CARE HOMES FOR OLDER PEOPLE
Havendene 2 Front Street Prudhoe Northumberland NE42 5HH
Lead Inspector Mary Blake Unannounced 20th May 2005 08:30. 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. Havendene Version 1.10 Page 3 SERVICE INFORMATION
Name of service Havendene Address 2 Front Street Prudhoe Northumberland NE42 5HH 01661 835683 N/A N/A Mrs Marylynn Liddell & Mrs Elizabeth Ann McDine Mrs M Westgarth CRH 25 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) Category(ies) of DE(E) Dementia - over 65 (18) registration, with number OP Old age (7) of places Havendene Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd November 2004 Brief Description of the Service: Havendene is situated in the centre of Prudhoe with easy access to its services. Converted from a vicarage an extension was added to create a home that is registered to provide care for 25 older people, of which 18 may have dementia. The home is on two floors with passenger lift to all levels, there are a variety of aids and adaptation to allow residents to move freely around the home. There is a car park at the front of the building and disabled access to the front door. The home does not provide nursing care. Havendene Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The registration of the home has changed to provide mainly for residents with dementia, this was discussed with the owner and manager and it was agreed that policies, procedures, training and practices would be reviewed to reflect these changes. The inspection was unannounced and took place over one full day. A full tour of the premises was carried out. Residents care records, staff rota, fire records plus additional statutory records were examined. The owner, manager, three staff and eight residents were spoken to. What the service does well: What has improved since the last inspection?
Decoration and furnishings have continued to improve and those areas are starting to look more welcoming and homely. The plan to refurbish the toilets and bathrooms is progressing and these were more practical and comfortable. The layout of the furniture and use of memorabilia, photographs, books and music within the lounges had made these rooms a pleasant space for residents to relax and socialise. Havendene Version 1.10 Page 6 Individual care plans have continued to improve and it was apparent that staff were more involved in planning and evaluating care. Staff and residents commented upon the improvements to social activities. Manager and staff have begun to address the specific needs of people with dementias. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Havendene Version 1.10 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 Havendene Version 1.10 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, Havendene do not provide intermediate care. Residents have the opportunity to visit the home prior to admission and generally satisfactory pre-admission assessments processes were in place in order to meet their needs. The pre-admission assessment did not provide sufficient information on the mental health needs of residents. EVIDENCE: Discussion with residents, staff and the manager confirmed that their care needs had been assessed prior to admission, however there was insufficient information on the mental health care needs of residents. Individual records for residents were examined for the last two admissions and assessments had been undertaken however these did not contain enough information about mental health needs. Havendene Version 1.10 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 & 11 The health and personal needs of residents were met and are kept under review. Individual care plans continue to improve. Staff use care plans to meet personal needs and are involved in completing them. Residents and their families are involved with their plans. Residents’ nutritional needs were adequately addressed. There was sufficient evidence of assessment, staff actions and recording in relation to individuals requiring nutritional support. Residents and families are reassured, that at the time of their death, their needs will be met with care and respect. EVIDENCE: Individual residents plans of care were examined and have continued to improve. These had been appropriately reviewed and updated with residents and their families involved in the plan.
Havendene Version 1.10 Page 10 Residents are weighed monthly and nutritional risk assessments are carried out. Residents were observed enjoying a meal that was tasty and nutritious, all commented on the quality and range of food served. A range of risk assessments are undertaken, residents have regular access to other health services such as doctor, district nurse, dentist, chiropodist and optician. Regular in house reviews had been undertaken. Staff had sensitively sought resident’s funeral wishes and this was documented within the care plans. Havendene Version 1.10 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 &13 Social care needs, recreation and stimulation are adequate. Residents are supported to maintain contact with family, friend and their local community. EVIDENCE: A number of residents said that the social and stimulating activities on offer had improved. These have been organised by staff, as the home does not have a social activities co-ordinator. Residents spoke of making decisions about visitors, of going into town and visitors were observed to see residents in private. Havendene Version 1.10 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 standard(s) 17 Resident’s rights to participate in political processes are upheld. EVIDENCE: Staff and residents spoke of their participation, where able, in the recent election process. Havendene Version 1.10 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 standard(s) 19,20,21,23,24,25 & 26 Improvements had been made to the décor, layout of the lounges and toilet/bathrooms. The home and external grounds were well maintained. Residents live in comfortable rooms with their own possessions. Insufficient risk assessments are in place for the safety of residents within the home. Residents live in safe and comfortable surroundings, which are clean, pleasant and hygienic, however insufficient hygiene systems are in place for hand washing. EVIDENCE: Havendene Version 1.10 Page 14 Since the last inspection the home had continued with the redecoration programme and residents and staff commented on these changes. A tour of the building and grounds indicated that the home was well maintained, continues to improve and was clean and free from offensive odours. The standards of cleanliness were high but towels and soap were used within communal toilets and bathrooms. These should be replaced with liquid soap and paper towels. Bedrooms were well decorated and personalised with residents commenting about having their own possessions. Upper floor windows did not have restrictors fitted and it was agreed with the owner and manager that risk assessments would be taken and restrictors fitted if necessary. Havendene Version 1.10 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 Resident’s needs are met by the number and skill mix of staff at the home. EVIDENCE: Discussions with the Manager, staff and examination of the staffing rotas confirmed that the home has remained consistently staffed, both during the day and night. All residents spoken to said that staff were kind and considerate. Havendene Version 1.10 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) 31 & 38 The Registered Manager’s leadership has been consistent and has ensured that residents receive consistent quality care. This has resulted in practices that have promoted and safeguarded the health, safety and welfare of the people using the service. EVIDENCE: The residents and staff made positive comment about the Registered Manager and staff team, residents gave examples of improved practices. It was evident from inspection and residents comments that the Registered Manager had sufficiently overviewed the management of the home. Havendene Version 1.10 Page 17 Inspection of records indicated that testing of fire equipment, regular fire drills and instruction had taken place and a fire risk assessment was available (this was due for update). Havendene Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x
COMPLAINTS AND PROTECTION 3 3 3 x x x 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 x 3 x 3 x x x x x 3 3 Havendene Version 1.10 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 1 Requirement The registered person must ensure that mental health needs are adequately addressed in the preadmission assessment. Risk assessments must be undertaken for the safety of upper floor windows and restrictors be fitted as required. Timescale for action 1st July 2005 1st June 2005 2. OP19 13(4)a 3. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP31 OP28 OP26 Good Practice Recommendations The Registered Manager to complete the Registered Managers Award by 2005 50 of care staff to have obtained NVQ 2 by 2005 Provide liquid soap and paper hand towels to all toilets and bathrooms Havendene Version 1.10 Page 20 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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