written care plans into a Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 11 format that the service user is better able to understand. Recent input from the local specialist team for adults with a learning disability has resulted in a number of recommendations in regard to the introduction of person-centered planning, health action planning and a detailed activities plan. Key staff involved are not clear as to how these recommendations could be implemented and would benefit from training in these specialist areas of communication. (See requirement 1) Care plans in regard to sexuality, social activities and dying and funeral arrangements are available. Some service users are reluctant to discuss and make decisions about the sensitive areas of death and dying and this is respected. Care plans on social activities and fulfilment are brief but staff demonstrate an understanding of individual service user’s wishes and habits in this regard and are able to describe the ways in which they and the activities organiser encourage service users to socialise and take part in activities. One service user said that he is not keen on joining in with communal activities but does enjoy playing dominoes in his room with a member of staff. Nursing stations situated on the first and second floors of the home do not provide adequate security and confidentiality of individual care records. New nursing stations are due to be fitted and these will provide confidential record storage. (See requirement 2) Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 & 17 Service users have opportunities for personal development and their rights are respected and responsibilities recognised in accordance with their individual abilities and any risk factors. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Some of the service users are able to access the community independently. One service user spoke of regular visits to his family home and areas that he knows well. Other service users need support to access the community and in some cases this is facilitated by one-to-one staffing arrangements. One service user regularly attends activities such as bowling with a local voluntary organisation with the support of a member of the home staff team. Placing authorities are impressed with the enthusiasm of the activities organisers. A range of in-house activities is available each week. Examples of activities available include group discussion, life history work, reminiscence, in-house religious services and music, games, quizzes and dominoes, local shopping trips and recreational walks. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 13 On the day of the inspection staff were supporting individual service users with life story work and flower arranging. Some service users attend local day centres and one service user has enrolled onto a computer course at a local college. Staff assist the service users with benefits/finance problems if they require. ANS is currently the state benefit appointee for 17 service users. There are no restrictions on visiting times, although the main reception is only staffed between the hours of 8.30a.m and 8.00p.m, after which the nursing staff can admit visitors via the gated entry system from each floor of the home. Friends and family can visit service users in their bedrooms or in the communal areas. Friends and family social events are held twice each year. Once during the Christmas period and, weather permitting, also for a summer barbecue. Service users have access to a payphone in a quiet communal area and some service users have private telephone lines in their bedrooms. Intimate personal relationships are assessed individually with input and specialist guidance where necessary, as some service users do not have capacity to consent or are otherwise vulnerable. The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in individual planning and contracts. Staff enter service users bedrooms and bathrooms with the individuals permission and normally in their presence. Staff were observed to knock on bedroom doors and await agreement before entering. Service users are offered a key to their own bedroom and service users who access the community independently are given the keypad security code for the main entrance of the home. Areas of the home are keypad code locked to ensure that service users who are at risk are prevented from wandering. Staff were observed to talk to interact with service users and to respect the wishes of service users who chose to be alone. Cooking, cleaning and laundry staff undertake these specific areas, but some service users who are able, take responsibility for keeping their bedrooms tidy. A range of nutritious, varied, balanced and attractively presented meals are provided in congenial dining rooms at reasonably flexible times. Service users Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 14 are offered a choice of suitable menus, which meet their dietary and cultural needs and individual preferences. One service the users said, The meals are very good, another said The foods all right, I like my West Indian food. Service users nutritional needs are assessed and regularly reviewed including risk factors associated with low weight, obesity and special dietary requirements such as diabetes. Service users who need help to eat or are fed artificially are assisted appropriately. There is regular input from the H.E.N team for service users who are on P.E.G feeds. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users receive personal support in the way they prefer and require. EVIDENCE: Personal support is provided in private and intimate care is provided by person of the same gender where possible and if the service user wishes. Service users choose their own clothes, hairstyle and makeup and their appearance reflects their personality. Particular attention had been paid to ensuring that one elderly service user maintains an immaculate manicure. Times for getting up/going to bed, baths, meals and other activities are reasonably flexible (including evenings and weekends) subject to any restrictions agreed in the individual plan. Service users receive additional specialist support and advice when needed from physiotherapists and occupational therapists. General and psychiatric nursing care is provided or supervised by registered nurses and is monitored, recorded and regularly reviewed. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 16 There is consistency and continuity of support for service users through a designated key worker system and individual working records setting out the preferred routines and likes and dislikes of service users who cannot easily communicate their needs and preferences. Some service users have a small team of designated one-to-one staff. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users feel their views are listened to and acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: The home has a clear and effective complaints procedure that meets the requirements of regulation. A service user said, If I wanted to make a complaint I would talk to the manager, another said, I tell the nurse. The previous inspection report recommended the recording of informal complaints or comments/suggestions in order for management and staff to be aware of and effectively monitor day-to-day issues. This has not been implemented. (See recommendation 1) There have been three complaints in the last 12 months. All were responded to within 28 days and all were investigated and found to be unsubstantiated. There have been three adult protection investigations in the last 12 months. The home manager has made appropriate contacts with the local authority adult protection coordinator on these occasions. Robust procedures are in place for responding to suspicion or evidence of abuse or neglect. Appropriate action has been taken on occasions when staff have failed to follow procedures in regard to recording significant events. The home manager is aware of the need to refer staff that may be unsuitable to work with vulnerable adults under P.O.V.A protocols. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 18 Staff demonstrated an understanding of the physical and verbal aggression displayed by some service users on occasion and there is also input from a local specialist behaviour support team for adults with a learning disability. The home has a policy that prohibits the use of restraint. The staff attended abuse awareness and managing aggression training in March 2005. Staff attended whistle-blowing and protection of vulnerable adults training in June 2005. These training sessions, along with P.O.V.A training are also planned for 2006. Senior staff are scheduled to attend training that includes breakaway techniques. During the inspection some staff said that they would feel more confident dealing with instances of physical aggression if they had knowledge of breakaway techniques. It is recommended that breakaway training be cascaded to all staff. (See recommendation 2) Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 28 The large home is reasonably comfortable and clean but some areas require redecoration and refurbishment. There is a need to develop plans to meet the expectation that from April 2007 service users are staffed and accommodated in clusters of 10 people or less. EVIDENCE: The purpose built home premises is suitable for its stated purpose; accessible, safe and reasonably well maintained. The home is comfortable clean and free from offensive odours with sufficient and suitable lighting and heating. However, some of the communal areas are in need of redecoration and one of the shower rooms has significant damp damage on the ceiling. (See requirement 3) There is good access to local amenities, local transport and relevant support services. CCTV cameras are in use for security purposes but are restricted to the exterior of the building and entrance areas for each floor of the home and do not impinge on the daily life of service users. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 20 The L.F.E.P.A inspected the premises 2005. Their inspection report of 06/10/05 and identifies eight contraventions of the Fire Precautions (Workplace) Regulations 1997 and the immediate action to be taken. Discussion with the home manager and maintenance manager provided evidence that the majority of the required action has been taken. The home manager said that he would seek clarification on two areas of the report from the L.F.E.P.A officer to ensure that all necessary action is/has been taken. (See requirement 4) Kitchen and laundry equipment has been replaced since the last inspection. The laundry room has two new washing machines; two new tumble driers, a new press and rotary iron. The kitchen has two new cooking ranges, four new refrigerators and three freezers, a new deep fat fryer, a new steamer, a new mixer and vegetable peeler and new heated trolleys for transporting prepared meals to dining areas. National minimum standard 24.3 stipulates that larger homes be organised into clusters of up to 10 service users sharing a staff group, dining area and other common facilities by first of April 2007. There are presently no plans in place to achieve this. (See requirement 5) Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Service users are supported by a well supervised, competent and qualified staff team, although greater emphasis must be placed on providing staff with training to meet individual needs. Current recruitment policy and procedures protect service users. However, recruitment practices prior to 2004 did not include the correct police check. EVIDENCE: BUPA are in the process of introducing an extensive staff training and professional development plan. Progress with this plan will be examined during the next inspection. A care staff induction programme in accordance with Skills for Care is in place. Statutory training includes fire safety, manual handling and moving, COSHH, food hygiene and health and safety. Nursing staff, support staff and ancillary staff received induction as appropriate to their individual roles. Staff were observed to be accessible to, approachable by and comfortable with service users. Staff providing one-to-one care for service users with higher needs were observed to have a depth of understanding of the service users needs and a sense of commitment to their individual care. The first language of 21 of the service users is not English. Staff on duty demonstrated the various communication methods in use and explained the Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 22 strategies for communication. Staff working with individuals regularly have familiarised themselves with commonly used phrases in the first language of the service users. Interpreters have been used for one service user from Kosovo and other service users use a computerised translator and pen and pad to assist effective communication. Staff also demonstrated an understanding of the cultural and religious heritage of each service user. For example, by working closely with families and providing appropriate room décor, music and meals. There are 14 registered nurses and 45 care staff. 8 of the nurses, inclusive of the home managers, are RMNs and a further 3 nurses are currently undertaking conversion training to obtain an RMN qualification. 60 of care staff hold an NVQ level 2 or above. In 2005 staff received training in dementia and the Mental Health Act, HIV and AIDS awareness, depression and risk assessment. The full training schedule for 2006 is not finalised but so far includes nutrition, managing aggression, infection control, care planning, challenging behaviour, accountability and data protection, cannulation and mentoring/supervision. Some of the service users have a learning disability. Specialist professionals in involved in the care of one service user have identified that key staff will benefit from training in person centred planning, health action planning and producing an accessible activities schedule. (See requirement 1) 14 members of staff have been employed since the last inspection visit. A satisfactory enhanced criminal records bureau disclosure were available for each member of staff. Full recruitment records for one member of staff were examined and all documents required by regulation were in place. Discussion with the home manager revealed that company policy prior to July 2004 was to obtain Scottish CRB disclosures. These are inadequate and new enhanced disclosures must be taken up for each member of staff involved. (See requirement 6) Staff spoken with during the inspection confirmed that there are established arrangements for managers to brief staff and receive direct feedback from staff. Staff confirmed that on call support is always available should the need arise. Staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day-to-day practice. Supervision meeting notes are brief. BUPA are introducing a new supervision format. This format is more detailed than the one currently in use. Progress Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 23 with the introduction of these supervision records will be examined during the next inspection. Staff providing supervision have not all attended supervision training, although this is planned for 2006. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Service users benefit from a well run home and can be confident that their views will underpin the monitoring and development of the home. Systems are in place to ensure the health, safety and welfare of service users, and the majority of areas are adequately covered. There is need for improved ways of ensuring that aids and adaptations are safe at all times and also to confirm that recent improvements to fire safety are in accordance with fire authority requirements. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. He has extensive management/supervisory experience and has nursing and management qualifications. ANS homes were taken over by BUPA in August 2005. There is a significant amount of organisational change going on at this time, including the Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 25 introduction of BUPA policies and procedures and new care planning and staff training packages. Staff spoken with during the inspection spoke positively about BUPA involvement so far and the plans for change in 2006. BUPA undertook a service user satisfaction survey in the autumn of 2005. The findings of this survey were published in February 2006. 30 of the Havelock Court service users received questionnaires and 97 responded. 76 rated the quality of service as excellent/very good, 21 rated the service as excellent, 55 rated the service as very good, 21 rated the service as quite good and 3 rated the service as neither good nor poor. Service users were asked to comment on staff in the home, the building and the surroundings, bedrooms and communal rooms, food and activities. They were also asked to make suggestions for improving the home. Service users will receive feedback about this involvement in the revised Service Users Guide to the home which is currently being developed. BUPA are in the process of introducing their quality monitoring system. This will include a full annual audit of all areas of the service provided. Progress with this will be examined during the next inspection. A representative of the registered provider visits the home on a regular basis and completes reports on the findings of these visits in accordance with regulation. These reports are maintained in the home and supplied to the CSCI Southwark office as required. Health and safety responsibilities are shared between the home manager and the maintenance manager. The home manager has overall responsibility for ensuring staff receive appropriate health and safety training applicable to the area of the home they are working in. The maintenance manager monitors environmental health and safety. The annual gas appliance safety certificate was issued in July 2005. The annual small electrical appliances tests were conducted in March 2005. Electrical circuitry was safety tested in December 2005. The test certificate is valid for five years. A pest control contract is in place and checks are conducted on a quarterly basis. There are currently no pest issues within the building. The L.F.E.P.A (fire authorities) inspected the premises in 2005. (See requirement 4) Legionella temperature checks were completed in February 2006. The passenger lift was most recently inspected professionally in January 2006. The emergency call system was most recently tested in October 2005. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 26 The maintenance manager carries out checks on wheelchairs in use in the home. During the inspection it was noted that a wheelchair belonging to one service user only had only one footplate. This placed the service user at risk of serious injury. The home manager took immediate action to ensure that the missing footplate was located and refitted. (See requirement 7) Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X 2 X Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 28 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 YA32YA6 Regulation 15(2)(a) Requirement The registered persons must ensure that staff are trained to produce care plans that are in language and a format that service users can understand. For example, person centred plans, health action plans and activities plans that are accessible to a service user with a learning disability. The registered persons must ensure that any confidential service user records are stored securely in the home. The previous timescale of 31/05/05 is not met and although the new timescale of 31/03/06 has not elapsed the remedial action will not be taken in time. The home manager said that this issue would be resolved when the nursing stations are redesigned at the end of this financial year. The registered persons must supply the CSCI Southwark office with the planned maintenance and renewal DS0000007024.V284678.R01.S.doc Timescale for action 31/10/05 2. YA10 17(1)(b) 31/08/06 3 YA28YA27YA24 23(2) 31/05/06 Havelock Court Nursing Home Version 5.1 Page 29 4 YA42YA24 5 YA24 6 YA34 7 YA42 programme for the fabric and decoration of the premises for 2006. This plan must include refurbishment of the shower room that is damp and redecoration of the communal areas. 23(4)(5) The registered persons must confirm that all areas of required action identified in the L.F.E.P.A (Fire Authorities) inspection report of 06/10/05 have been taken. 23(2)(a) The registered persons must 18(1) supply the CSCI Southwark office with plans on how the home will achieve clusters of no more than 10 service users sharing a staff group, a dining area and other common facilities by 01/04/07. 19 The registered person must Sch 2.7(a) ensure that new enhanced criminal records bureau disclosures are taken up for any member of staff who has a Scottish CRB check. 13(4)(c) The registered person must 12(1) ensure that wheelchairs in use at the home are safe at all times (one wheelchair had a missing foot plate). 12/05/06 30/06/06 30/06/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The registered persons should ensure that a comments/suggestions book is kept on each floor for service users and staff to access to record and monitor day-to-day issues. The registered persons should ensure that staff are trained DS0000007024.V284678.R01.S.doc Version 5.1 Page 30 2 YA23 Havelock Court Nursing Home in safe breakaway techniques to better equip them to deal with challenging behaviour and physical aggression. Havelock Court Nursing Home DS0000007024.V284678.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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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