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Inspection on 21/07/05 for Havencroft Nursing Home

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

This inspection was carried out on 21st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

A number of residents in the home required intensive nursing care, this was given in a highly professional manner, which promoted privacy and dignity. Residents told the inspector they were happy and one resident said `you could not come to a better home`.

What has improved since the last inspection?

The registered manager continued to ensure residents needs were met; training was in place to ensure staff were equipped with the required training to meet residents needs and there was a continual programme of upgrading of the premises.

What the care home could do better:

Care plans seen needed further development to ensure the care needs of residents were reflected in care plans. Further planned refurbishment of the home will enhance the communal and living areas of the home.

CARE HOMES FOR OLDER PEOPLE Havencroft Lea End Lane Hopwood, Birmingham West Midlands B48 7AS Lead Inspector Chrissy Presley Unannounced 21 July 2005 1.50PM 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. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Havencroft Address Lea End Lane, Hopwood, Birmingham, West Midlands B48 7AS 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) 0121 445 2154 Regal Care Limited Lesley Ann Owen Care Home 32 Category(ies) of OP Old Age both genders (32) registration, with number PD(E) Physical disability over 65 both genders of places (32) DE(E) Dementia over 65 both genders (5) PD physical disability both genders (4) Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31 January 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.The stated aim of the home is to provide the best quality of life for service users in an environment which is clean, comfortable, safe and welcoming, and where people are treated as individuals, with respect and sensitivity.The Company owns nursing homes in Darlaston, Wolverhampton, Liverpool, and also South Hayes Nursing Home in Worcester. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during an afternoon. A tour of the premises, care records and policy and procedure documents were inspected. Five residents, one visitor and two staff were spoken to during the inspection. The inspection lasted four hours. What the service does well: What has improved since the last inspection? What they could do better: Care plans seen needed further development to ensure the care needs of residents were reflected in care plans. Further planned refurbishment of the home will enhance the communal and living areas of the home. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 6 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 E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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) 3 The assessment of need documentation seen did not contain enough information to ensure resident’s needs could be met on admission. EVIDENCE: Three assessment of need documents were seen, the information gathered and written during this time did not ensure that the home could meet the residents needs and did not contain enough information to formulate a care plan. The registered manager agreed further work on the documentation needed to take place. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 & 10 Care plan documentation did not reflect current care needs of residents, these shortfalls have potential to put residents at risk. EVIDENCE: Residents were well cared for and told the inspector they were happy and could not ask for better care. Four care plans were inspected and although these appear to have been updated they did not reflect the current care needs of residents and an immediate notice was left with the home to ensure these were updated within 24 hours. The registered manager told the inspector she was trying to involve families and residents in reviews of care plans this was proving difficult. There was evidence of multidisciplinary team working which included the infection control nurse, the tissue viability nurse and the community psychiatric nurse. Staff were observed interacting with residents in a positive an inclusive manner. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 10 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 &15 Residents were offered a stimulating programme of activities. A varied menu, which was nutritionally wholesome, was offered to residents. EVIDENCE: Residents on the afternoon of the inspection were observed enjoying a sing along with an external entertainer who visited the home weekly. Further entertainment was offered every Friday and a member of staff told the inspector she had never worked in a home where there was so much entertainment offered. A number of residents were planning a day trip the following day; the home has access to a disabled bus from another home within the group. The Roman Catholic priest visited on request and Communion was offered on request. Menus seen appeared to offer a wholesome and nutritious diet. Further development regarding records of food given to residents was necessary. Residents spoken to said they enjoyed the food particularly one resident who had had strawberries and cream for pudding. Residents who need full assistance with food were offered this in a dignified manner. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 12 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 policies and procedures for the protection of the vulnerable adult were not robust and there was no assurance that residents would be protected from abuse. The complaints procedure requires further development to ensure resident’s complaints are listened to. EVIDENCE: The complaints policy had reference to the National Care Standards Commission and did not contain any time scales. Residents spoken to said they would not be afraid to complain. The policies and procedures for the protection of the vulnerable adult was not robust and needed further development. Staff were receiving training in the protection of the vulnerable adult and staff had a good understanding of their responsibilities in protecting. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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) 19,24 & 26 The home provides warm, safe and comfortable accommodation for residents. EVIDENCE: There were some areas around the home, which needed attention, and immediate requirements were left with the home. Further environmental requirements were made following a tour of the premises, which could potentially compromise the health and safety of residents. The infection control policy needed to be further developed to ensure staff were aware of their responsibilities. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 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 Staff in the home cared for residents well and had training appropriate to the care needs of residents. EVIDENCE: Staff were employed in enough numbers during the day and night to care for residents. Staff spoken to felt there was enough time to care for residents and spend time talking with them. The home had a full compliment of domestic, laundry and catering staff seven days per week. It was noted that during the course of the inspection a member of staff was employed who had not had a Protection Of Vulnerable Adult register clearance check. An immediate notice was left with the home. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 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 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) 37 & 38 The home was well managed by the experienced manager who ensured the health and safety of resident’s, staff and visitors to the home. EVIDENCE: The registered manager is the health and safety officer and is a registered nurse. Her deputy manager ensured that all staff had received mandatory training in moving and handling, fire safety, first aid, food hygiene and infection control. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 17 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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 3 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 18 YES 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 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. Records of food given to residents must be kept and be open to inspection The complaints procedure must be ammended 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 negelect must be drawn up with the Public Disclosure Act 1998 and the Department of Guidance No Secrets. Fire doors must not be wedged open with devices that do not conform to fire regulations The carpet identified during the Timescale for action 30/08/05 2. OP7 15 15/08/05 3. 4. 5. OP7 OP15 OP16 15 17 Schedule 4 22 Immediate 31/07/05 30/08/05 6. OP18 12,13 30/08/05 7. 8. OP19 OP19 23 13 Immediate notice Immediate Page 19 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 9. 10. 11. 12. OP19 OP19 OP19 OP24 13 13 16 16 13. OP24 12,13 14. OP24 12,13 15. OP26 13,16 16. OP38 23 17. OP37 26 rinspection must be risk assessed immediately and replaced within 2 weeks. The cupboard containing hazardous products must be kept locked at all times The bolt on the outside of the sluice door must be removed and a keypad lock fitted The carpets in the communal rooms must be deep cleaned or replaced All the items of furniture specified in standard 24.2 must be provided in rooms occupied by residents. If the provision of any item poses an unacceptable risk to the resident or they decline the provision, details of the discussions about the decision must be recorded in the assessment of the residents needs. Residents must be provided with keys to their bedroom doors unless a risk assessment suggests otherwise Residents must be provided with lockable storage space for medication, money and valuables and a key which he or she can retain (unless the reason for not doing so is explained in the care plan) 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 There must be evidience that all staff have been involved in a fire drill or had fire training every three months Visits to the home by the registered provider must take place at least once a month in notice Immediate Notice Immediate 30/08/05 30/09/05 30/09/05 30/09/05 30/08/05 Immediate 30/08/05 Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 20 18. OP37 26 19. OP29 17 20. OP38 13 accordance with the requirements of Regulation 26. The person carrying out the monthly visit on behalf of the registered provider must prepare a written report on the conduct of the care home and supply copies to the Commission, the registered manager and the registered provider in accordance with the requirements of Regulation 26. Staff must not be employed in the home unless a POVA first check has been carried out and a risk assessment is in place for those staff members under the age of 18. An environmental risk assessment must be carried out. 30/08/05 Immediate requiremen t. 30/09/05 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 OP18 Good Practice Recommendations A policy should be developed and implemented regarding residents money and financial affairs, and preclude staff involvement in assisting in the making and benefiting from residents wills. Havencroft E52 S4115 Havencroft V232418 210705.doc Version 1.40 Page 21 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 E52 S4115 Havencroft V232418 210705.doc Version 1.40 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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