Inspection on 03/07/07 for Haven House (Haslemere)

This inspection was carried out on 3rd July 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven House (Haslemere) 03/08/06

Haven House (Haslemere) 29/09/05

Haven House (Haslemere) 26/04/05

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 (Haslemere) Haven House 44 Kings Road Haslemere Surrey GU27 2QG Lead Inspector Sarah MacLennan Unannounced Inspection 3rd July 2007 09:30 Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 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.V339186.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 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.V339186.R01.S.doc Version 5.2 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 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.V339186.R01.S.doc Version 5.2 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 3rd August 2006 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 homely and secure environment where residents are encouraged towards independence and social inclusion. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit formed part of the key inspection process and took place over 5 hours commencing at 09:30 and ending at 14:30. Sarah MacLennan, Regulation Inspector, carried out the visit. The acting manager was present throughout the inspection. As part of the inspection process a tour of the premises took place. Various written records were examined, including three care plans and service user assessments, three staff personnel files, samples of staff training records, the complaints record, the medication storage facilities and a sample of the medication administration records. The inspector spoke to a number of service users. Some staff members were spoken to during the course of the inspection. Some of the comments made to the inspector are quoted within this report. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the visit. What the service does well: The service users had comprehensive care plans that covered all aspects of personal and social support and healthcare needs. They included details of service users preferences, likes, dislikes and communication methods. Service users are encouraged and enabled to live a full life and to partake in age related activities, they are encouraged to be as independent as possible and to make their own choices. Staff were observed to treat the service users in a calm and confident manner and with respect. The acting manager demonstrated a thorough knowledge and awareness of the service users needs, a sound grasp of her managerial responsibilities, regulations and legal requirements. Service users were seen to interact readily with her. An open and inclusive atmosphere was evident within the home. All staff and service users appeared happy, contented and relaxed with the inspection process. The atmosphere within the home during the inspection was lively and cheerful. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 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.V339186.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to admission to the home to ensure that the home can meet their needs. EVIDENCE: The home had an appropriate Service Users Guide and Statement of Purpose, which have been recently updated to reflect the management arrangements within the home. The Service Users Guide is available in a symbol / pictoral format and is clearly displayed in the hallway. All current service users have been at the home for a number of years, there had not been a new admission since 2003. Discussion with the homes acting manager evidenced that a full and comprehensive pre-admission assessment would be carried out prior to a new service user being admitted. The inspector was informed that, in the event of a new service user requesting a placement, a full needs assessment would be requested from the purchasing authority, and an assessment undertaken by the homes manager. The manager also visits the prospective service users in varying settings that they are already familiar with, such as their current home, day services or educational establishments. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 9 All service users have been issued with contract amendments, which have been signed by the service users representatives, meeting the requirement made at the previous inspection. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans and risk assessments were in place. EVIDENCE: Three service users care plans and daily statements were looked at. The service users had comprehensive care plans that covered all aspects of personal and social support and healthcare needs. They included details of service users preferences, likes, dislikes and communication methods. Comments from relative’s surveys included ‘there is good support for all health needs’ Conversation with staff and examination of written records evidenced that the service users are encouraged to be as independent as possible and to make Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 11 their own choices, such interactions were observed. Many of the service users are non-verbal, staff were observed to readily communicate with them using Makaton. The specific communication methods that service users used were clearly detailed within their care plans. Samples of risk assessments were seen and included topics such as, community access, shopping, safe environment, personal care and fire evacuation. The risk assessments appeared comprehensive. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities enables service users to lead a full and active life and to participate in the local community. Meals are well balanced, varied and chosen by the service users. EVIDENCE: From examination of the service user recorded and discussion with staff it was apparent that service users are encouraged and enabled to live a full life and to partake in age related activities such as having BBQ’s, garden parties, watching TV and DVD’s, art and craft session and music therapy. Service users participate in the local community. They attend local facilities including shopping centres, cinema and theatre. The home has its’ own transport and the service users have various trips out including attending the South of England County Show, other trips are arranged on an ad-hoc basis at Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 13 the request of the service users. The home had a ‘places of interest’ file to facilitate service users choice. Comments from relatives surveys included ‘outings / holidays are well planned’. Visitors are welcomed and the home has unrestricted visiting times. Service users contact with family is encouraged. Comments from relative’s surveys included ‘we are kept up to date with her progress’ Conversation with staff and service users evidenced that the service users are encouraged to be as independent as possible and to make their own choices, such interactions were observed. Staff were observed to treat the service users in a calm and confident manner and with respect. Service users are encouraged to be involved in the day to day running of the home, they participate in household duties, including, loading the dishwasher, cleaning and laying the tables, laundry and cleaning and tidying their rooms. The service users take turns to choose the main meal of the day. This is discussed at the service users meetings; samples of the minutes were seen during the inspection. Alternatives to the main meal choice are always available. Staff were able to show the inspector pictures and photographs, which were used to enable the non-verbal service users to make choices regarding their diet. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health needs are met and they receive the support they require. EVIDENCE: Staff spoken to were aware of the guidance and support required by the service users. Service users received additional specialist support including behavioural specialists, community nurses, OT, GP and psychiatrist. Daily statements are made on each service user, samples of which were seen at inspection. These statements were comprehensive in nature and related to the service user care plans. The homes storage and recording of medication were seen and found to be in order. The home had a suitable policy for the administration of medication. The manager stated that all staff responsible for the administration of medication were suitably trained, samples of training files were seen. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 15 One of the service users had their medication crushed and administered in food. This method of administration was following consultation with the service users General Practitioner. The service users care plan stated that staff should inform the service user prior to the administration of the medication. There was no evidence of consent from the service user to this method of medication administration. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a simple and accessible complaints procedure and systems are in place for the protection of vulnerable adults. EVIDENCE: The home had a simple and accessible complaints procedure. No complaints had been received since the last inspection. All appropriate safeguarding adults policies and procedures were in place and readily available to staff. All staff spoken to were aware of these policies and procedures and their whistle blowing responsibilities. All staff had had training in the protection of vulnerable adults. Comments from relative’s surveys included ‘my daughter is safe, happy and well cared for’. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an environment suitable for the needs of its service users. EVIDENCE: The inspector toured areas of the home. Service users are encouraged to personalise their rooms; this was evident on inspection. They had a sense of ownership of their home, and their personal space reflected their individual lifestyles. One service user informed the inspector that she liked her room and had chosen her curtains. The home was suitable for the needs of the service users. The décor was domestic in nature and general standards of maintenance were good. At the time of the inspection the home was being redecorated. The inspector was informed that new carpets and curtains were on order. The home was seen to be clean, tidy and free from offensive odours. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff and are protected by the homes recruitment policy and practices. EVIDENCE: Samples of the staff’s training files were seen. This evidenced that training of staff is given high priority. Staff had received training in health and safety, first aid and food hygiene as well as service user specific training. Service user specific training included; communication methods such as makaton and dementia. The staff rotas were inspected and the staffing levels were found to be satisfactory to meet the needs of the current service users. The home maintains staffing numbers of three during the day and one waking and one sleeping member of night staff. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 19 Recruitment of staff is carried out under the homes policy and procedure on Staff Recruitment that incorporates the equal opportunity policy and procedure of the home. Three staff files were seen and found to contain the required information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). There was no evidence that Criminal Records Checks of existing staff are reviewed. Examination of staff records and discussion with staff evidenced that staff receive regular supervision sessions with the acting manager. Staff morale appeared high and the staff on duty appeared to enjoy their jobs. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from an open, positive and inclusive atmosphere, effective systems are in place to monitor the quality of care and services provided and to protect the health, safety and welfare of service users. EVIDENCE: The acting manager demonstrated a thorough knowledge and awareness of the service users needs, a sound grasp of her managerial responsibilities, regulations and legal requirements. Service users were seen to interact readily with her. An open and inclusive atmosphere was evident within the home. All staff and service users appeared happy, contented and relaxed with the inspection process. The atmosphere within the home during the inspection was lively and cheerful. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 21 The acting manager stated that various quality audit systems were in place. These included service user meetings, relatives’ questionnaires, staff meetings and staff supervision. These records were randomly sampled. The acting manager is aware of the need to maintain a safe environment for service users and staff. Required policies, procedures and safety checks were in place; samples of which were seen. Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 3 X Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 12 (2) Requirement The registered person must provide evidence of service user consent regarding crushing of their medication and administering it in food. Timescale for action 03/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Haven House (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 (Haslemere) DS0000013666.V339186.R01.S.doc Version 5.2 Page 25 - 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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