Inspection on 04/05/05 for Haven House

This inspection was carried out on 4th May 2005.

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

Haven House 13/04/10

Haven House 15/12/09

Haven House 02/01/09

Haven House 05/11/08

Haven House 03/07/08

Haven House 08/01/08

Haven House 30/05/07

Haven House 11/05/06

Haven House 01/09/05

Haven House 23/11/04

Haven House 29/04/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Haven House Residential Ltd Warwick Road Kineton Warwick CV35 0HN Lead Inspector Jo Johnson Unannounced 04 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Haven House Residential Ltd Address Warwick Road Kineton Warwick Warwickshire CV35 0HN 01926 641714 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Haven House Residential Ltd OP - Old Age 20 Category(ies) of PC - Care Home only 20 registration, with number of places Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 23 November 2004 Brief Description of the Service: Haven House is a conversion of three period houses in the large village of Kineton. There are twenty single bedrooms, nineteen of which have en-suite facilities. There is a shaft lift as well as two staircases, one at each end of the home. There are two sitting rooms and a dining room, and there is level access to the attractive walled garden at the rear, which gives access to the car park. Haven House is within a few minutes level walk of the village centre of Kineton, which has three churches, hairdressers, a variety of shops, restaurants, pubs, banks and a post office. Two doctors’ surgeries, a chiropodist, an optician and a dentist are all nearby. There is a limited ‘bus service to Stratford-upon-Avon, Banbury, Leamington Spa and surrounding villages. Nursing care is not provided. Residents in need of attention from a nurse have access to the community nursing service, as they would in their own homes. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and was unannounced. This was the first visit of the inspection year and the focus of the inspection was to establish progress on outstanding requirements. A majority of the inspection was spent talking with and observing the residents who live at the home. Care and staffing records were inspected. The owner, acting manager, three staff and six of the twenty residents were spoken to. What the service does well: What has improved since the last inspection? There are a number of areas where there has been improvement since the last inspection. Information for residents and their families has been reviewed. There is now a weekly programme of activities and a newly set up ‘Residents Committee’. Residents say that there is a choice of main meals. The standard of cleanliness in the kitchen has improved following a visit from the Environmental Health Officer. The carpet in the downstairs corridor has been replaced. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 6 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. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 Assessment format and procedures that are in place do not provide staff with sufficient information to ensure that residents’ needs can be met. Residents and or their families have the opportunity to visit the home in order to decide the suitability, quality and facilities of the home. EVIDENCE: The pre admission assessment information is not adequate to inform staff of the actions to be taken and to ensure that new residents needs are properly assessed and planned for. There was no assessment for one resident who had recently moved in. Assessments with varying levels of information were seen in four other residents care records. One resident said that the manager had visited her prior to moving into the home. They had discussed what information staff would need to know to be able to care for her. Another resident said that he had been offered a place and moved in the next day. He said no one had been to see him to see whether they could meet his care needs. Residents spoken to said that their relatives had visited the home. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 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 standard(s) 7 and 9 Important elements of residents’ care needs are not set out in care plans. Staff do not have all the information required to fully meet residents’ needs. Residents’ medication is managed safely by the systems in place at the home. EVIDENCE: Some individual care plans did not have sufficient information to ensure that residents personal care, health and social needs are planned for and fully met. Risk assessments were not in place for moving and handling and other potential risks. One care plan had all the information needed to ensure that staff can meet that resident’s needs. This should be used as a guide for other plans. Residents spoken to during the visit were unaware of their care plans and there was little documented evidence of resident/relative involvement in care reviews. Some care plans had been reviewed by social services. The administration of medication and the records were observed and were correct. Only staff that have been trained administer the medication. Controlled drugs records and administration were correct. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 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 standard(s) 12 and 15 There has been an improvement in the recreational facilities on offer at the home. Residents now benefit from a regular programme of in house activities that ensure that some of their social and recreational needs are catered for. Staffing shortages impact on the staff’s ability to provide the planned programme of activities. Residents are given a choice of tasty main midday meals. The availability of fresh, varied and wholesome food is limited. EVIDENCE: During the inspection staff were playing hoopla and skittles with the residents and in the afternoon they had organised a birthday party for one of the residents. Residents said that they now have a variety of regular activities including skittles and keep fit organised by the staff. Staffing shortages mean that the activities programme cannot always be carried out. Residents spoke very highly of two external activity organisers who came to the home. This should be continued. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 11 The inspector ate lunch with the residents and the meal was well presented and tasty. Residents said that they are always given a choice at meal times and that they have sufficient food and drinks. They commented on how tasty the main midday meals are. Staff assisted residents who needed help with eating in a very sensitive manner; they sat and talked with the residents throughout the meal. The kitchen cupboards were not well stocked and the main store cupboard is locked and the key is not available once the cook goes home. A majority of the food stocks in the cupboards, fridges and freezers was a ’value’ brand from a supermarket. There was no fresh fruit available once the cook goes home. The nutritional value of the diet provided to the residents should be assessed and fresh fruits must be made available at all times. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standard were not specifically assessed at this inspection. EVIDENCE: Residents knew who to speak to if they are unhappy or wish to make a complaint. The procedure for reporting any allegations of abuse displayed does not refer to all the ways of making reports. The procedure must be reviewed so that residents, staff, visitors and relative know how to report any allegations of abuse. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 The home is comfortable for the residents. The standard of furnishings and fittings are just adequate. The décor in communal areas and corridors are looking tired and worn. The lack of specific risk assessments on the environment potentially places the residents at risk of harm. There is no evidence of a planned programme of redecoration, replacement and refurbishment. EVIDENCE: The carpet in the upstairs corridor is worn in places and will be a trip hazard for residents. The carpet in the downstairs corridor has recently been replaced. The bath equipment in the upstairs bathrooms is stained and unsightly. The equipment and bathrooms were clean. The cupboard door in the bathroom was not attached and propped up against the cupboard. The windows were dirty throughout the home and need to be cleaned on a regular basis. Residents’ views were obscured due to the dirty windows in some of the bedrooms. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 14 First floor windows have not been risk assessed for possible harm to residents following a previous requirement. A radiator next to a resident’s bed must be risk assessed to ensure no injury can happen. From discussion with the owner and acting manager there is no specific plan for redecoration and renewal of equipment, furnishing and fittings. A plan must be produced. Comments from relatives regarding the low standard of the décor were seen in the recent quality assurance questionnaires. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, 29,30 The procedures for the recruitment of staff are not robust and lack appropriate pre employment checks. This potentially leave residents at risk. The number of staff available particularly during the afternoons and at weekends, is below agreed levels and is not sufficient to meet residents’ needs. Progress is being made on the training plan for staff. The NVQ and training programme is compromised by the lack of commitment from the registered provider. Staff do not currently have the skills base to meet all the needs of the residents. EVIDENCE: The staff files of three recently appointed staff members showed that the acting manager and owner had not completed all the necessary recruitment checks to ensure the protection of residents. Only one reference was seen for one staff member and none were seen for two members of staff. Staff files did not include a specific risk assessment and all the documentation required. Immediate action was required on this matter. There is a small committed staff team at the home. The owner states that agency staff are not used. However, due to the small staff team there is no flexibility or sufficient numbers of staff to cover staff shortages. Rotas show that staffing levels regularly fall below agreed levels. Residents confirmed that staffing levels are sometimes lower in the afternoons, evening and weekends. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 16 Discussion with the acting manager and owner determined that the rationale for lower staffing was based on a task focused way of providing care and not based on residents’ actual needs. Immediate action was required to be taken. Residents spoke very highly of the qualities of the staff and the standard of care they receive despite the frequent staffing shortages. The acting manager has produced a training plan for the coming year. This is good progress. The plan includes the basic food training that has been the subject of previous requirements. From discussion with staff and the acting manager there remains concern about the funding of an NVQ programme at an appropriate level for some of the more experienced staff. There were no staff on duty who have completed the NVQ qualification. A number of staff are now registered and are making progress with NVQ Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not specifically assessed at this inspection. EVIDENCE: A residents’ committee has recently been formed with nominated resident representatives and a resident chairperson. From discussion with the resident chairperson and other committee members they are confident that the issues they have raised will be addressed by the acting manager and owner. This is good progress. The progress of the committee and other ways of increasing resident involvement and influence will be monitored during the next inspections. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x 2 x STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement Assessment of needs must be completed in sufficient detail to ensure that staff can meet the needs of residents. Assessments must be completed prior to a residents admission to the home Care plans must be completed in sufficient detail to ensure staff can meet the needs of the residents. The care plans must be person centred and include all elements of the standards. Care plans must have a recent photograph of the resident. Document the involvement of residents and/ or their relatives in the development and review of their care plan. Risk assessments must be in place for any individuals moving and handling and/ or any areas of risk to individuals. The registered provider must ensure that residents have access to fresh fruit at all times. There must be access to food stores at all times. Evidence must be provided to the Commission of the nutritional value of the current diet Timescale for action 01.07.05 2. 7 15 01.08.05 3. 7 13,14,15 01.07.05 4. 15 16 01.07.05 Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 20 provided to the residents. 5. 18 13 The procedure for reporting allegations of abuse must state the different contact details of Police, Social Services Department and The Commission. The registered provider must provide The Commission with the planned programme of redecoration, replacement, regular maintenance and refurbishment. This plan must include: the replacement of the upstairs corridor carpet, the regular cleaning of the windows, fitting of appropriate locks to bedroom doors, providing lockable space for residents, the deep cleaning of bath equipment the repair of the cupboard door in bathroom. (some elements included in previous unmet requirement 30.06.04 & 31.01.05) Risk assess all of the first floor windows and the adequacy of any window restrictors. (old timescale 31.01.05) The risks to the resident ,whos bed is next to the radiator, must be assessed. Staffing levels must be maintained at the agreed levels of four care staff in the mornings and three in the afternoons and evenings. Two written references, Criminal Records Bureau Disclosures and evidence of staff fitness must be obtained prior to staff starting work at the home. The registered provider must develop robust recruitment selection policies and procedures. (old timescale 31.01.05) 01.06.05 6. 19 16,23 01.07.05 7. 19 13 01.07.05 8. 9. 19 27 13 18 01.06.05 Immediate 10. 29 19 Immediate 11. 29 19 01.07.05 Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 21 12. 27 18 13. 30 18 14. 30 18 The Registered Manager must employ sufficient staff to meet the needs of residents. There must be enough staff employed to cover the rota and holidays and sickness. The registered provider must promote and give a commitment to providing the means for staff to complete NVQ qualifications in the home.(old timescale 28.02.05) Staff preparing and handling food must be trained in Basic Food Handling. (old timescales 30.06.04 & 31.01.05) 01.08.05 01.11.05 01.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 12 29 Good Practice Recommendations The use of external activities should continued to supplement the activities and stimulation provided by staff. A recruitment and selection checklist that is based on schedule 2 of the Care Homes Regulations should be produced. Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Haven House Residential Ltd v224899 e53 s4321 haven house v224899 040505 stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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