Inspection on 06/11/07 for Haven House (Knaphill)

This inspection was carried out on 6th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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) 10/01/07

Haven House (Knaphill) 15/12/05

Haven House (Knaphill) 04/07/05

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 (Knaphill) Haven House Limecroft Road Knaphill Surrey GU21 2TH Lead Inspector Joseph Croft Unannounced Inspection 6th November 2007 10:00 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.V347650.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 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.V347650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven House (Knaphill) Address Haven House Limecroft Road Knaphill Surrey GU21 2TH 01483 489197 01483 489337 philip.stow@btconnect.com 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 Philip Stow 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.V347650.R01.S.doc Version 5.2 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 10th January 2007 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. 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 summerhouse and is accessible to all the residents, particularly residents who smoke. The manager stated that the weekly fees for the home range from £375 to £500. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 6th November 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of seven hours, commencing at 10:00 and concluding at 17:00. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the menu, policies and procedures, staff training records, recruitment files and records of medication. The Inspector had discussions with members of staff on duty, and four residents. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home, and surveys from residents, their relatives, staff and other associated professionals have been used as sources of evidence in this report. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager at the end of this site visit. What the service does well: The home continues to regularly seek the views of residents in regard to the care they receive living at the home. Prospective residents have a pre-admission assessment undertaken, and are encouraged to visit the home, including overnight visits, before they decide to accept a place. People who use the service have care plans that ensure their personal and health care needs are being met. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 6 Residents are encouraged by staff to participate in a range of activities both within the home and the local community. Residents stated that activities are usually organised by the home. One resident informed the Inspector about their recent holiday at a renowned holiday camp, stating that they enjoyed the week’s holiday. Residents stated that the food was very good and they always have a choice of meals. Meals are varied with individual choices and preferences, and special dietary needs are catered for. Lunch and the evening meals were observed to be relaxed informal occasions with staff available to offer support. Residents are from different religious backgrounds, and are encouraged and supported by staff to practice their religion if they so wish. What has improved since the last inspection? What they could do better: Risk assessments must be reviewed on daily activities to ensure they detail the concern and action to be taken. They must be dated, signed and reviewed regularly and when necessary. Records of food provided to all residents, including special diets, must be maintained. The Complaints Policy and Procedures must be reviewed to ensure it contains the appropriate information. A copy must be supplied to any person acting on behalf of a resident. All staff must receive training in Safeguarding Adults. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 7 The home must undertake risk assessments whilst awaiting the fitting of protective guards to the pipe work and radiators. Any remedial action found to be necessary must be undertaken. The identified areas around the home environment must be addressed as detailed in the report, including the malodours in the two identified bedrooms. The registered person must not employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended). Training in regard to Manual Handling, Fire, Food Hygiene and Infection Control must be provided to all members of staff. 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 (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 8 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.V347650.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The manager informed the Inspector that the Statement of Purpose and Service Users Guide are currently being reviewed and updated, a copy of which will be forwarded to the Commission For Social Care Inspection local office on completion. The care file of the person most recently admitted to the home was viewed. This provided evidence that a pre- admission assessment had been undertaken prior to admission to the home. This included an assessment on the personal, health and social care needs. However, this had not been signed or dated by the person conducting the assessment. The manager informed the Inspector that this would be attended to. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 10 The manager informed the Inspector that prospective residents are encouraged to visit the home before moving in. This was confirmed during discussions with the most recently admitted resident, who stated they visited the home for a day and stayed for a weekend before deciding to move into the home Information provided in the Annual Quality Assurance Assessment (AQAA) informed that the home liaises with the mental health teams to ensure residents receive the mental health care based on their individual assessed needs. The home has a Referral and Admissions Policy and Procedure that was dated September 2006. The manager informed the Inspector that the home does not offer intermediate care. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans that ensure their personal and health care needs are being met. Residents are supported by staff to lead active lives, however, risk assessments require reviewing to ensure they include aspects of daily living. EVIDENCE: Three care plans were sampled as part of the case tracking process. These included a copy of the Care Plan Approach, and provided evidence of how staff are to meet the physical and mental health needs of residents. However, there was a lack of detail in regard to attending to personal care needs. A good practice recommendation has been made that care plans should provide more detail in regard to the way in which residents prefer staff to support them in regard to their personal care. Care plans were reviewed on a regular basis. During discussions, some residents could not recollect having a care plan, one resident had a copy of their care plan that had been recently reviewed, and proudly showed this to the Inspector. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 12 Surveys received from relatives informed that the home always or usually supports their relative as agreed. Two care plans sampled included risk assessments. The third care plan sampled had just one risk assessment that only stated this person was a heavy smoker. However, evidence was viewed that this person had visited a ‘stop smoking clinic’ to help them to give up smoking. Two risk assessments viewed for one resident had no date of when they were produced or last reviewed. Risk assessments in place did not inform the reader of the action to be taken when the resident becomes exposed to the risk. A requirement has been made that all risk assessments in place must be reviewed on daily activities to ensure they detail the concern, the action to be taken, dated, a signature and are reviewed regularly and when necessary. This will ensure that residents’ safety and well being is promoted and protected. From discussions with staff and residents, and from viewing records, it was clear that residents have access to health care professionals including a General Practitioner, Dentist, Optician and Chiropodist. However, information in regard to medical appointments were contained in different books. The care files sampled had a specific section for the recording of all health care appointments, and these had not been kept up to date. A good practice recommendation has made that staff should use the health care section provided in the care plans for the recording of all medical appointments. This will ensure that all information pertaining to the resident is kept in one place that is easily accessible to staff and residents. From surveys and discussions with residents, it was clear that they receive the appropriate medical support they need. The home has several residents who are diabetic. The manager informed the Inspector that staff observe these residents testing their blood sugar levels. Records of these are maintained by the home, some of which were sampled during the site visit. The manager informed the Inspector that he is a qualified Registered Mental Nurse and provides in-house training to all staff in regard to Diabetes. Information provided in the Annual Quality Assurance Assessment (AQAA) informs that the home has a Medical Policy and Procedure that was last reviewed in July 2006. The home uses the blister packs that are provided by the local pharmacy, and Medication Administration Record sheets (MARs) for the recording of medicines. The MAR records for residents who were part of the case tracking process were sampled. These included a photograph of the resident, and were accurately maintained. The manager informed the Inspector that no resident is self-medicating or taking a Controlled Drug. Evidence of training in regard to staff dispensing medication was viewed on the training records sampled Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 13 during this site visit. The home has a copy of specimen signatures of all staff who dispense the medication. The manager informed the Inspector that the Pharmacist last visited the home in December 2006. Medication is stored in a secure locked room, as recommended at the previous inspection. The lunchtime medication round was observed on the day of the visit; the member of staff with this responsibility was administering medication appropriately. The home maintains a record of medicines received into the home, however, the medication returns book was not viewed during this site visit. Residents informed the Inspector that they always receive their medication at the correct time. Residents living at the home are from different cultural backgrounds, and are cared for by a multi-cultural staff team. Staff informed the Inspector that they support residents to follow their religion if they choose to. The manager informed the Inspector that meals from different cultural backgrounds are provided on a regular basis. During discussions staff informed the Inspector that they respect residents’ privacy and dignity through knocking on their bedroom doors, addressing them by their preferred names and undertaking personal care, when required, in the privacy of bathrooms. This was confirmed during discussions with residents. Staff and residents were observed interacting in an appropriate manner. Residents stated that they could make and receive telephone calls in private; some residents have their own mobile telephones. Surveys received from residents, their relatives and discussions during the site visit informed that on occasions some residents’ mail has been opened before they receive it. This was discussed with the manager who informed the inspector that he was not aware of this, however, he would be vigilant to ensure that residents receive all their mail un-opened. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in activities both within the home and the local community that enables them to exercise choice and control over their lives. Meals are varied with individual choices and preferences, and special dietary needs are catered for ensuring that residents receive an appealing and balanced diet. EVIDENCE: Information provided in the AQAA informed that residents have access to the local community amenities and day centres. Staff informed the Inspector that residents take part in activities that include cooking, walks, visiting restaurants and pubs. This was confirmed during discussions with residents who also informed the Inspector that they take part in word and board games. Staff stated residents are ambulant and are encouraged to be independent, therefore they are able to go out alone. Some travel on the buses and trains, using their travel passes, and are able to attend various activities including day centres. One resident places small bets on horse racing, and showed the Inspector his book where he records all his betting activity. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 15 The home had a firework display on the day before this site visit. Residents spoken to stated they had enjoyed watching the fireworks. The home maintains a list of daily-organised activities offered to residents, however, these were limited to the same two activities each day. During discussions the manager informed the Inspector that a review of the in house activity programme is to be undertaken, and a list of weekly activities would be circulated to all residents. This agreed with the information provided in the AQAA in regard to plans for improvement in the next twelve months. Surveys received from residents informed that activities are usually organised by the home. One resident spoke to the Inspector about their recent holiday at a renowned holiday camp, stating that they enjoyed the week’s holiday. Residents are from different religious backgrounds, and are encouraged and supported to practice their religion if they wish. One resident is a practising Hindu. This person informed the Inspector that she attends the Temple with her son and daughter. The resident stated that staff respect her religious beliefs and the home provides her with the appropriate dietary requirements. The manager informed the Inspector that a current member of staff is a Hindu and provides information in regard to this to all staff at the home. Staff informed the Inspector that most residents have relatives who visit on a regular basis; there are no restrictions on visitors to the home unless the resident states they do not want to see them. Some residents go home to their relatives for weekends and holidays. The manager informed the Inspector that discussions took place with residents who do not have relatives in regard to having access to advocates, but all residents stated they did not require this. Residents were observed spending time in their bedrooms listening to music and/or watching the television. This was their choice. Residents spoken to stated they could choose to do as they wish. Some residents informed the Inspector that they have to get up in the mornings at 6:15am so they can have their breakfast. This was discussed with the manager who informed the Inspector that some residents do like getting up at this time, however, residents are able to get up later in the morning if they wish to, and breakfast would still be available to them. The manager was advised to ensure all residents are made aware of this. One resident informed the Inspector that she would like a chest of drawers, as some of her clothes had gone missing. This resident stated that she has to keep some clothes in a suitcase. This was discussed with the manager who stated he was aware of this situation and that the resident has been provided Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 16 with a key to her bedroom. The resident confirmed this. The manager stated that a chest of drawers would be provided for this resident’s bedroom. The home uses a three-week menu that was viewed during the site visit. Residents are offered choices. Meals provided included meat, pasta, fish vegetables and fresh fruit. The manager was informed that some resident questionnaires had stated there was not enough fresh vegetables provided for meals. The manager informed the Inspector that this has recently been attended to, and fresh vegetables are now provided. Fresh vegetables were provided on the day of the site visit. Special dietary needs are catered for, however, it was noted that records of these meals were not being maintained. A requirement has been made that records of food provided to all residents, including special diets, must be maintained to provide evidence that a satisfactory and nutritious diet is provided to all residents. Staff cook all the meals, sometimes with the help of residents. It was noted that not all staff had attended training in regard to Food Hygiene and Handling. This has been addressed under the Staffing part of this report. Residents spoken to during the site visit stated that the food was very good and they always have a choice of meals. Lunch and the evening meal were observed, and were both relaxed and unhurried occasions with staff available in the dining room to offer support as and when required. Staff were observed asking residents for their choice of meals for the following day. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a complaints system that enables residents and their families to raise concerns. Policies and procedures are in place to ensure that residents are safeguarded from abuse, however, staff require training in Protection of Vulnerable Adults to ensure residents are fully protected. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the care home. The home has a Complaints Policy and Procedure dated July 2006, a copy of which is displayed on the notice board at the entrance to the home. It was noted that this document had not been updated to reflect the change of contact details for the Commission For Social Care Inspection local office. Surveys returned from relatives informed that the majority of them were not aware of how to make a complaint. A requirement has been made that the complaints procedures must be updated and a copy of the Complaints Procedure must be supplied to any person acting on behalf of a resident. During discussions residents stated they would make a complaint to the manager if they needed to. One resident stated that they would put a complaint in writing as well as talking to the manager. The manager informed the Inspector that the home has not received any complaints. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 18 The home has a Safeguarding and Whistle Blowing Policy and Procedures that had been reviewed in September 2006 and May 2006 respectfully. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. During discussions staff were able to demonstrate an understanding of Safeguarding Adults issues, stating that all concerns would be reported to the manager. Staff were aware that the management of the home must follow the Surrey Safeguarding procedures when suspicions of or actual abuse has taken place. The viewing of training records provided evidence that four staff had not attended training in regard to Safeguarding Adults. Another four staff had attended this training, but now require this to be updated. A requirement has been made that all staff working at the care home must receive training in Safeguarding Adults. This will ensure that service users are protected from abuse. There are no current ongoing issues in regard to the Protection of Vulnerable Adults. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere. However, several areas around the home need attention to ensure residents continue to live a safe and well maintained the environment. EVIDENCE: A tour of the premises was undertaken during the site visit. The home is a large detached property set within its own grounds. Accommodation is provided for up to nineteen adults and is based on two floors. 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 summerhouse and is accessible to all the residents. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 20 Bedrooms were appropriately decorated, and residents had family photographs, televisions and other personal possessions. A lot of work has been undertaken to the environment of the home during the last eighteen months, which includes the refurbishment of the dining room, including new flooring. This enhances the relaxed atmosphere during meal times. A vacated storeroom has been converted into a secure medication room. One bathroom has been totally refurbished with a walk in shower. Communal bathrooms and toilets had liquid soap and hand driers had been installed. On the day if the site visit the ground floor bathroom was in the process of being refurbished by an external professional. The home has a three-year maintenance schedule that details work that is in the process of being undertaken on the environment. This includes a full redecoration of bedrooms, new carpets for the whole of the ground floor corridor, replacement of vanity units and repairs to windows. The home had an Environmental Health Organisation visit in October 2007. Only one recommendation was made during that visit, which the home has addressed. During the previous inspection it was stated that radiators should have protective covers fitted, unless the radiators are specifically of the low surface temperature type. The manager informed the Inspector that there are thermostats on the radiators. The Inspector was shown quotes for this work to be undertaken, however, this had not yet been commissioned by the home. The home has a three-year maintenance schedule that states radiator covers would be fitted in February 2008. A requirement has been made that the home must undertake risk assessments whilst awaiting the fitting of protective guards to the pipe work and radiators. Any remedial action found to be necessary must be taken. This will ensure the health and safety of residents and staff is safeguarded. It was noted that not all bedroom windows on the first floor had restrictors fitted. A requirement has been made that unnecessary risks to the health or safety of residents must be eliminated. Other identified areas around the home that require attention include: Two bedrooms visited during the site visit had a malodour that must be addressed to ensure the home continues to be clean and hygienic. Two bedrooms on the first floor at the front of the house require attention to the ventilation to prevent the build up of condensation to the windows. A requirement has been made that all the identified areas in regard to the environment must be attended to. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 21 It was observed that Control of Substances Hazardous to Health (COSHH) were in the food cupboard, however, the manager immediately removed these and stated these would be stored in the appropriate secure cupboard. There is a large garden to the rear of the premises that was spacious and appropriately maintained. On the day of the site visit the home was clean and tidy. Staff informed the Inspector that residents help the staff with the cleaning duties. One resident was observed helping in the kitchen after the meal times had finished. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff team supports residents to ensure their needs are met. Residents are not supported and protected by the home’s recruitment policy and procedures. Staff require further training to ensure they are trained and competent to do their jobs. EVIDENCE: The staff team consists of male and female staff. The manager informed the Inspector that there are two members of staff on duty during each shift, one of whom is a senior carer. The manager is on duty from 9:00am until 17:00, and is hands on during this time. The manager informed the Inspector that the proprietor also works at the home. Each night there is one waking night staff and one member of staff on call. The manager informed the Inspector that there is always a member of staff who has the minimum of NVQ level 2 on duty each shift. Discussions took place with the manager in regard to him having non – contact time built into his rota to enable him to attend to the managerial duties required of a registered manager. The manager stated that he would further discuss this with the proprietor. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 23 Staff at the home undertake the cooking and domestic duties with residents. The current residents living at the home are all ambulant and able to care for themselves. However, in light of the ageing population of the home, it is strongly recommended that the home undertakes a review of staffing levels now to ensure all cooking, domestic and training activities can be attended to with sufficient numbers of staff working at the home. Staff and resident surveys informed that there are always or usually enough staff on duty to meet the individual needs of residents. During discussions residents informed the Inspector that the staff look after them well, “They do a good job.” Three staff recruitment files were sampled during this site visit. It was noted that two files did not contain two written references; one file had an application form that did not provide a full employment history, names of two referees, dates of/or records for gaps in employment/study. An immediate requirement was made in regard to this, and these staff must not work unsupervised until these documents and records have been obtained. The Criminal Record Bureau reference numbers for all staff working at the care home are maintained in the office. The home does not have a written policy and procedure in regard to recruitment of staff. It is strongly recommended that the home develops a robust recruitment policy and procedure that will ensure the correct recruitment procedures are being fully followed by the home, therefore protecting residents living at the home. The manager informed the Inspector that two staff hold the NVQ level 2, and two hold the NVQ level 4, therefore the home meets with the National Minimum standards in regard to 50 of staff working at the home holding the minimum of an NVQ level 2. Evidence of NVQ and staff induction training was viewed on the staff files sampled. Other training has included the Mental Health Act, Aggressive Behaviour and Oral Care. Whilst viewing training records it was noted that staff had not attended the entire mandatory training as required. The majority of staff had attended training in regard to First Aid and Medication, four had attended Manual Handling and three had received Fire training, two of which now require updating. Training records shown to the Inspector evidenced that four staff had attended Food Hygiene training, one of which was in December 2002. Only one member of staff had attended training in regard to Infection Control. A requirement has been made in regard to this. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, however, issues in regard to complaints, training, staff recruitment and Health and Safety must be addressed to ensure the safety of residents is met. EVIDENCE: The manager has been working at the home since March 2006 and is registered with the Commission For Social Care Inspection. He is a qualified Registered Mental Nurse (RMN), and has kept his PIN number active. The manager informed the Inspector that he has thirty-six years working in the caring profession, most of which was with the Mental Health Service. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 25 The manager stated that he has undertaken training in regard to fire, first aid and the protection of vulnerable adults, and he holds the Diploma in Management Studies. The manager must attend to the issues raised in this report in regard to complaints, training, staff recruitment and Health and Safety. The Inspector had discussions with the manager in regard to completing the AQAA. The manager was advised to follow the guidance that is available, and ensure that he responds to all the National Minimum Standards that are highlighted in bold. The home conducts weekly meetings for all residents, minutes of which were viewed. A quality assurance questionnaire had been undertaken to ascertain the views of residents, and the home had a summary of the findings. The manager informed the Inspector that identified issues had been attended to, for example, the refurbishment of bathrooms and toilets. The manager stated that residents and/or their relatives are responsible for managing residents’ monies. All residents have their own bank or post office accounts. Records of money sampled for one resident were accurately maintained. The viewing of the accident book informed that there had not been any accidents at the home since May 2006. The home has a Health and Safety policy that was last reviewed in July 2006. Information provided in the AQAA informs that annual testing of Health and Safety equipment had been undertaken. The following were sampled during this site visit: Portable Electrical Equipment, Electrical circuits, Legionella, Passenger Lift and the Fire Detection and Fighting Equipment. The manager informed the Inspector that the Fire officer was due to visit the home, but this has now been rearranged for January 2008. Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13 (4) Requirement Risk assessments must be reviewed on all daily activities to ensure they detail the concern, action to be taken, dates and signatures, and must be reviewed regularly and when necessary. This will ensure that residents’ safety and well being is promoted and protected. Timescale for action 06/12/07 2. OP15 Sch 4 (13) 3. OP16 22 Records of food provided to all residents, including special diets, must be maintained to provide evidence that a satisfactory and nutritious diet is provided to all residents. The Complaints Policy and Procedures must be reviewed to ensure it contains all of the appropriate information. A copy must be supplied to any person acting on behalf of a resident. This will ensure that residents and their representatives’ views are listened to and acted upon. 06/12/07 06/12/07 Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 28 4. OP18 13 (6) All staff must receive training in Safeguarding Adults. This will ensure that residents are protected from abuse. The home must undertake risk assessments whilst awaiting the fitting of protective guards to the pipe work and radiators. Any remedial action found to be necessary must be taken. Restrictors must be fitted to all windows on the first floor. This will ensure that unnecessary risks to the health or safety of residents are eliminated. The identified areas around the home environment must be addressed as detailed in the report. This will ensure that residents continue to live in a safe and hygienic environment. The registered person must not employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended). This will ensure that residents are supported and protected by robust recruitment procedures. Training in regard to Manual Handling, Fire Safety, Food Hygiene and Infection Control must be provided to all members of staff. 06/12/07 5. OP19 13 (4) (a) (c ) 06/12/07 6. OP19 16 (2) (k) 23 06/01/08 7. OP29 19(1)(b) Schedule2 06/11/07 8. OP30 18(c)(i) 28/02/08 Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 29 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 OP7 Good Practice Recommendations Care plans should provide more detail in regard to the way in which residents prefer staff to support them in regard to their personal care. Staff should use the health care section in the care plans for the recording of all medical appointments. It is strongly recommended that the home undertakes a review of staffing levels now to ensure the future aging needs of residents living at the home can be met, and all cooking, domestic and training activities can be attended to with sufficient numbers of staff working at the home. It is strongly recommended that the home develops a robust recruitment policy and procedure that will ensure the correct recruitment procedures are being fully followed by the home, therefore protecting residents living at the home. 2. 3. OP8 OP27 4. OP29 Haven House (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast, Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 (Knaphill) DS0000013665.V347650.R01.S.doc Version 5.2 Page 31 - 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!