Inspection on 26/04/07 for Havelock House

This inspection was carried out on 26th April 2007.

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

Havelock House 01/09/09

Havelock House 18/12/08

Havelock House 17/01/08

Havelock House 03/05/06

Havelock House 04/10/05

Havelock House 19/04/05

Havelock House 21/12/04

Havelock House 06/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Havelock House 57 - 59 Victoria Road Polegate East Sussex BN26 6BY Lead Inspector Kathy Flynn Key Unannounced Inspection 26th April 2007 11:20 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 Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 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. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havelock House Address 57 - 59 Victoria Road Polegate East Sussex BN26 6BY 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) 01323-482291 01323 482622 Mr Bhardwaj Dhunnoo Mrs Tarramattee Dhunnnoo Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty seven (27). The service can provide up to twenty-six (26) nursing place and one (1) social care place. Service users must be aged sixty-five (65) years of age or over on admission. 14th December 2006 Date of last inspection Brief Description of the Service: Havelock House is registered to provide nursing care for up to 26 older people and personal support for one. Situated in a residential area of Polegate, it is within walking distance of the high street and the railway station, with a library, GP and dentist surgeries easily accessible. The home is on two floors with a shaft lift and stair lift giving residents access to all parts of the home. There are 21 single rooms 3 double rooms with no ensuite facilities, although there are two assisted bathrooms, an assisted shower and a number of assisted toilets. There is a large lounge, looking out to the rear garden that is accessible to wheelchairs and is used when weather permits, and a separate dining room. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on the 26th April and took place over 7 and a half hours. The inspection included a tour of the home, a review of pre-admission assessments, care plans, accident records, staff records and training, medication records, activities, policies and procedures and menus. There were 25 residents at the home during the inspection. All the residents and a number of visitors were spoken with and those who expressed an opinion were happy to discuss the support provided at the home. The acting manager, the nurse on duty, senior carers, the care staff and the cook discussed the care and support they provide at the home. A pre-inspection questionnaire and 10 residents/relative surveys were sent to the home prior to the inspection. These were not returned to the Commission. The reader should aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term service user to describe those living in care home settings. However for the purposes of this report those living at Havelock House will be referred to as residents. What the service does well: The atmosphere at the home was relaxed and the residents were able to choose to spend their time in the lounge or in their own rooms. Communication between residents and staff was friendly and reflected the staffs understanding of their needs and the support they require. The residents and relatives spoken with were positive about the care provided saying the staff are ‘very good’ and offer the care they need. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 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 Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Preadmission assessments are carried out for all prospective residents, to ensure that the home can meet their individual needs. EVIDENCE: The acting manager, in consultation with prospective residents and their relatives, carries out an assessment of their individual needs. Sufficient information is collected to enable the acting manager to decide if the home can provide the support and care needed, before prospective residents Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 9 are offered a place at the home. The preadmission assessments are used as the basis for the care plans. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service, experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The information provided in the care planning system enables staff to offer residents an appropriate level of support and care, and staff protect residents by following the homes policies and procedures for medication. EVIDENCE: Improvements have been made to the care planning system and the care plans contain an overview of each of the residents individual needs. Referrals Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 11 are made to the GP, the dietician and the tissue viability nurse as required, and appropriate pressure relieving aids are in place. Residents who are at risk because they have poor appetites, or have lost weight, are identified and the acting manager advised that food and fluid charts are completed so that their individual nutritional needs can be assessed on a daily basis. However, it was noted that these charts had not been completed appropriately although staff said that the residents had been eating and drinking. Some of the assessments had not been completed, including nutritional and continence care, bed barrier agreements were not in place for in a number of residents, and some care plans had not been reviewed on a regular basis. The nurse in charge said that each of the nurses is responsible for a number of care plans, and advised that they will work together to make sure that all the care plans are up-to-date and contain all the relevant information. The homes medication procedures have been reviewed by the pharmacist, and the acting manager confirmed that some changes have been made to their procedures following this. The nurse in charge confirmed that the nurses had attended the medication training and the policies and procedures are up-todate, and the Medicine Administration Record (MAR) charts were completed appropriately. The atmosphere in the home was comfortable, and the conversations between staff, residents and visitors were noted to be relaxed and friendly. Residents who expressed an opinion said that the ‘home is very good’, the ‘staff are friendly’ and they’ help me do what I want to do’. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have good quality food and they are able to make choices about all aspects of their day to day lives. EVIDENCE: The home has recently employed an activity person with 5 years experience of providing a range of activities for people living in care homes. She has spent her first two weeks getting to know the residents, finding out what interests they have and how they like to spend their time. She confirmed that a programme of activities will be developed to ensure that each resident has ‘opportunities to do something they enjoy’. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 13 During the inspection a group of residents took part in a reminiscence session and indoor skittles in the lounge, and one resident enjoyed a sing-a-long in the afternoon. Visitors are welcome at any time and those spoken with during the inspection were positive about the care and support their relatives receive and said the home is ‘very good’. Residents are encouraged to make choices about all aspects of their day, some prefer to stay in their rooms while others sit in the lounge for part of the day. One resident is particularly interested in sport and will spend most of the time watching the TV in his room. Staff said it is their home and they should be supported to do what they like, and those residents who expressed an opinion said they can choose how they spend their time. The food at Havelock House is good, residents are offered choices for each meal and those who require assistance or have special dietary needs are well supported. Residents spoken with said ‘the food is good’ and they can have something different from the menu if they want. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. One complaint has been made to the acting manager since the last inspection. This has been investigated and appropriate action has been taken, and staff training is provided to ensure residents are protected from abuse. EVIDENCE: Polices and procedures are in place for dealing with complaints. The feed back from residents was positive and those spoken with who expressed an opinion said they did not have any concerns. The acting manager has completed a course regarding Adult Protection and is now qualified to provided training in abuse and the protection of vulnerable adults for staff. She confirmed that all new staff are required to do this training, and this will be extended to include all staff at the home to make sure they are up to date. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 15 Staff spoken with said they have completed training in the protection of vulnerable adults and are clear about what action they would take if they have any concerns. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to personalise their rooms and many bring pictures and ornaments to the home. However residents are at risk because some of the furniture is damaged and worn and cannot be cleaned properly, and staff are failing to follow the homes infection control policies to protect residents. EVIDENCE: Residents are able to bring their own possessions with them to the home and many have personalised their rooms with pictures and ornaments. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 17 However the improvements identified at the last inspection have not been met. Residents continue to use bed tables and commodes that are chipped and rusty, which places them at risk of infection because staff are unable to clean them effectively. Some divan beds are used in the home, the acting manager advised that rooms are allocated depending on the needs of the individuals, and she confirmed that the beds are included in these assessments to ensure they can provided the correct support for residents. This has a direct affect on which prospective residents can be admitted to the home. The acting manager advised there is no plan to replace them with the adjustable beds, which enable staff to support residents who need assistance transferring from bed to chair. Staff spoken with during the inspection said that they have attended infection control training and understand the procedures they should follow to protect residents. It was noted that some staff were using gloves and aprons inappropriately and the acting manager and nurse in charge said this is a training issue and will be addressed. One of the bedrooms was being decorated at the time of the inspection. But a maintenance plan has not been developed to ensure that the home is kept in a reasonable state of repair, and an audit of furniture, discussed at the last inspection, has not been carried out. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The residents are provided with care and support by staff who have attended appropriate training and are aware of their roles and responsibilities while assisting residents. However the residents are at risk because staff do not follow some of the homes policies, and provide support on the basis of completing tasks rather than offering twenty four hour care. EVIDENCE: The acting manager confirmed that there are sufficient staff on duty at Havelock House. An additional member of staff is now employed during the day to ensure that the needs of residents can be met as the numbers have increased. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 19 The concern that staff are offering support and care in terms of completing tasks rather than providing a continuous service was highlighted during the inspection. The acting manager advised that the home aims to support residents over a twenty four hour period and staff should be offering care on this basis, however she is aware that this is not always provided and will continue to address this on a daily basis and during supervision. Robust recruitment procedures are followed and the acting manager said that staff are not employed at the home until all the relevant checks have been completed, including Protection of Vulnerable Adults and Criminal Registration Bureau, an application form with work history and two references. The personnel files for new staff were viewed and contained all the relevant information. Staff are encourage to work towards National Vocational Qualifications (NVQ) when they have completed the homes induction course. A number have applied and have started these courses although they were not at the home during the inspection. All new staff are required to complete the induction course, the acting manager said that the new member of the care staff team would be starting his induction when he has been at the home for one week and she will be supporting him through this. Staff training, including moving and handling, infection control, food hygiene, fire training is provided for staff, and the acting manager said that she will be organising training over the year to ensure that they are all up to date. Staff spoken with said they enjoy working at the home and feel that they are able to offer residents the support and care they need. Residents also said that the staff are good and help them when they need support. However some staff do not follow the homes policies and procedures, with regard to infection control and completing care plans, and the manager and nurse in charge said these issues will be addressed. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The management of the home does not meet all the assessed needs of residents, and some practices in the home do not promote and safeguard the health, safety and welfare of residents. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 21 EVIDENCE: There has been no registered manager at Havelock House since February 2005. The acting manager is a registered nurse and has been in place since December 5th 2005. An application to register with the Commission as manager has not yet been received. The acting manager demonstrated an understanding of the needs of residents. She advised that she has reviewed the homes policies and procedures and training is provided for staff including moving and handling, infection control and fire training. However the staff were noted not to follow the homes policies and procedures for controlling the spread of infection, and because some of the furniture is of a poor quality and staff are unable to clean them properly residents are not protected from infection. There is no quality assurance and monitoring system in place, although the acting manager advised that she does talk to the residents, visitors and staff on a regular basis to make sure that the residents receive the care they need. A residents and relatives meeting had been arranged for the previous day and the acting manager and activity person felt that this had been a very positive move and they are expecting to arrange these at regular intervals throughout the year. Discussions with the acting manager identified that quality assurance does not only involve talking to residents regarding the care they receive. It also includes assessment of the homes environment and the staff, to include training, as well as the management of the home. The systems are not in place to address all the areas that affect the lives of people living at the home. Door guards have been purchased and placed on some residents doors in line with assessments that identified those at greatest need. However one of the residents doors was propped open using a table and staff were unable to explain why this was done. Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 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 3 17 X 18 3 1 X X X X 1 X 1 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 13 Requirement An ongoing maintenance programme to be developed and introduced to ensure the safety of residents. Previous timescale of 28/11/05 and 03/07/06 not met. Staffing numbers and deployment of staff to be reviewed in line with the assessed needs of residents. Previous timescale of 01/11/05 and 03/05/06 not met. An effective quality assurance and monitoring system to be implemented. Previous timescale of 06/03/06 and 06/07/06 not met. A programme of formal supervision to be developed and introduced to ensure that all staff are aware of their roles and responsibilities. Previous timescale of 19/04/05, 16/01/06 DS0000013997.V335862.R01.S.doc Timescale for action 04/06/07 2. OP27 18 (1)(a) 04/06/07 3. OP33 24 & 26 04/06/07 4. OP36 18 (2) 04/06/07 Havelock House Version 5.2 Page 24 and 07/08/06 not met. 5. OP7 15 The care plans are to reflect the assessed needs of residents, to include all risk assessments including falls and continence, and the use of bed barriers to enable staff to provide appropriate care. Training for staff to be provided. Previous timescale of 01/06/06 not met. Consult with Health and Safety Executive and take suitable advice concerning protecting residents from the risk of hot surface temperatures from radiators. Furniture to be audited and replaced or bought as required to ensure infection control is effective and there is a sufficient number of tables for all residents use. Staff training in infection control to be reviewed an updated to ensure staff follow the homes policies to protect residents. 04/06/07 6. OP25 13 (4)(c) 07/05/07 7. OP26 OP38 13 (4)(c) 04/06/07 8. OP30 13 (4(c) 04/06/07 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 Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Havelock House DS0000013997.V335862.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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