Inspection on 26/04/05 for Haven House (Haslemere)

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 (Haslemere) 03/07/07

Haven House (Haslemere) 03/08/06

Haven House (Haslemere) 29/09/05

Haven House (Haslemere) 02/09/04

Haven House (Haslemere) 04/05/04

Haven House (Haslemere) 04/02/04

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

CARE HOME ADULTS 18-65 Haven House 44 Kings Road Haslemere Surrey GU27 2QG Lead Inspector John Chivers Unannounced 26 April 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Haven House Address 44 Kings Road Haslemere Surrey GU27 2QG 01428 661440 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) Whitmore Vale Housing Association Limited Phillipa Alves (To be Confirmed) Care Home 9 Category(ies) of LD - Learning Disability (9) registration, with number MD - Mental Disorder (1) of places PD - Physical Disability (5) SI - Sensory Impairment (5) Haven House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 - The age/age range of the persons to be accommodated will be 21 - 55 years, 1 resident 55 - 65 years. 2 - All 9 residents will have a Learning Disability (LD) 3 - Up to 5 of the residents may have a Sensory Impairment (SI) and/or a Physical Disability (PD) 4 - 1 of the residents may have an additional Mental Disorder (MD). Date of last inspection 2nd September 2004 Brief Description of the Service: Haven House is registered for a maximum of nine residents within the age range of 21 - 65 years. All of the residents have learning disabilities. The home is managed by Whitmore Vale Housing Association Limited and is one of a number of services registered within the county of Surrey. The home is a detached purpose built property situated close to the town centre. The home provides a a homely and secure environment where residents are encouraged towards independance and social inclusion. Haven House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 12 25pm. The duration of the inspection was 6 hours. As part of the inspection process two staff and two residents were interviewed. Discussion/communication was also held with a further three residents. In addition discussion was held with the home’s management. The process included inspecting the home’ policies, procedures, records, staff personnel files and test certificates. The premises were also inspected on this occasion. The findings of the inspection evidenced that the home is managed in a satisfactory manner and afforded a good standard of care to the residents. Residents were open, friendly and some were eager to communicate. The home has a warm, comfortable and friendly atmosphere. Staff were supportive of the home’s management. What the service does well: The home has created and maintained a homely and accepting environment where staff are committed to the wellbeing of residents. The staff have established positive and engaging relationships with residents and encourage them in areas of independence and social inclusion. Of particular commendation is the maintenance of residents in day centre placements and voluntary employment. The home has a clear regard for health and medical matters concerning the residents and care plans, risk assessments and other areas are monitored regularly. The home is pro-active at seeking residents and their relative’s views on the service provided. Staff training is active and there is a commitment to NVQ training. The home also has a sound regard for maintaining a safe environment. Haven House Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Haven House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Haven House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home is competent at meeting the assessed needs, aspirations and wishes of the residents. EVIDENCE: A sample of residents written needs assessments were inspected. The assessments covered all key areas with evidence of reviewing and updating on a six monthly basis. Future review dates were also set. Residents needs are monitored and any progress/issues are recorded in the residents daily notes. This was evidenced during the inspection. The deputy manager stated that due to communication difficulties some residents communicate their wishes and aspirations via gestures, expressions and ‘makaton’. Those residents who could communicate verbally stated during interview that staff looked after them well and that they were given assistance in areas such as washing, dressing and being escorted to appointments, and that they are listened to and helped by staff. Haven House Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Residents are made aware of their care plans and are encouraged to make decisions and take risks commensurate to their individual levels of ability and detailed risk assessments. EVIDENCE: Written care plans were available in the sample of residents’ files inspected. Initial care plans in the sample were clearly dated with evidence of review and updating as appropriate. One resident stated that they had a care plan and another stated that they had not. This was soon retracted by the resident when she remembered that she had. The deputy manager stated that residents are encouraged to make decisions and this was evidenced by the residents’ house meeting minutes where choices and decisions were made regarding meals, holidays, activities and daily life in the home. Some residents were able to confirm in discussion that they decided to take holidays in ‘Disneyland’ and a ‘big posh’ hotel in London. Residents are invited to attend their reviews and make a contribution. Some residents stated this during discussion. Haven House Version 1.10 Page 10 Written risk assessments were held. The sample inspected were assessed as the ‘higher’ risk category with evidence of review and updating on a regular basis. Residents stated that they “could do certain things around the home like making a cup of tea and doing some jobs around the house but could not do other things because staff said it might not be safe”. Haven House Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17 The home has a clear regard for maintaining residents in day centre placements and employment, in addition to providing a stimulating activity programme within the home and the local community. The home is focused at encouraging residents to maintain relationships with family and friends and ensuring that residents have enjoyable holidays. Daily routines are that of a normal household and mealtimes. EVIDENCE: It was evidenced that six of the residents attend day centre placements. One resident works on a voluntary basis in a day centre for the elderly and another resident works voluntarily in the sewing room at a nearby Boarding School. Residents stated in discussion that they took part in a range of activities in the day centres and that they make a lot of friends there. The home provides a range of activities, which are detailed in the weekly programme, and one resident had just returned from horse riding at the time of the inspection. Haven House Version 1.10 Page 12 Residents maintain links in the local community and staff accompany them on excursions to shops, public houses and restaurants. Residents stated that they enjoyed these outings. The deputy manager stated that the home has a good rapport with neighbours, a local Church and a nearby School. There was evidence of annual holidays to various destinations including Spain and a resident recently made a request to go on a short cruise. Residents stated in discussion that they enjoy holidays and excursions. Residents maintain contact with their families, relatives and friends. Such contact is recorded. Residents confirmed their contact with family and friends during discussion. The routines in the home were observed to be that of an ordinary domestic household. Residents are encouraged to undertake small domestic tasks and participate in the homes weekly programme. Residents stated in discussion and interview that they were ‘happy’ living in the home and they felt safe and well cared for by staff. The home’s menu provides for a varied and balanced diet. The menu was available in written and pictorial form. The home liaises with a dietician regarding the menu and is based on the ‘Traffic Light’ menu plan. The home had just purchased a wide range of provisions at the time of the inspection. Provisions were safely and correctly stored. Residents were observed to enjoy their meal and stated in discussion that they enjoyed the meals provided. Staff prepare all of the meals. Some residents may assist on occasions. There are also ‘theme’ nights specialising in certain cuisine. Temperatures of the refrigerators and freezer are taken and recorded on a daily basis. At the time of the inspection the temperature of the refrigerator and freezer were 2 degrees and – 20 degrees centigrade respectively. The kitchen was modern, well equipped and standards of cleanliness and hygiene were high. Haven House Version 1.10 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The home is committed to meeting the personal and health care needs of the residents and currently evidences this area. Clear records are maintained and held. Medication storage arrangements are satisfactory and diligence is evidenced via audit/balance checks on medication held. EVIDENCE: The home has a ‘key’ worker system and a support worker is also allocated to individual residents. Pictures of staff are clearly displayed for the residents. Residents interviewed were able to name their key workers and stated that their key workers “help them a lot” and help them to “help themselves” and provide personal care such as assistance with bathing and dressing etc. Some also confirmed that key workers and other staff talk to them and can approach them when they are worried or have problems. The manager stated that four of the current residents need assistance with personal care. This was evidenced in the care plans in the sample of residents files inspected. Health/medical details are held in resident’s assessments and care plans. Such areas are monitored and recorded in resident’s daily notes. One particular resident’s health care is currently being very closely monitored. Visits to the doctor, dentist and other health care professionals are recorded. Residents stated that staff accompany them to such appointments. Haven House Version 1.10 Page 14 The home’s medication policy and procedure was available. The policy is dated December 2003 and according to the manager is in the process of being reviewed and updated by the organisation. A sample of the residents’ medication administered records were inspected. Recording was clear and evidenced no gaps. It was also evidenced that some resident’s GP’s had given written consent for staff to ‘crush’ medication prior to administering it to the residents. Medication is stored in a locked metal cabinet, which has separate storage for ‘controlled’ drugs. The controlled drugs book was available and evidenced that two staff sign the book following medication being administered. There is also a balance check on the quantity of drugs held. This is sound and necessary practice as recently two ‘Tamazepam’ capsules were unaccounted for. This was reported to the Police and to the CSCI Surrey Local Office under Regulation 37 (The Notification of Significant Events.) The home’s management also held an internal enquiry. To date it is not known what happened to the missing capsules. Following this seven staff received updated medication training on 18th April 05. Other staff are due to attend the same training in the near future. Old or discarded medication is returned to the pharmacy for disposal and a record is kept. Haven House Version 1.10 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home takes any complaint seriously, investigates and records the outcome. The home has a clear regard for the protection and wellbeing of residents. EVIDENCE: The home’s complaint policy and procedure was available. During interviews staff confirmed their awareness of the procedure. The manager stated that no complaints had been received and that in the event complaints would be recorded in the residents’ individual files and also at the organisations head office. The home held the Surrey County Council Multi-Agency Adult Protection procedures. The home also had its internal adult protection procedures available. The manage stated that these are in the process of being updated consistent with the new Surrey County Council procedures which were updated in February 05. Staff that were interviewed were aware of the home’s procedures and stated that they would be prepared to ‘whistle-blow’ on colleagues if any form of abuse was suspected. It was evidenced that a number of staff received the Surrey County Council Multi-Agency training in the Protection of Vulnerable Adults in December 04 and the manager stated that new staff would also receive training, which will be arranged by the organisation. It was also evidenced that Adult Protection is also included in the home’s staff induction programme. Haven House Version 1.10 Page 16 A sample of the resident’s personal finances were inspected. The balance in the resident’s individual cash tins was consistent with the balance entered in the cashbook. Residents stated in discussion/interview that they had no complaints or worries about the way staff treat them and that they were ‘happy’ with the care that is provided. Haven House Version 1.10 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, and 30 The exterior and interior of the home provides a homely, well-maintained and comfortable living environment that meets the needs of the residents. EVIDENCE: The home is a detached purpose built building situated in a residential area close to the town centre. The exterior of the premises is in good order and is well maintained. There is a high level patio at the rear of the house and a good-sized fenced rear garden. Currently staff maintain the garden; however the manager stated that external contractors are being sought regarding maintaining this area. There is an electricity sub-station immediately to the side of the patio. The area has a six-foot fence provided by the electricity company around the station and the home has erected a terrace fence around the patio area as added protection. No safety hazards were evident in the garden area. A sample of the resident’s bedrooms were inspected. All of the bedrooms were decorated and furnished to a very good standard and were well cared for. The residents’ have a choice regarding colour schemes and Haven House Version 1.10 Page 18 items of furniture for their rooms. All of the bedrooms are personalised with a range of residents’ effects and possessions. Residents stated in discussion/ interviews that their beds were comfortable and that they liked their rooms. Communal areas were decorated and furnished to an equal standard and were homely and comfortable. Residents were observed to be relaxed in their environment and stated that they “liked the home”. Washing, bathing and toilet facilities were of a very good standard and consistent for use by people with disabilities. Hoists and special baths are used. These facilities afford adequate privacy for the residents. The laundry is well equipped. It was noted that this room was uncomfortably hot and the manager stated that the organisation is currently in the process of arranging to have additional ventilation installed. As this is already in progress a requirement will not be made. The home’s infection control policy was available. Standards of cleanliness and hygiene were high throughout the home and no safety hazards were identified. Staff and residents are to be commended for their input in maintaining the premises. Haven House Version 1.10 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The home’s recruitment and vetting procedures are sound. The home has a clear regard for the importance of staff training and this area is active within the service. EVIDENCE: The home has a recruitment policy. The policy is dated May 2000. The personnel files of three staff appointed since the last inspection and one longer serving member of staff were inspected. The files contained an abundance of information and in the main included: staff personal details, completed application form, interview notes, copy of job description, two written references, health questionnaire, contract, induction programme, copies of birth/marriage certificates and driving documentation. Photographs of all staff had recently been taken and were in evidence and were about to be placed on staff files. ‘POVA’ checks and copies of qualifications and training certificates. Criminal Record Bureau check reference numbers, dates of checks and a copy of certificates were held. These are held at the organisations head office with evidence also kept at the home. There was evidence of staff training on topics such as: medication, food hygiene, health & safety, adult protection and moving and handling. It was further evidenced that training in autism and ‘nail cutting’ is planned for later in the year. Haven House Version 1.10 Page 20 Three staff hold the NVQ level 2 qualification and one member of staff holds the NVQ level 3. Two staff are due to commence NVQ 2 training on 13th May 05. Staff interviewed confirmed their attendance on training courses including the induction programme. Staff also thought the organisation supportive at enabling staff training. Haven House Version 1.10 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home is effectively managed, affords a very good standard of care to the residents and has a clear regard for securing resident’s and their relative’s views. The home has a positive regard for health and safety matters. EVIDENCE: The new manager is about to commence a monthly audit, which will serve as an internal quality assurance mechanism. The format for the audit is comprehensive and was evidenced at the inspection. As this is in progress a requirement will not be made. Regulation 26 visit reports were available for the months preceding the last inspection. These were for the months of October 04, November 04, December 04, January 05 February 05 and March 05. The reports evidence a good level of scrutiny. Haven House Version 1.10 Page 22 Annual survey forms completed by staff on behalf of residents or by residents’ relatives were available. These were dated June 04 and included comments such as: “excellent home, staff reliable, cheerful attitude and atmosphere, caring and loving home, all staff are so good, wonderful home and we cannot speak too highly of it”. Residents stated/indicated similar opinions during interviews/discussion. The home’s health & safety policy was available. The policy was dated July 04. The home’s health & safety ‘law’ poster was prominently displayed. The home’s fire risk assessment dated January 04 was available. The new manager stated that this is scheduled for review. As this is due to be progressed, a requirement will not be made. There is also a written fire risk assessment for each resident, which is updated annually or as necessary. There were also risk assessments regarding activities, equipment, the garden area and COSHH product risk assessments. All of these are reviewed on an annual basis. The home’s fire book was inspected. Fire evacuation drills were in evidence; however it was noted that the drill scheduled for January 05 had not been undertaken. Fire alarm tests were evidenced as occurring weekly. There was also evidence of equipment tests and vehicle safety checks. The home has a safety audit check list. The home had current certificates for the testing of gas, water and Legionella. It was evidenced by correspondence that the home had received an electrical systems test in October 04; however the test certificate had not been sent to the home. The manager thought this might have been forwarded to the organisation’s head office. A check of portable electric appliances occurred on 13th March 05. Hot water temperatures are taken and recorded on a daily basis. Average temperatures show as being between 40 – 41 degrees centigrade. Haven House Version 1.10 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x Haven House Version 1.10 Page 24 NO 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 42 Regulation 13, (4) (a) Requirement That the electricity systems test certificate is obtained from the organisation and kept at the home. Timescale for action 1 / 6 / 05 2. 3. 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 Good Practice Recommendations Haven House Version 1.10 Page 25 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Version 1.10 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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