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Inspection on 16/12/05 for Havencroft Nursing Home

Also see our care home review for Havencroft Nursing Home for more information

This inspection was carried out on 16th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a comfortable homely environment. Some of the bedrooms have been personalised by the resident, and this helps to give a more homely appearance.

What has improved since the last inspection?

It was difficult to assess whether their had been any improvements since the last inspection, given the serious concerns highlighted at this visit. The home had not complied with the requirements from the last inspection.

What the care home could do better:

Care plans were in need of review, they failed to demonstrate the care needs of the residents and how nursing and care staff should deliver that care. Risk assessments were in need of further developing and review. Accident records were inaccurate and given the importance of these records. The home must ensure they notify the CSCI of serious accidents and incidents. Medication management was in need of review. Fire safety issues were raised for the home to address.

CARE HOMES FOR OLDER PEOPLE Havencroft Nursing Home Lea End Lane Hopwood Birmingham West Midlands B48 7AS Lead Inspector Chris Potter Unannounced Inspection 16th December 2005 12:00h 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 Havencroft Nursing Home DS0000004115.V273621.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. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Havencroft Nursing Home Address Lea End Lane Hopwood Birmingham West Midlands B48 7AS 0121 445 2154 0121 445 2159 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) Regal Care Limited Lesley Ann Owen Care Home 32 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (32), of places Physical disability (4), Physical disability over 65 years of age (32) Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2005 Brief Description of the Service: Havencroft is a large, Victorian, 3 storey residence which is located in the village of Hopwood, close to the boundary of the City of Birmingham. The home is registered to provide nursing care for up to 32 frail elderly people, who may have a physical disability. In addition, registration has been granted for up to 5 service users, over the age of 65 years who have a dementia type illness, and for up to 4 service users, between the ages of 55 and 64 years, who have a physical disability. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of one day and was undertaken by two regulation inspectors from the Worcester office of the Commission for Social Care Inspection (CSCI). The inspection lasted a total of 9 hours inspectors’ time. A part tour of the premises took place, residents’ care documentation, medication, health and safety records were reviewed. The inspection also focused on a complaint resulting from an incident that occurred between two residents. As a result of the inspection and investigating the complaint, serious concerns were raised and immediate requirement notices was issued for the home to address. Failure for the home to comply with the immediate requirement notice may result in the Commission for Social Care Inspection taking enforcement action. Following the inspection and immediate requirement notices, the registered provider and registered manager attended a meeting at the CSCI offices, and provided an action plan, and updated the CSCI with the action already taken to address the concerns. What the service does well: What has improved since the last inspection? It was difficult to assess whether their had been any improvements since the last inspection, given the serious concerns highlighted at this visit. The home had not complied with the requirements from the last inspection. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 6 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. Havencroft Nursing Home DS0000004115.V273621.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 Havencroft Nursing Home DS0000004115.V273621.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): 2 and 3 The assessment of need carried out prior to admission does not contain enough information to ensure the residents’ needs can be met. EVIDENCE: Five residents’ care documents was reviewed at the inspection. Given the homes category of registration the home must ensure that residents admitted are suitable for the homes registration. The pre-admission assessment must include all the appropriate information. From this assessment staff should be able to develop a care plan and appropriate risk assessments to ensure the residents care needs are met. All nursing and care staff must be competent to meet the care needs of all residents at the home. Residents are provided with a contract on admission to the home these contain relevant information to comply with the standard. Havencroft Nursing Home DS0000004115.V273621.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): 7,8 and 9 Care plans and risk assessments were insufficient, and therefore fail to protect residents - in that they did not give the necessary detail regarding residents’ care needs to ensure that staff are able to provide the level of input required. The management, recording and administration of medication must be improved to ensure that residents are not placed at risk. EVIDENCE: The residents’ care plans reviewed showed that they were not accurately reflecting their current care needs. One care plan stated that the resident was to be weighed weekly, this was being undertaken two monthly. This was to address the residents’ weight loss from admission and staff were not following the nutritional risk assessment guidance. Care plans and risk assessments were not being reviewed monthly or as the residents care needs changed. Care plans should be updated monthly. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 10 For one resident, a lot of details had not been completed on the care plan. No changes to the care plan or risk assessments had been undertaken even though the residents care needs had changed. Another resident’s care plan had requested daily reviews of their condition. This had not been completed. Some details in the daily entries should have resulted in the care plan and risk assessment being updated. This had not been actioned. Wound care records were poor and failed to demonstrate the progress of the wound. Accident records highlighted a number of shortfalls. Incidents involving bedrails were not risk assessed or evaluated to prevent reoccurrence. Incidents recorded in the residents’ daily records had not been recorded in the accident records. The home was failing to notify the CSCI of significant events as required under regulation 37. As part of the inspection the management and administration of medication was assessed. The inspectors were advised that no staff had received medication update training. The home must ensure that for all handwritten entries on the Medication Administration Record (MAR) have two staff signatures for accountability. Medication dispensed in boxes should record the date of opening to assist in auditing medication. The home should be able to account for every tablet and medicine in their control. It was not possible to audit medication given dates of opening had not been recorded. The home should also develop a protocol for any medication prescribed as PRN. The temperature of the clinic room was 27°C at the time of the inspection, which is too hot for the safe storage of medicines. The home was issued with an immediate requirement notice to address care plans, risk assessments and medication issues. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 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 the following standard(s): These standards were not reviewed at this inspection. EVIDENCE: Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 12 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 and 18 Polices and procedures are in place in relation to complaints which provide direction to residents and staff. EVIDENCE: One complaint was reported to the CSCI and this was reviewed during the inspection process. The complainant raised concerns relating to an incident that had occurred between two residents. The investigation raised concerns that staff did not have the competencies to meet the care needs appropriately for the one resident. The home also failed to report the incident under regulation 37 to the CSCI, and made no referral to the protection of vulnerable adults co-ordinator. All staff must receive training about the protection of vulnerable adults and whistle blowing. It was recommended that the resident be reassessed to establish if an alternative placement may be required. The home must ensure that all residents are within the homes category of registration. The manager assisted fully with the investigation and took action address the situation. The home has received no complaints directly since the last inspection. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 13 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): 19,21,22,23,24 and 26 There has been some progress since the last inspection to improve the standard of the environment. Further refurbishment and improvements are now necessary to ensure residents have a clean and safe place to live in. EVIDENCE: The home is a large Victorian building located in the village of Hopwood. It provides accommodation for residents in both single and shared bedrooms. The bedrooms had been personalised by the individual to provide a more homely appearance. The home provides lounges, dining facilities, specialist bathrooms and a passenger lift is fitted to assist residents to access all areas of the home. Many areas of the home’s decor appeared tired and carpets in parts were well worn. The manager stated that plans were in hand to extend the home and refurnish it throughout. The need to address some areas of decoration was Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 14 required. Some requirements from the last inspection had not been implemented. Bedroom locks have not been fitted on the residents’ bedroom doors, the manager stated that this was in hand. A window restraint was observed to be broken during the visit. The home should ensure that window restraints are checked regulalary and repaired urgently when broken. Toiletries were observed in the bathrooms that were not identified to an identified resident. To avoid the risk of cross infection, residents’ toiletries should be stored in their bedrooms. The home must develop an environmental risk assessment. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 15 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): 27 and 30 Staffing levels per shift appeared appropriate for the number of residents in the home. Staff had not received mandatory training to ensure they remain competent to meet the needs of the residents. EVIDENCE: The homes duty rota evidenced that the home is providing staffing levels in proportion for the number of residents in the home. The home use agency staff to maintain the staffing numbers. It was recommended that the home provide two nurses on some shifts to assist in maintaining the residents’ care documentation and management of medication. Training records evidenced that one member of staff had not received moving and handling training, nine staff had not received health and safety training, and nine staff had no food hygiene training. Eight staff had received some adult protection training. Six staff had completed a half-day first aid course. No staff had received dementia training even though the home was accommodating residents with dementia type illnesses. Fire training records evidenced staff had not received any training during 2005. An immediate requirement notice was issued on the fire training. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 16 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): 31 and 38 The management of health and safety must improve to safeguard both residents and staff EVIDENCE: The manager is appropriately qualified to manage the home. However given the concerns highlighted as a result of the complaint and inspection, it questions if the manager is appropriately supported. The need for a deputy manager and additional nursing staff was recommended to assist in improving the standards. The weekly fire testing records evidenced that since October 2005, the testing was not carried out in order and there were gaps when no drill had taken place. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 17 The home had no record of fire extinguisher visual checks taking place at the time of the inspection. The registered provider was requested to provide clarification regarding the electrical report dated 08/07/05. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 18 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 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 3 3 2 X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 1 Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 Requirement A written assessment must be completed before admission of any resident in accordance with the requirements of Regulation 14 and Standard 3 The residents care plan must be drawn up with the residents consent and must cover all aspects of Regulation 15 and Standard 7 All care plans must be reviewed at least monthly, and must reflect altered care needs. The home must ensure that all residents’ risk assessments are reviewed and updated more frequently. The home must ensure that suitable risk assessments are undertaken and accurate records maintained. The home must ensure that accurate accident / incident records are completed, and notify the CSCI of serious incidents. The home must be able to audit all medication in the home. To DS0000004115.V273621.R01.S.doc Timescale for action 16/12/05 2. OP7 15 31/01/06 3. 4 OP7 OP7 15 15 31/01/06 31/01/06 5 OP8 15 16/12/05 6 OP8 13 37 16/12/05 7 OP9 13 16/12/05 Havencroft Nursing Home Version 5.0 Page 20 8 OP9 13 9 OP16 22 10 OP18 12,13 11 12 OP19 OP19 23 23 13 14 15 OP24 OP38 OP26 16 23(4)(d) 13,16 16 17 18 OP19 OP26 OP38 13 13 23 19 OP38 23 assist this all boxes should be dated on opening. All handwritten entries on the Medication Administration Chart should have two staff signatures for verification. The complaints procedure must be amended to include timescales for dealing with complaints as specified in Regulation 22 and Standard 16 Procedures for responding to suspicion or evidence of abuse or neglect must be drawn up with the Public Disclosure Act 1998 and the Department of Guidance No Secrets. The carpet identified during the inspection must be replaced urgently. The registered person must supply the CSCI with a redecoration program prioritising both internal and external areas damaged from water leaks The home must provide suitable locks to enable residents to lock their doors if they wish to. The home must ensure all staff receive regular fire drill training. Policies on the control of infection must be drawn up to include the safe handling and disposal of clinical waste, dealing with spillages provision of protective clothing and hand washing An environmental risk assessment must be undertaken. All toiletries should be returned to residents bedrooms to avoid the risk of cross infection. The home must ensure that the weekly fire alarm test is carried out and an accurate record maintained. The emergency lighting records DS0000004115.V273621.R01.S.doc 16/12/05 20/02/06 16/12/05 31/01/06 31/01/06 20/02/06 16/12/05 28/02/06 31/01/06 16/12/05 16/12/05 16/12/05 Page 21 Havencroft Nursing Home Version 5.0 20 OP30 18 21 OP38 13 do not show action taken in the event of faults shown. The home must ensure that all staff have the appropriate skills through training to meet the care needs of the residents. The home must develop a system for ensuring window restraints are working. 16/12/05 16/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP27 Good Practice Recommendations It is recommended that the skill mix is reviewed to assist the manager to ensure that care plans, medication, staff supervision, staff training is being reviewed. Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Havencroft Nursing Home DS0000004115.V273621.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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