Inspection on 08/01/08 for Haven House

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 30/05/07

Haven House 11/05/06

Haven House 01/09/05

Haven House 04/05/05

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 Warwick Road Kineton Warwick Warwickshire CV35 0HN Lead Inspector Jo Johnson Key Unannounced Inspection 8th January 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haven House DS0000004321.V353661.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. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven House Address Warwick Road Kineton Warwick Warwickshire CV35 0HN 01926 641714 01926 641714 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) Haven House Residential Limited vacant post Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must sucessfully complete the Registered Managers Award by April 2007. 30th May 2007 Date of last inspection 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 garden at the rear, which gives access to the car park. The car park is not in use at the present time due to building materials being stored. Haven House is within a few minutes 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. The home’s fees as quoted by management range from £358- £412 per week. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. This process considers the agency’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The acting manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were sent to ten of the people living at the home, the care staff and relatives and visitors. Unfortunately, the surveys were delayed in the Christmas post and had insufficient postage put on. The acting manager did distribute the surveys but non were returned at the time of writing the report. This was the home’s second key inspection of 2007/2008. The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 8th January between 9am and 5pm. On the day of the inspection there were 15 people living at the home. The inspection involved: • • • Observations of and talking with the people who live at the home and the staff, acting manager and owner. Observation of working practices and of the interaction between individuals and staff. Three people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • The inspector would like to thank the people who live at the home, acting manager, owner and staff for their hospitality and cooperation during the inspection visit. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? People’s needs are fully assessed so that they home can determine whether they can meet their needs. The home has only admitted older people in line with their registration category. There have been no further admissions of older people with dementia since the last inspection. Care plans are now in enough detail and reviewed monthly to make sure that staff can meet the needs of the people living at the home. The management and administration of medication has improved. New drugs trolleys have been purchased; new systems for the checking of prescriptions and the safe disposal of unwanted or unused medication have been developed. People living at the home have been formally consulted about their social interests and there is now a programme of activities. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 7 The standard of cleanliness of the laundry has improved. The home is clean and free from offensive odours. Information about the chemicals and cleaning materials is now kept. Most areas of risk assessment and management have improved. An approved electrical contractor has tested the electrics and has now been appointed to make the electrics safe. 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. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 8 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 Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good People’s needs are assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, there been no admissions of people with dementia. The home is registered for older people only and the acting manager has made sure that they only take referrals and admits people without dementia. Three people’s assessments were seen. They included all of their identified needs and had been updated as and when their needs had changed. One person had an updated assessment by the home and the community mental health team that supports them. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 10 The most recent admission to the home had been admitted as an emergency. There was a social services assessment and a comprehensive assessment that had been completed the day of their admission. The person said ‘I was made to feel very welcome and xxx (deputy manager) asked me about the support and care that I need’. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 11 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, 10 Quality in this outcome area is adequate The health and personal care that people receive is based on their individual needs. The principles if respect, dignity and privacy are put into practice. The non-application of prescribed creams may potentially put maintaining people’s health at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three people’s care plans were seen. There has a general improvement in the standard of care planning, risk assessment and review since the last inspection. The care plans were in sufficient detail for staff to able to meet peoples identified needs. All of the people had tissue viability, nutritional and moving and handling risk assessments and management plans in place. Specific risk Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 12 assessments were in place for one person’s mental health. This is an improvement from the previous inspection. Peoples’ preference of gender of staff is identified on their assessment and as there is a mixed staff group, they are able to meet people’s preferences. People spoken with confirmed that they are asked their preferences but do not mind either gender of staff as they know them all well. Since the last inspection, people’s spiritual needs are now identified and planned for. One person’s assessment, care plan and monthly review had been updated following deterioration in their ability to swallow. However, the nutritional risk assessment had not been reviewed since May 2007 and the change to soft diet was in November 2007. Risk assessments must be updated when people’s needs change and the ways of managing those risks changed. This is because as people’s needs change so do the risks associated with any deterioration in their abilities. There were monthly reviews for each person they were comprehensive and covered peoples’ identified needs. It is recommended that risk assessments be reviewed during this monthly review as well so that they reflect the changes identified in the assessments and made to care plans. The acting manager took immediate action to include this in the review format. Two of the three people had not signed their care plans or reviews. From discussion with people, they were aware of their plans and the records kept about them. People or their relatives should sign their care plans and monthly reviews to show that they have been involved in the process. The people case tracked have been weighed monthly and this is monitored during the monthly reviews. Discussion with people living at the home, the manager, staff, care plans and daily records showed that people living in the home have access to other health professionals such as GP, dietician, dentist and specialist consultants and chiropodist. Since the last inspection medication management at the home has improved. Two new medication trolleys have been purchased following advice from the pharmacist. The trolleys were well organised and all of the medication stored in the trolley was in date and currently prescribed. The pharmacist now arranges for regular collection of unused or unwanted medication. All prescriptions are now photocopied and checked against the dispensed medication. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 13 Only staff that have completed the safe handling of medication training administer medication. The person responsible for medication administration is hi-lighted on the care rota each morning and evening. The administration of medication was observed in the morning and at lunchtime and the care worker was knowledgeable about the systems, medications and they were safely administered. The care worker who is responsible for checking in the medication said that it is difficult to do the task when they are also part of the care rota. The person checking in the medication should be supernumerary to the care rota so that they are able to concentrate and safely check in the medication. The medication records seen were correct, however, the new months supply had only started the day before. The medication records for the previous month were not available (as the acting manager had left for the day) but the records for September 2007 were seen and they were all signed for. One person spoken with has eczema on their hand and said that they were not sure whether they had the cream applied twice a day and that it was quite sore. The medication record had only been started the day before and the cream had been signed for. However, as the previous month’s records were not available, it was not possible to see whether it had been consistently applied. People must have creams applied as prescribed and if any area is not healing then they must be referred back to the General Practitioner. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is good. People living in the home are supported to maintain their independence, contact with important others and lifestyle, which maintains their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection, people chose to spend their time in their bedrooms or in the main lounge. Staff spent time chatting with people in the lounge in the morning, there was relaxed atmosphere and staff and people clearly enjoyed each other’s company. In the afternoon, there was a music and movement session from a visiting activity worker and their dog. People of very differing abilities participated, became animated and were clearly enjoying the session and the company of the dog. A few people with dementia have lived at the home of a number of years. There was positive interaction observed between the staff and individuals. People had dolls if they chose and there were items around the home for Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 15 people to pick up and do if they chose to. Staff ensured that people were occupied and people were settled and did not show any signs of anxiety. Since the last inspection, the previous manager had completed a consultation exercise about activities and how people like to spend their time. The questionnaires were seen and showed that people are generally satisfied with the activities on offer and any suggestions have been implemented. They highlighted that they liked to spend time with staff chatting, music and movement, cooking, going out and Bingo. There is now Bingo on a Wednesday and ‘Music and Movement’ every fortnight. The staff and people said that they had made biscuits the previous week and had good fun. People spoken with said that their visitors were made to feel welcome whenever they visited. One person said, “my visitors are made welcome, staff will get them a drink”. Another person went out for lunch with their visitors. The inspector joined people for lunch. Two choices were offered to people just before lunch and the cook said that they would cook something else if people did not want what was on offer. People spoken with said they enjoy the meals and stated that they are always offered choices. One person said, “food is very good, there is enough and when the chef is on it’s excellent”. Staff were observed to sit with people and assist them to eat where needed. The support given was relaxed, sensitive and discreet. Staff spoke to people through out the meal about what they were eating and offering choices. Specialist plate guards and a soft diet were provided for one of the people spoken with. The owner gave a commitment to replace the crockery and cutlery, as it is very old and does not match, and the cutlery is tarnished. The kitchen was well stocked with a variety of fresh and long-life foodstuffs. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 16 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, 18 Quality in this outcome area is good. Complaints procedures make sure that peoples, relatives and representatives concerns and complaints are listened to and acted upon. A staff team who have a good knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy is displayed in the entrance hall of the home and is in the service users guide. People spoken with knew how to complain or raise their concerns. One person said, “I could talk to staff, they are exceptionally kind and listen”. Another said, “ I would talk to xxx (acting manager) and she always sorts it out and I raise things at the residents meetings and they get sorted out that way as well”. There has been one complaint made to the commission since the last inspection. The previous manager and owner investigated the complaint. The investigation, outcome and feed back records were seen and the complaint is now resolved. There have been no other complaints made to the home. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 17 Staff spoken with had a good understanding of how to recognise and report any allegations of abuse. This means that people are supported and cared for by staff who know how to keep them safe from harm. People spoken with said that the felt safe at the home. One person said, “yes I do feel safe I cannot think of any occasion when I haven’t felt safe…I have never heard staff shout and they manage people who are muddled very well”. Two people with dementia were observed to be very relaxed with staff, gave them many smiles and were happy to approach them. This may indicate that they feel safe. There have been no allegations of abuse at the home. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is adequate. Areas of the home are not well maintained and furnished. This means that although the house is homely and clean, people do not live in a well decorated, maintained and comfortable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is ongoing building work on an extension to the home. The owner and acting manager have made sure that all areas of the garden that are accessible to people have been kept clear. A risk assessment was seen for the ongoing building work and the actions taken to minimise the risks to people living at the home. As highlighted in previous reports there are still areas of the home that need redecorating and ongoing refurbishment. The lounge furniture needs replacing Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 19 and the owner said that they would be changed when the new furniture is ordered for the new extension. There are still bed bases that need replacing. The downstairs toilet sliding door does not close properly or slide on it’s runners smoothly. This needs repairing to maintain people’s privacy. Most radiators are now covered but two radiators in one of the downstairs corridor had blue foam pipe lagging placed on the top. The owner agreed with the inspector that although it gave some protection from touching the top of the radiator it looked very unsightly. He explained that standard radiator covers did not fit so needed to find some that do. He gave a commitment to replacing them within four weeks of the inspection. In general, the home was much cleaner than at previous inspections and there were no offensive odours. There is now a cleaner employed to work Monday to Friday, they are shown on the rota and there is a daily cleaning schedule. The schedule was seen and the tasks had been completed on a regular basis. There was a build up of spilt soap powder around the washing machine; the acting manager took immediate action to get the area cleaned and added it to the cleaning schedule. The kitchen had an Environmental Health inspection in December 2007. New fridges and freezers were purchased to comply with the requirements given by the environmental health officer. A kitchen cleaning schedule should be implemented for cleaning the insides of the kitchen cupboards, as some were stained and dirty. Staff are undertaking a distance learning ‘Infection Control’ course. They were able to go through how they have improved their practices and how informative the course is. They confirmed that protective clothing and hand washing facilities are always available and kept stocked up. All of the bathrooms and toilets had sufficient hand washing and drying facilities and protective clothing and gloves were available on the day of inspection. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is adequate. Staff in the home are trained, skilled and a majority of the time in sufficient numbers and safely recruited to support the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were 15 people living at the home. Staff rotas showed that Monday to Friday there is three or four staff on duty in the mornings, two staff in the afternoons and evenings. There is two waking night staff all week. The acting manager is supernumerary to the care rota Monday to Friday and is available to support the care workers up until 5pm. At weekends, the staffing is increased by one throughout the day. From discussion with staff, the acting manager and owner the staffing levels in the afternoon and evening had been reduced to two the previous week. This was following the death of an individual who had high care needs. During the inspection, the staffing levels were adequate to meet the needs of people living at the home. However, from discussions with staff and one person living at the home, the staffing levels in the evenings mean that there are periods of time when staff are preparing tea and assisting people to bed Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 21 that only one person is available for 14 people. The acting manager and owner agreed to increase the staffing to three in the evenings from the following day. Staffing levels have consistently been a concern at the home for a number of years. There now does appear to a more needs based approach to the calculating the staffing. However, there still is not any evidence as to how staffing is worked out. This should be produced and constantly kept under review by consultation with and observation of people as to whether their needs are being met and discussions with staff. A long-standing staff group work at the home. From discussions with them, they are committed to providing good care to the people that live there. They were able to discuss how practices had improved since the last inspection. Senior carers have been appointed since the last inspection with specific areas of responsibility. There is an active NVQ programme and over 50 of staff have achieved level 2 or above. A majority of staff have achieved a certificate in dementia care and are undertaking infection control training. There is now an induction programme in place for new staff and they have been registered for their NVQ. People spoke positively of the staff that work at the home. They said, “Staff are exceptionally kind and good to the clients, they are lovely” and “I’m very happy here, the staff are kind”. Three staff files were seen including the most recently recruited staff, the cook and a care worker. They all included CRB (Criminal Records Bureau) and PoVA (Protection of Vulnerable Adults) checks. However, there were only records of telephone references for the cook. The owner confirmed that they were still waiting for the written copies of the references. Copies of the verified references were faxed to the inspector two days following the inspection. Written references must be obtained before staff start working at the home. One staff member had declared that they did not have any criminal convictions on their application form. Their CRB showed that they had a number of driving offences. The acting manager had completed a risk assessment on receipt if the CRB and discussed the matter with the individual. This is good practice. However, any inaccurate declarations on an application form should be followed up before confirming employment. The application form that the home is using should be reviewed and updated. This is because it only requests a five year working history and does not ask for the names and contact details of referees. A full adult life or working history should be requested and any gaps in employment explored. This Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 22 information should be obtained to make sure that staff are suitable and safe to work with vulnerable people. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 23 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, 38 Quality in this outcome area is adequate. People benefit from living in an improving home. People are able to express their views and these are listened to and acted upon. The shortfall in an effective quality assurance system means that some health and safety areas are not identified, assessed and minimised to reduce the risks to people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, the manager has left the home. The deputy manager who has worked at the home for many years is acting as manager until a new manager can be appointed. From discussion with the owner, he Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 24 plans to recruit an experienced manager in dementia care to support the plans for a dementia care unit in the new extension. There has been an improvement in a number of areas since the last inspection and outstanding requirements have now been met. There is a basic quality assurance system in place and the previous manager undertook resident and relative surveys following the last inspection. The new manager should prioritise the quality assurance systems to make sure that a plan is developed to meet any ongoing shortfalls. There is a residents’ committee that meets approximately six weekly. It is chaired by one of the people living at the home and facilitated by the acting manager. The minutes were seen and the chairperson confirmed that it is still effective in making some changes such as food and activities. Any monies kept in safekeeping on behalf of people were securely stored, with records kept. A review of two peoples’ personal allowances was undertaken and it was found that records and monies kept were accurate. A requirement was made at the last inspection to obtain a five year fixed electrical wiring test. The owner appointed an approved electrical contractor to assess the state of the wiring and electrics in October 2007. There were many shortfalls identified and major works are required. The owner provided a copy of the report to the inspector. The electrical contractor faxed confirmation during the inspection that the works were due to start on 21st January 2008 and they were not able to start the work any earlier. The information for compliance with the Control of Substances Hazardous to Health (COSHH) Regulations was seen for all chemicals held or used at the home. The accident book was seen. Accurate records were kept that corresponded with peoples’ daily records and evidence in their care plan reviews. From discussion with the acting manager, there is no formal monitoring of falls or accidents as part of the quality assurance system. Falls in particular should be reviewed on a monthly basis to establish the times, causes and frequency, and whether they relate to staffing or health factors. Information provided before the inspection, by the acting manager in the AQAA (Annual Quality Assurance Assessment) and records and risk assessments seen show that most health and safety matters are being better managed at the home. However, the inspector did have some concerns about the suitability if a new fire escape from the kitchen following the building of the new extension. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 25 The owner explained that the new fire escape was by means of a window with purpose built steps. He said that he had consulted with the fire service and all other means of escape for the home remain the same as before the building work started. There was no updated fire risk assessment and staff had not had any fire training or drills since the completion of the new fire escape in the kitchen. A person experienced in fire risk assessment must complete a new fire risk assessment and the Fire Service and Building Control officer must be consulted about the new means of escape. Staff must be trained in fire safety and undertake a fire drill. The acting manager and staff would still benefit from health and safety and risk assessment training as identified at the last inspection and in this report. It is strongly recommended that this training be provided as a matter of priority. Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 x x 2 Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(c) Requirement Risk assessments must be updated as and when people’s needs change. This is to make sure that any risks are assessed and staff know what action to take minimise any risks identified. Medicated creams must be administered as prescribed. This is to make sure that people have cream applied as prescribed and so they can be referred back to the doctor if the treatment is not working. A person experienced in fire risk assessment must complete a new fire risk assessment and the Fire Service and Building Control officer must be consulted about the new means of escape. This is to make sure that there is adequate means of escape from a fire in the kitchen. Staff must be trained in fire safety and undertake fire drills. Timescale for action 01/04/08 2 OP9 13(2) 01/03/08 3 OP38 23 (4)(a)(b) (c) 01/02/08 4 OP38 23(d) (e) 01/06/08 Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 28 This is so that they know what to do in the event of a fire. 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 OP7 Good Practice Recommendations It is recommended that risk assessments be reviewed during this monthly review as well so that they reflect the changes identified in the assessments and made to care plans. People or their relatives should sign their care plans and monthly reviews to show that they have been involved in the process. The person checking in the medication should be supernumerary to the care rota so that they are able to concentrate and safely check in the medication. An audit of the bed bases should be completed and any worn bases should be replaced. This is to make sure that people have a good quality beds to sleep on. The downstairs side corridor sliding toilet door should be repaired so that is smoothly shuts and so that people can have privacy whilst using the toilet. A kitchen cleaning schedule should be implemented for cleaning the insides of the kitchen cupboards, as some were stained and dirty. Evidence of how staffing levels are calculated should be produced and constantly kept under review by consultation with and observation of people as to whether their needs are being met and discussions with staff. Written references need to be obtained before staff start work at home. This is to establish whether people are suitable to work with vulnerable people. Any inaccurate declarations on an application forms should be followed up before confirming employment. This is to clarify the honesty of person completing the application. The application form should be reviewed and updated to include: • A full adult life or working history should be requested so that any gaps in employment can be explored DS0000004321.V353661.R01.S.doc Version 5.2 Page 29 2 3 4 5 6 7 OP7 OP9 OP19 OP19 OP26 OP27 8 9 10 OP29 OP29 OP29 Haven House • The names and contact details of two referees. 11 OP33 This is to make sure that staff are suitable and safe to work with vulnerable people and referees correspond with their working history. The formal monitoring of falls or accidents should be part of the quality assurance system. Falls in particular should be reviewed on a monthly basis to establish the times, causes and frequency, and whether they relate to staffing or health factors. The manager and staff should be provided with health and safety and risk assessment training. To make sure that they have the skills and knowledge to be able to identify and manage risk to prevent risk to the service users. 12 OP38 Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Haven House DS0000004321.V353661.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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