Inspection on 04/07/05 for Haven House (Knaphill)

This inspection was carried out on 4th July 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 (Knaphill) 18/11/08

Haven House (Knaphill) 06/11/07

Haven House (Knaphill) 10/01/07

Haven House (Knaphill) 15/12/05

Haven House (Knaphill) 11/11/04

Haven House (Knaphill) 15/06/04

Haven House (Knaphill) 08/01/04

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

CARE HOMES FOR OLDER PEOPLE Haven House Limecroft Road Knaphill Surrey GU21 2TH Lead Inspector Lisa Johnson Announced 04 July 2005 10:00 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 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) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Haven House (Knaphill) Address Limecroft Road Knaphill Surrey GU21 2TH 01483 489197 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) Mr Kreshna Poonyth & Mrs Elizabeth Poonyth Ashgrove, Bisley Green, Bisley, Woking, Surrey, GU24 9EW Mr Martyn James Williams Care Home (CRH) 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) 19 of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 19 Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Of the 19 service users accommodated all 19 may fall within the category of either MD or MD(E). 2 The age range of service users will be: 50 years and over Date of last inspection 11 November 2004 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. Accomodation 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 conservetory and large garden which has a small summerhouse which is accessible to all the residents. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection carried out in 2005/2006. One inspector carried out the announced inspection over six and half hours. The main focus of the inspection was to review the requirements made at the last inspection. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspector spoke to eight residents who live in the home and to the manager and two members of staff. The inspector left some business cards and information leaflets. The inspector would like to thank the residents and staff for their cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection? The home has had pre-set valves installed to regulate the hot water temperature to hot water outlets in line with current legislation. A copy of the Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 6 action plan, based on the recommendations of the Occupational therapist has been sent to the Commission of Social Care Inspection. A recommendation was made at the last inspection that the home expands its quality monitoring system to include others as well as residents. This has now taken place and copies were made available to the inspector. 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) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 & 5 The home provides adequate information to enable prospective residents decide whether they wish to live there. Contracts were in place and assessments completed prior to new persons being admitted to the home. EVIDENCE: The home has a comprehensive statement of purpose, which was professionally presented. The statement of purpose clearly describes the services it is able to offer. A complaint procedure was available and incorporated in the service users guide. Evidence was available that assessments were undertaken prior to admission and these were sampled and trial visits are accommodated. One resident spoken to who was staying at the home for a trial period, confirmed that he was in possession of a service user guide and was made aware of the homes complaint procedure. Individual contracts were in place in the form of statement of terms and conditions. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 &11 The health and personal care needs of residents were being met. Residents were treated with dignity and respect. Residents were referred to other specialists when required and health screen checks were taking place. Residents are protected by the homes policies and procedures for dealing with medication. A policy has been implemented in respect of death of a resident. EVIDENCE: Three care plans were sampled and each individual had a comprehensive plan in place, which incorporated risk plans. Plans were based on physical and mental health needs assessments and activities of daily living. Intervention plans and health care checklists were in place. There was clear evidence that regular reviews were taking place involving residents and outcomes were recorded. Staff liaise with other specialists as necessary including the GP, community psychiatric nurse, care managers, physiotherapists and occupational therapists. Staff were observed to be speaking to residents respectfully and courteously and maintained privacy by knocking on residents doors before entering. Medication records were sampled and were maintained adequately and found to be stored securely. A signatory list was available for all staff who are able Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 10 to administer medication and who have completed up to date training. One resident administers his own medication and a risk assessment was in place. The home has received an audit from the local pharmacist. A requirement was made that a policy and an updated list of all homely remedy medication used in the home should be made available. The home has implemented a policy in respect of death of a resident. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Residents were offered a range of leisure and recreational activities, which take into account individual preferences and are supported to exercise choice and control over their lives. Residents were able to participate in aspects of life in the home and maintain contact with family, friends and local community as they wish. Residents were offered a well-balanced, choice of meals. EVIDENCE: All residents have individually planned daily activities based on their interests and personal preferences. Two service users stated that they attend the vine day centre and one resident holds a gardening job. Some of the residents go out independently and go shopping and to cafes. Six residents have been on a holiday to Butlins this year. A number of activities are held in the home and supported by staff including newspaper group, word wheel and bingo, which was observed on the day of the inspection. Residents were clearly enjoying this activity. Some residents enjoy participating in household activities such as in meal preparation and household tasks. One resident stated, “I enjoy helping in the house, it helps keep my independence, it feels like real home”. Residents maintain contact with family and friends and there are no restrictions to visiting the home. Access to a telephone is available. Residents confirmed that a weekly meeting is held in the home to discuss issues. A varied menu was in place and choices of meals were available. The lunchtime meal was observed and was nutritious. There was pleasant and Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 12 relaxed atmosphere in the dining room and a majority of the service users stated that meals are satisfactory. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 The home is able to demonstrate that resident views are important and listened to and residents are appropriately protected. Policies and procedures were in place in respect of complaints and adult protection. EVIDENCE: An adequate complaints policy was in place and was available in the service user guide and on display in the hallway. A complaints register is maintained and no complaints have been received since the last inspection. Three residents spoken to were aware of the homes complaints procedure. All residents spoken to felt that could approach staff with any concerns and that they will listen and try to help. One resident stated, “The staff are very helpful, they will listen and help with any problems that I may have”. Another resident stated, “Staff are supportive and always try and help”. Staff receive Protection of Vulnerable Adult training and senior staff attend the local authority multiagency training. The home made available the local authority Protection of Vulnerable Adult policy and whistle blowing policy. However a requirement has been made that the home obtains the updated version. Two staff spoken to were clear about what action that they would take if they ever witnessed any incident of abuse taking place. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 22, 23,24, 25 &26 The home is able to demonstrate that it provides a clean, safe, homely and comfortable environment for the residents to live. EVIDENCE: The home is well maintained and a programme of routine servicing and maintenance was available. On the day of the inspection the home was clean and hygienic. The lounge and dining room portray a homely appearance. The kitchen was cleaned to a high standard and food hygiene regulations adhered to. There is an extra smaller sitting room and a conservatory, which is available for residents who wish to smoke. A large garden is available that is pleasant and well maintained which also contains a summerhouse. Specialist equipment and aids were installed to meet the assessed needs of residents in consultation with a physiotherapist and occupational therapist. Bedrooms were pleasant and comfortable and are decorated to personal choice with a varied range of personal possessions on display. There is one double room that is shared by two people and screening is provided to maintain privacy. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 15 Ventilation and lighting is adequate and ample hand washing facilities are available. Window restrictors have been installed. The home provides laundry facilities in a utility room separate to the kitchen and was well maintained. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The staff work positively with residents in the home to improve the quality in their lives. The staffing levels were adequate to meet the needs of the residents. Staff are supported to undertake training and development. Appropriate recruitment practices were in place to ensure the safety and protection of residents. EVIDENCE: The staff work positively with residents in the home. Staffing levels were adequate to meet the needs of the residents and the staffing remains stable, as there have been no staff changes since the last inspection. Staff are supported to undertake training and development. Mandatory training has taken place and training completed in basic mental health. Three staff are registered nurses and sixty percent of the care staff have obtained National Vocational qualifications in level two or above. Some staff certificates were sampled, but a recommendation was made that the manager considers implementing a staff-training schedule to keep dates of any training undertaken up-to-date. Three staff files were sampled and the home operates a thorough recruitment process. Police checks and other required documents are available. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33,36,37 & 38. The home is well managed in an open and positive atmosphere. An effective quality assurance system is in place based on seeking views from residents and others. Staff are supported by receiving regular supervision. Adequate record keeping is maintained and policies and procedures have been implemented to promote the health and safety of residents. EVIDENCE: The management style in the home was found to be open and inclusive. The manager is experienced and is completing the registered managers award and has also obtained a professional trainers certificate. Residents and staff confirm that the manager is supportive and approachable. A quality assurance system has been implemented which has been based on seeking views from residents and others such as the General Practioner, community nurses and care managers. The outcomes have been analysed and show positive responses to the care in the home. Copies of the reports have Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 18 been made available to the Commission for Social Care inspection. Staff receive regular supervision and this was confirmed by staff spoken to and written copies are maintained on staff files. Record keeping was maintained to an adequate standard. A confidentiality and disclosure policy was in place and records were stored appropriately. Comprehensive policies and procedures have been implemented to protect the health and welfare of residents and staff including fire safety, food hygiene, manual handling, and control of harmful substances. Detailed environmental risk assessments have been undertaken and kept under review, Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x 3 3 3 Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 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 18 Regulation 13 (6) Requirement The home must obtain an updated copy of the local authority Protection of Vulnerable Adult procedure A procedure for the administration of all homely remedy medication used in the house must be made available. Timescale for action 1 month 4/08/05 1 month 4/08/05 2. 9 13 ( 2) 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 30 Good Practice Recommendations The home should consider implementing a schedule to maintain up to date records of all staff training undertaken in the home. Haven House (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 Page 21 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 (Knaphill) H58 S13665 Haven House (Knaphill) V228111 040705 Stage 4.doc Version 1.30 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. 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