CARE HOMES FOR OLDER PEOPLE
Havendene 2 Front Street Prudhoe Northumberland NE42 5HH Lead Inspector
Mary Blake Key Unannounced Inspection 09:00 6 September 2006
th 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.V289899.R01.S.doc Version 5.1 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.V289899.R01.S.doc Version 5.1 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.V289899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Havendene is situated in the centre of Prudhoe with easy access to its services. The home was a former vicarage that has been converted and extended 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 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. The current weekly fees are £336 to £378. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day and involved one inspector. All of the key standards have been assessed during this visit and from other information provided to the Commission. Residents care records, staff rota plus additional statutory records were examined. The Proprietor, Registered Manager, deputy, three staff, two ancillary staff and twelve residents and one relative were spoken to. Four resident questionnaires and three relative questionnaires were received prior to the inspection. The majority were satisfied with the care provided What the service does well:
Staff were kind and considerate when helping residents. Residents explained the admission process; this includes a gradual introduction to the home and a detailed pre-admission assessment. This helps new residents adjust and settle into living in the home. Residents, where able, described good relationships with the staff and said they were all polite and helpful. Staff were friendly and relaxed and showed a good understanding of residents needs. Arrangements for residents to maintain contact with their family and friends are good. Visitors confirmed that they are always made welcome and kept informed and involved. The home provides a consistent, well trained staff team, which provides continuity and reassurance to residents. The staff have a good understanding of residents individual needs. The residents and relatives were very complimentary about the staff. For example “they are lovely girls” “staff are very helpful” “they have helped me feel at home” “ I am very happy here ”. Meals are varied, well balanced and nicely presented offering good choice and nutritious food at all meals. All of the residents and relatives spoken to were pleased with the quality and choice available. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 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.V289899.R01.S.doc Version 5.1 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.V289899.R01.S.doc Version 5.1 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, 4, 5 6 not applicable Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home undertakes a detailed pre admission assessment and liaises with the residents and family prior to admission. Satisfactory pre-admission assessments are undertaken and developed further in the care plan. EVIDENCE: Pre-admission assessments are undertaken and reflect the needs of the residents. Care plans had good information to ensure that the home can meet the needs of the prospective resident. The Manager is involved in the decisions and in the majority of instances visits the residents herself prior to their admission. A resident spoke of their relative visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier.
Havendene DS0000000629.V289899.R01.S.doc Version 5.1 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): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The residents are having their needs met by the staff in the home and the staff are skilled in providing the care in a sensitive and dignified manner. This is shown in the documentation and care plans in place. The residents receive their prescribed medication in line with safe working practices. EVIDENCE: Three care plans were examined; they were of a good standard, with relevant risk assessments for the prevention of falls, nutrition, moving and assisting, continence promotion. The plans are regularly reviewed and updated. The care plans showed that the residents have access to all NHS services and facilities. A number of assessment tools are in use they were reviewed monthly and were dated and signed by care staff. Daily reporting of residents
Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 10 care was satisfactory with the changing health care and mental health care of residents being reviewed and up dated. The medicines in the home are well managed and safely disposed. The medicines were stored safely within the new drug cupboards and stock control had improved reducing risk to residents. The controlled drugs procedures were satisfactory. These systems ensure that residents receive their medication in a safe and appropriate way. Staff were treating residents with respect and dignity. Personal care was given in privacy. Staff used residents preferred name at all times. Residents, where able, were complimentary about the staff in the home and felt that they were able to have privacy in their own rooms. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 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): 12,13,14,&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the flexibility of their routines for daily living and activities. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. Social activities are in place and enjoyed by residents. The food served is good and the residents are happy with the quality and the quantity. EVIDENCE: Residents were generally happy and enjoyed being able to move freely around the home. The home has an activities co-ordinator who is very committed and enthusiastic. A good rapport between residents and the activities person was observed. Residents were enjoying listening to music, dancing, playing ball games and having a visit from the pat dog, a scheme, which gives residents opportunity to meet, and stroke trained dogs, which they thoroughly enjoyed. Residents did not have sufficient information recorded about their social interests. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 12 The residents are encouraged to go to places in the local area and families are encouraged and supported to take residents out and about. Residents take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. All residents, who could, said that they are able to make choices about how they spend their day. The residents’ bedrooms were personalised reflecting individual choices and preferences. Residents said they were happy with the decoration. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. The meals served were good and all of the residents enjoyed the food, which was well cooked. Staff support was on hand. The tables were nicely set and lunch was seen as a social occasion. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 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): 16 & 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home ensures residents and relatives are aware of the complaints policy by making it available in a variety of places. Complaints are managed satisfactorily and the necessary action taken. Staff had completed training in the Protection of Vulnerable adults and this is necessary to ensure that residents are protected. EVIDENCE: The complaints procedure is displayed in the home. The records of the complaints made to the home was examined and was satisfactory. Two of the residents said that they knew problems were dealt with and how this would be done “everyone is approachable”. A relative visiting the home was aware of the complaints procedure but had not needed to use it. The Manager stated that all staff were aware of the whistle blowing policy and informing the Manager of any incidents or issues of which there are concern. Staff confirmed this. Staff had completed Protection of Vulnerable Adults training. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 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 & 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The residents live in a safe environment. There are good communal areas. There are suitable toilets and baths. The bedroom areas are personalised and comfortable. The home is clean, pleasant and hygienic. EVIDENCE: The location and layout is suitable for the residents who live here. There are lounges and dining rooms on each floor. They are pleasantly decorated and furnished. Residents were able to use the entire home and there was a range of television and audio equipment available for their use. There are bathrooms, shower facilities and toilets near to all communal areas and residents bedrooms. The residents have been encouraged and supported to bring personal items with them resulting in individualised rooms reflecting personal taste and previous lifestyles.
Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 15 The communal areas of the home are well decorated, maintained and clean. A number of resident’s bedrooms were seen these were personalised. Those parts of the home that were seen were clean and hygienic with no obvious smells or odours. There was good domestic support and care staff manage the laundry, residents were complimentary about the cleanliness of the home and laundering of their clothes. The laundry was inspected and was clean, tidy and well organised. Staff had a good knowledge of safe hygiene practices. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 16 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, 28 29 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager ensures there are adequate numbers of staff on duty that have appropriate skills and experience to care for the residents. External and internal training takes place and the recruitment processes in place protect residents. EVIDENCE: Staffing rotas showed that there are enough staff are on duty to meet the necessary staffing levels. Staff had undertaken mandatory, National Vocational Qualifications in Care and other training. Staff said that they are undertaking or had completed National Vocational Qualification in Care level 2 or over and the home has an induction and training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of residents. There had been improvements to the organisation of staff training files enabling the manager to have a clear overview of staff training needs. Recruitment files were not examined, as no new staff had been appointed and records were satisfactory at the previous inspection.
Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 17 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): 31,33,35,36,37 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in a home, which is well run and managed by an experienced person. The Manager has systems in place to organise the home taking into account the needs and wishes of the residents. Quality systems are established and developed. Resident’s financial interests are safeguarded. Staff are appropriately supervised The health, safety and welfare of residents and staff are generally promoted or protected. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 18 EVIDENCE: The residents and staff made positive comment about the Registered Manager and staff team; they gave examples of improved practices for example dining was a more relaxed and social occasion following the reorganisation of the rooms and staff support, and of the staff team taking time to listen and respond to any concerns they may have. Accidents are recorded effectively with management overview being completed and risk preventions being undertaken to safeguard residents Resident monies records were checked; there was evidence of regular personal expenditures, with two staff signatories for all transactions. Money balances were checked and found to be correct. Receipts were available. Records of staff supervision records showed a comprehensive process and that the timescales of six per year would be met. System testing had been undertaken and maintenance certificates available except for Portable electrical appliances and landlords gas certificates, which was not available. Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 19 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 20 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 OP12 Regulation 16(2)(m) Requirement The Registered Manager must consult with, and record, resident’s social interests within the care plan. The Registered Manager must ensure that satisfactory staff fire training must be in place, staff must undertake fire drills at the timescales of three monthly for night staff and six monthly all others The Registered Provider must provide evidence of a) Portable Electrical Appliance Testing b) Landlords Gas safety certificate Timescale for action 01/12/06 2 OP38 23(4)(e) 01/12/06 3 OP38 23(2)(c) 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Havendene DS0000000629.V289899.R01.S.doc Version 5.1 Page 21 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
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