CARE HOMES FOR OLDER PEOPLE
Haven House (Knaphill) Haven House Limecroft Road Knaphill Surrey GU21 2TH Lead Inspector
Lisa Johnson Unannounced Inspection 15th December 2005 10:25 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 (Knaphill) DS0000013665.V269186.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 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 (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Haven House (Knaphill) Address Haven House Limecroft Road Knaphill Surrey GU21 2TH 01483 489197 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) Mr Kreshna Kumar Poonyth Mrs Elizabeth Mary Poonyth Mr Martyn James Williams Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (19) Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Of the 19 service users accommodated all 19 may fall within the category of either MD or MD(E). The age range of service users will be: 50 years and over Date of last inspection 4th July 2005 Brief Description of the Service: Haven House is a large detached property set within its own grounds. The home is within walking distance of local facilities. Accommodation is provided for up to nineteen adults and is based on two floors. All but one of the eighteen rooms provides single occupancy. Two people share one double sized room. The communal areas are spacious and consist of a dining room, main lounge, a smaller lounge and a large kitchen, which is accessible to residents. There is a conservatory and large garden, which has a small summerhouse, which is accessible to all the residents. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over four and half hours. The focus of the inspection was to review the requirements made at the last inspection and to look at other required standards. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspector spoke to six residents who live in the home and to and one member of staff. This was a positive inspection. The inspector would like to thank the residents and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
The home has now obtained the updated version of the local authority protection of vulnerable adults procedure. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 6 A requirement was made at the previous inspection that a procedure is introduced in respect of homely medications administered in the home. This has now been completed and an agreed list is in place authorized by the General Practitioner. The home has responded to a recommendation that a training schedule should be implemented for monitoring the dates of staff training. 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 (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection. EVIDENCE: For Information please refer to the report dated 4th July 2005. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Each resident is provided with a completed care plan that is based on assessment. The home is able to demonstrate that goal plans are reviewed. The home needs to ensure that service users agree to their personal goals. EVIDENCE: Care plans were sampled and each resident is issued with a comprehensive care plan outlining their health, emotional and social care needs. One plan sampled was for an individual who been admitted since the previous inspection. It was clear that comprehensive assessments were completed. Regular reviews were completed with comprehensive records maintained. However one plan was not signed by the individual and no photograph was present and a requirement was made that this is completed. This is to ensure that residents are consulted and agree their plan. Although medication administration systems and records were not examined on this inspection the home has responded to a recommendation that a procedure is put in place in respect of the administration of homely remedy medicines. An approved list is in place and has been authorized by the General Practitioner.
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The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 The home supports service users to maintain independent living skills. Service users take part in fulfilling activities and participate in the local community. Service users engage in a range of leisure activities and are supported to exercise choice. Residents were offered a choice of meals, which were well balanced. EVIDENCE: One resident spoken to likes going to the theatre to shows, which he visits independently. Two residents spoken to said they been on holiday to Butlins this year. One individual said, “You can do what you like and make choices”. Some residents said they take themselves to the local shops, use cafes, attend the vine day centre and use the local bus. At the time of the inspection one resident was cooking with staff in the kitchen and another individual was clearing tables. Another resident says he likes to help with the hoovering. During the inspection residents and staff were observed to be participating in a word wheel game, which everybody was clearly enjoying. The lunchtime meal was observed which was nicely presented and nutritious. Residents spoken to confirmed that they are able to make choices about their meals. Tea and coffee was offered between meals.
Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The home is able to demonstrate that there is an accessible complaints procedure. Resident’s legal rights are protected. Written policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: The complaints register was sampled and no complaints have been received since the previous inspection. The complaints procedure was seen on display. Residents spoken to indicate that they are happy living in the home and individuals spoken to stated that staff are kind, supportive and helpful. One resident said, “ Staff know us well and when we need more help and support”. Residents stated that staff were approachable and felt they could talk to staff if they had any concerns. Another individual described the home as, “Marvellous, the staff are kind”. Residents were offered the opportunity to participate in voting in the election process. The home has now obtained the updated version of the local authority protection of vulnerable adults policy. The staff-training schedule was sampled and indicates that staff are receiving training in the protection of vulnerable adults. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 The home is able to demonstrate that it provides a homely, well-maintained, clean and safe environment for service users to live in. live in a safe and comfortable home to live in which is clean and hygienic. EVIDENCE: The service provides a homely place for residents to live, which is well maintained and is appropriately furnished. The home provides accessible toilets and bathrooms, which were pleasantly decorated and clean. Externally the house is well maintained with a pleasant garden, which is tidy and accessible to residents. The home was cleaned to a high standard and was hygienic. The home maintains records of routine maintenance and a renewal programme Records are maintained for room servicing and linen changes.
Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 The home is able to demonstrate that residents are protected by the homes recruitment policies and practices. Staff are supported to undertake training and development to ensure that they are competent to carry out their job. EVIDENCE: A new member of staff has joined the team since the previous inspection and the personal file was examined. All the required documentation was present and a police check completed. The home has responded to a recommendation in respect of implementing an update staff training record schedule, which was sampled. The schedule indicated that staff are accessing mandatory and other related training. A member of staff who was the shift leader on the day of the inspection confirmed that she was completing a National vocational qualification level to in care and has completed mandatory training courses. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 37 & 38 Residents are safeguarded by the financial procedures of the home. The interests of residents are promoted by the homes record keeping, policies and procedures. Health and safety procedures within the home protect service users from harm but must make available some up-to-date required maintenance certificates. EVIDENCE: Residents have their own bank accounts and some residents access their accounts independently. Some monies are maintained in the home for individuals who require support. Records were sampled and were maintained appropriately and balances were sampled which were correct. A business plan is in place, which was sampled. Clear performance objectives were documented. Insurance cover is provided and the employers liability insurance was on display. Accounts are maintained by the home but were unavailable for inspection as the accountant was reviewing them. A
Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 15 recommendation was made that these should be made available at the next inspection for sampling. A range of policies and procedures were in place, which were sampled including equal opportunities. Financial affairs, record keeping and staff disciplinary procedures. One file, which is dated and signed, was not present in the home and it is strongly recommended that this file be maintained in the home if access is required. Fire records were sampled with updated records maintained for fire drills and equipment testing. Fridge and freezer temperatures are recorded appropriately. Water temperatures are tested regularly and accidents records were adequately maintained. As the registered manager was not available for this inspection a requirement was made that up-to-date records and certificates for gas, electrical and legionella testing are made available to the Commission for Social Care Inspection. This is to ensure that the health, safety and welfare of residents and staff is protected. Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 16 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 X 3 2 Haven House (Knaphill) DS0000013665.V269186.R01.S.doc Version 5.0 Page 17 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 OP 7 Regulation 15(2)(a) (C) Schedule 3 13 (1)(5) Requirement The registered manager must ensure that one residents care plan contains a photograph and is signed by the individual. This is to ensure that residents are consulted and agree their plan. The registered manager must Supply copies of the updated certificates for gas, electrical testing and legionella. This is to ensure that the safety and welfare of residents and staff is protected. Timescale for action 29/12/05 2. OP 38 05/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP 34 OP 37 Good Practice Recommendations The registered manager should supply the updated financial accounts of the home to the Commission for Social Care Inspection for sampling at the next inspection. It is recommended that the procedure file that is signed and dated should be made available at all times in the home.
DS0000013665.V269186.R01.S.doc Version 5.0 Page 18 Haven House (Knaphill) 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
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