Inspection on 29/09/05 for Haven House (Haslemere)

This inspection was carried out on 29th September 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven House (Haslemere) 03/07/07

Haven House (Haslemere) 03/08/06

Haven House (Haslemere) 26/04/05

Haven House (Haslemere) 02/09/04

Haven House (Haslemere) 04/05/04

Haven House (Haslemere) 04/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Haven House (Haslemere) Haven House 44 Kings Road Haslemere Surrey GU27 2QG Lead Inspector John Chivers Announced Inspection 29th September 2005 Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 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 (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Haven House (Haslemere) Address Haven House 44 Kings Road Haslemere Surrey GU27 2QG 01428 661440 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) Whitmore Vale Housing Association Limited Miss Phillippa Kate Alves Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Physical disability (5), Sensory impairment (5) Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The age/age range of the persons to be accommodated will be 21 - 55 years, one (1) resident 55-65 years. All 9 (nine) residents will have a learning disability (LD). Up to 5 (five) of the residents may have a sensory impairment (SI) and/or a physical disability (PD). 1 (one) of the residents may have an additional mental disorder (MD). Date of last inspection 26th April 2005 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 registered services within the county of Surrey. The home is a detached purpose built property situated close to the town centre. The home provides a homely and comfortable environment where residents are encouraged towards independence and social inclusion. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was undertaken on 29th September 05. The duration of the inspection was four hours. It must be noted that all of the CSCI ‘Core’ Standards were inspected at the previous inspection and with the exception of Standards 22 and 23, which were revisited on this occasion the remainder were a ‘random’ selection of ‘non core’ standards. As part of the inspection process discussion was held with one resident and formal interviews were held with two staff. Discussion was also held with the home’s management. The inspection included examination of a sample of the home’s policies, procedures and records. The personnel files of the last two recently appointed members of staff were inspected. The home submitted the required pre-inspection information and questionnaires were also received from residents, their relatives, placing authorities and other professionals connected with the home. The findings of the inspection were again positive with evidence of good management and care practice. The home had policies and procedures in place. These documents were informative; however some needed expansion to include certain details as required by The Care Home’s Regulations 2001 and The National Minimum Standards for Care Home’s for Younger Adults. There was observed evidence that staff related positively to residents and engaged them appropriately in communication and activities. Staff were also observed to treat residents with humour, dignity and respect. Staff interviewed were knowledgeable regarding residents care plans and were aware of the home’s key policies and procedures. The home’s records were well kept and easily accessible. Recruitment and vetting procedures were sound. Staff interviewed were supportive and appreciative of the home’s management and thought the service to now be more organised and consistent. Written feedback from the range of questionnaires received was positive and complementary regarding all aspects of the home’s service. What the service does well: Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 6 The home has continued to maintain its standards and quality of care to the residents. The home is well organised with evidence of staff commitment to the residents and their care plans. The home provides a wide range of internal and external activities and is aware of the importance of encouraging independence and social inclusion. The home has regard for the safety and protection of its residents and its staff recruitment and vetting procedures are sound. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5. The homes Statement of Purpose and Service User guide are comprehensive and accurately describe the service provided. The home ensures that resident’s receive contracts/terms and conditions of residence. EVIDENCE: The home’s Statement of Purpose and Service User guide were available. The documents are detailed and hold all information required by Regulation 4, Schedule 1 of The Care Home’s Regulations 2001. The service user guide is also in pictorial form. The documents are given to resident’s, their relatives and significant others. Written contracts/terms and conditions of residence were held in the sample of resident’s files inspected. The contracts are also in pictorial form. It was noted that one of the contracts had not been signed. It is important that the resident or their representative sign and date the document. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 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 the following standard(s): 8 and 10. The home has regard for encouraging resident’s to participate in the running of the home. Staff were clear regarding the importance of keeping appropriate information confidential. EVIDENCE: Resident’s participate in the running of the home and there was recorded evidence via resident’s meeting minutes that they are consulted and their views sought. Resident’s stated/indicated in discussion that their opinions are listened to and acted upon. The home has a policy regarding ‘confidentiality’. Staff were aware of the importance of confidentiality and the topic is covered in the home’s induction programme. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. The home has regard for ensuring that resident’s are appropriately stimulated and engaged in purposeful activities. EVIDENCE: The home provides a wide range of sedentary and active pastimes. Resident’s confirmed their involvement in activities during discussion. Residents have a daily activities programme, which includes attendance at ‘Day Centres’. The day centre programme is in pictorial form. One resident undertakes voluntary work at a nearby Boarding School. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21. The home ensures that resident’s funeral arrangement wishes are held; however this information also needs to be transferred on to the resident’s individual care plan and that such documents are signed by the resident’s or their representative. EVIDENCE: The home has a policy and procedure regarding ‘ageing and death’. Resident’s have funeral wishes arrangement discussion forms on their individual files. It would be important that the content of the forms is also transferred to the resident’s individual care plans and that the resident’s or their representatives sign the funeral wishes arrangement forms. A requirement will be made regarding the former and a recommendation regarding the latter. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has regard for the area of complaints; however its policy and procedures need to be expanded consistent to the Regulations and Standards stated below. The home has regard for the safety and protection of its residents. EVIDENCE: The home has a written complaint policy and procedure. The policy is comprehensive; however it needs to be expanded consistent with Regulation 22, (4) of The Care Home’s Regulations 2001 and Standard 22. (4) of The National Minimum Standards for Care Home’s for Younger Adults to state that a complaint will be responded to within 28 days. The policy also needs to include the contact address and telephone number of the CSCI Surrey Local Office. Requirements will be made regarding these areas. The home also has a complaint procedure in pictorial form for the residents. This procedure contains the details outlined above. The home’s complaint book was available. The complaint book evidenced that no complaints had been received. Staff interviewed were aware of the complaint procedure. Resident’s stated in discussion that they had no complaints about the home and that they were “very happy” with the service provided. The home has a policy and procedure regarding the Protection of Vulnerable Adults. In addition the home holds the Surrey County Council Multi-Agency Vulnerable Adult Protection procedures. There was recorded evidence that all but one of the home’s staff have received training in the protection of Vulnerable Adults. This occurred on 22nd July 05. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 13 Such training for the remaining member of staff has been arranged for 13th October 05. Staff interviewed were clear regarding the Adult Protection procedures and stated they would be prepared to ‘whistle blow’ on colleagues in appropriate circumstances. A sample of the resident’s personal finances was inspected. The cash held was consistent with the balance entered in the resident’s cashbooks. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. The home ensures that appropriate specialist equipment is obtained for the residents. EVIDENCE: A full inspection of the premises was undertaken at the previous inspection and no requirements or recommendations were made. The home has specialist equipment including: a lift, hoists, special beds, baths and toilets. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. The home has a competent staff team that enables the service to meet its aims and objectives. Recruitment and vetting procedures are sound and the home is committed to staff receiving NVQ training. The frequency of ‘formal’ staff supervision has increased since the new manager commenced duties. EVIDENCE: The home has a ‘core’ of experienced staff that ensures the less experienced staff are appropriately supervised. The staff on duty at the time of the inspection were observed to be competent and efficient at meeting the needs of the residents. Relationships were positive with good levels of two-way communication evident. Staff interviewed had a sound understanding of residents needs and were aware and knowledgeable regarding care plans. The staff were also of the opinion that they work well as a team, are caring and consistent. The personnel files of two recently appointed members of staff were inspected. The files evidenced good recruitment and vetting procedures and held all details required by Regulation 19, Schedule 2 of The Care Home’s Regulations 2001. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 16 Currently one member of staff holds the NVQ level 3 qualification and the deputy manager is due to commence such training in the New Year. Three staff hold NVQ level 2 and two staff are currently undertaking NVQ level 2 training. A further two staff will undertake NVQ level 2 training when they have completed their probationary period. One of the senior staff is due to commence NVQ Assessor training. There was recorded evidence that ‘formal’ staff supervision has increased and staff stated in interviews that they were satisfied with the frequency and content of supervision sessions. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 43. The home is well managed with evidence of close internal monitoring and scrutiny of the service. EVIDENCE: The manager is currently undertaking the Registered Managers Award. The manager has substantial experience in residential work with children and people with learning disabilities. There was evidence to show that the home continues to be managed in a satisfactory and consistent manner and staff interviewed were supportive of the managers input and leadership regarding the service. The manager has received appropriate training since her appointment to the home and has also attended the ‘Food Hygiene’ trainer’s course. The home’s Certificate of Registration was prominently displayed and the home held a current insurance liability certificate. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 18 The home had an annual development plan dated July 05. The plan had been drawn up in consultation with the home’s line-management. The manager undertakes a monthly audit of the service and scrutinises twenty areas in the process. Regulation 26 visits also occur each month. Copies of the Regulation 26 visit reports are forwarded to the CSCI Surrey Area Office. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Haven House (Haslemere) Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 X X X X X 3 DS0000013666.V254680.R01.S.doc Version 5.0 Page 20 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 YA5 Regulation 5, (1) (b) Requirement That residents or their representative sign and date resident’s contracts/terms and conditions of residence. That the contact address and telephone number of the CSCI Surrey Local Office is included in the home’s main complaint procedure. Timescale for action 10/11/05 2 YA22 22, (7) (a) 10/11/05 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 Refer to Standard YA21 Good Practice Recommendations That residents or their authorised representative sign the funeral wishes arrangement forms. Haven House (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office 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 (Haslemere) DS0000013666.V254680.R01.S.doc Version 5.0 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!