Inspection on 31/01/06 for Havendene

This inspection was carried out on 31st January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Havendene 23/09/08

Havendene 06/09/06

Havendene 20/05/05

Havendene 23/11/04

Havendene 26/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Havendene 2 Front Street Prudhoe Northumberland NE42 5HH Lead Inspector Mary Blake Unannounced Inspection 09:00 31 January 2006 st 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 Havendene DS0000000629.V249969.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. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Havendene Address 2 Front Street Prudhoe Northumberland NE42 5HH 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) 01661-835683 Mrs Marylynn Liddell Mrs Elizabeth Ann McDine Mrs M Westgarth Care Home 25 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (7) of places Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th May 2005 Brief Description of the Service: Havendene cares for 25 people in a two storey detached property. It is set in a residential area in the centre of the town of Prudhoe. The home is on two floors with a passenger lift to all levels. There are a variety of aids and adaptations to allow service users to move freely around their part of the home. The majority of bedrooms are single, with communal bathing and toilet facilities situated around the home. There is sufficient communal lounge and dining space. The home is close to local amenities and transport networks. Havendene is registered to provide residential care for frail older people and older people with dementias Havendene DS0000000629.V249969.R01.S.doc Version 5.0 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 previously 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, the second of the year and took place over one day. A full tour of the premises was carried out. Residents care records, staff files, medication systems, fire records plus additional statutory records were examined. The owner, three staff, cook and eight residents were spoken to. What the service does well: It was observed that staff were kind, considerate and supportive to residents. Staff were friendly and relaxed with the inspector and were keen to discuss their work and the residents care needs. Meals are varied, well balanced and nicely presented offering good choice and nutritious food at all meals. Staff and residents commented upon the improvements to social activities. Manager and staff have begun to address the specific needs of people with dementias. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Havendene DS0000000629.V249969.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 Havendene DS0000000629.V249969.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): 3 was previously assessed and met. EVIDENCE: Havendene DS0000000629.V249969.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 & 11 previously assessed and met. 7 & 9 assessed and not met.10 Residents care plans do not set out their individual mental health needs. Residents are not protected by the homes policies and procedures in dealing with medicines. Residents feel that their privacy was respected and that staff treat them with respect. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 10 EVIDENCE: Examination of resident care plans showed that these continue to improve and are regularly reviewed and updated. There was insufficient information about the mental health needs of one resident. The examination of the ordering, storage, administration and disposal of medication was unsatisfactory. The following issues were identified • Storage of medication was unsatisfactory the cupboard was very messy, with out dated medicines and medication of ex residents. • Loose and unlabelled tablets were evident. • Stock control appeared haphazard • Medication administration record was not accurately completed with high instances of medication not administered without any reason given. • Recordings within the MAR record were not always clear Staff had undertaken training in the safe administration of medication Residents spoke of staff giving them privacy but also supporting their independence and that staff were respectful in their dealings with them. This was also observed during the inspection. Havendene DS0000000629.V249969.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): 12 & 13 previously assessed. 14 & 15 assessed and met. Residents are supported to maintain contact with family, friends and the local community of Prudhoe and to maintain choice and control over their lives, where able. The menu, food choices and quality of food on offer were good and sufficient to meet the needs of residents. The meals offer choice, variety and good nutrition. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 12 EVIDENCE: Residents and families spoke of bringing in personal possessions, of being involved with their care plans and of maintaining contact with family and friends. Residents stated that they are able to choose from the menu with the cook consulting with individuals about any variation or preferences. Meals are varied, well balanced and nicely presented offering good choice and nutritious food at all meals. All of the residents spoken to were more than pleased with the quality and choice available. Good quality fresh vegetables and food were seen and residents commented that the food being served was always fresh, nutritious and tasty. Meals are taken in pleasant, well-lit dining rooms, with well laid tables, with good staff attendance and supervision. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 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 the following standard(s): 17 previously assessed and met. 16 was assessed and met. 18 was assessed A satisfactory complaints system was in place and residents appeared confident that their concerns would be listened to, taken seriously and acted upon. Residents are not fully protected from abuse. EVIDENCE: The home has a complaint procedure, which is displayed. Examination of the complaint record indicated that there had been no recorded complaints since the previous inspection. The Commission has not been asked to investigate any complaints since the last inspection. Previous discussions with the residents/families indicated that they felt confident with the Registered Manager and how she responds to any concerns they raise. Records indicated that seven staff have undertaken the one day training on the Protection of Vulnerable Adults. It was unclear when the majority of the staff team would undertake this training, this must be addressed. Allegations or cause for concern within the home have been appropriately acted upon. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,23,24,25 & 26 were previously assessed and now met. EVIDENCE: Havendene DS0000000629.V249969.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 previously assessed. 29 was assessed and met. 30 was assessed and not Residents are safe and protected by the home’s recruitment policy and practices. It was not clearly evident if staff are trained and competent to do their jobs. EVIDENCE: There have been a consistent staff team with minimal turnover. From examination of two staff files adequate recruitment and induction procedures are in place. It was unclear from the two staff training files examined if staff have undertaken mandatory, NVQ and other relevant training in meeting the care needs of older people. It was agreed with the proprietor that a training plan would be submitted outlining achieved and projected training for all staff. This would also include POVA and dementia training. 8 staff have NVQ 2 or above and 1 staff is undertaking NVQ level 2, a shortfall in the standard. Havendene DS0000000629.V249969.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 & 38 previously assessed and met. 35 assessed and met. 33 assessed and The home is generally run in the best interests of the residents but the quality assurance and monitoring systems should be improved. Resident’s financial interests are safeguarded. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 17 EVIDENCE: It was evident from inspection and residents comments that the Registered Manager had sufficiently overviewed the standards within the home and continues to improve the quality of life of the residents. Basic quality assurance systems are in place and have involved family/resident surveys. This was discussed with the proprietor and a recommendation made. Examination of two residents financial records indicated that these were appropriately documented, signed, individually kept and securely stored. Havendene DS0000000629.V249969.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 X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 19 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 OP37OP7 Regulation 15 Requirement The registered person must ensure that mental health needs are identified and recorded within the care plan. To review the storage, administration and recording of medication. To forward a full staff training plan outlining dates of attendance at mandatory, NVQ, POVA and dementia training. Timescale for action 01/04/06 2 3 OP37OP9 OP30OP18 13 2 13 6 18 1 15/03/06 01/04/06 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 OP30 OP33 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 To review the internal quality assurance systems and the use of internal resident/supporters questionnaires. Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office 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 © 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 Havendene DS0000000629.V249969.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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