CARE HOMES FOR OLDER PEOPLE
Havengore House 27 Fairfield Road, Eastwood, Leigh On Sea, Essex SS9 5RZ Lead Inspector
Trevor Davey Unannounced 7th June 2005 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. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Havengore House Address 27 Fairfield Road, Eastwood, Leigh On Sea, Essex, SS9 5RZ 01702 529243 n/a ivan.anne.shum@lineone.nt Mrs Anne Sik Yee Shum & Mr Cheuk Wah Shum 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 registration, with number of places Zoe Benedetti CRH Care Home 20 OP Old Age (20 Places ) DE Dementia (4 Places ) Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Personal care to be provided for up to 20 older people aged 65 years and over. 2. Personal care to be provided for up to four older people aged over 65 years who have dementia. 3. Total number of residents for whom personal care can be provided must not exceed 20. Date of last inspection 7th February 2005 Brief Description of the Service: Havengore house is registered to provide personal care and accommodation for twenty older people over 65 years of age including four places for residents who have been diagnosed with dementia. The home is located at the end of a short private road of a quiet residential street in Eastwood. The premises are situated within a short walking distance of numerous bus routes which have direct links to really in Southend. The building is a converted an extended farmhouse in its own gardens and as such, provides spacious rooms many of which have ensuite facilities. A shaft lift has been provided. Residents in the home are encouraged to be involved in social activities both within the home and in the local community. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 7th of June 2005 lasting five hours. The inspection process included discussions with the Registered Provider and manager, five staff, two residents individually and other residents in groups. A tour of the premises took place and a sample of policies and records were inspected. Fifteen standards were covered and requirements and recommendations are listed at the end of the report. What the service does well: What has improved since the last inspection?
The management have updated personal-care records and have involved other professional health-care workers in this process. The standard of record keeping has improved since the last inspection and care staff are more involved and regularly supervised in maintaining up-to-date information. A number of staff has completed various training courses since the last inspection and other training days have been arranged. Maintenance safety certificates, which were out of date at the last inspection, have now been renewed. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 service operates a full admission and assessment procedure to ensure that perspective residents are suitably placed in accordance with individual needs to ensure the overall care and support can be provided. EVIDENCE: From sample checks made, pre-admission assessments had been completed which identified health and mobility needs as well as mental state, continence and the use of medication. Dietary needs and social interests were also recorded. Care plans had been drawn up as a result of this information, which had been reviewed, on a regular basis. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 Residents personal health, care and social needs are being appropriately recorded in individual care plans although some information relating to risk assessments had not been included. Respect for residents and their right to privacy was being upheld. EVIDENCE: Some of the residents spoken to confirmed that their care needs are discussed with them and the district nurse as well as other healthcare professionals, visit to give treatment as required. Residents were also positive in the support and care provided by staff which included washing and dressing whilst at the same time, they were encouraged to exercise their independence whenever possible. Staffs were observed to be responding appropriately in supporting residents during the inspection. Residents also stated that staff responded promptly when called upon both day and night. Care plans were detailed, easy to follow and most risk assessments had been included. The majority of these records had been reviewed each month. Some of the moving and handling assessments had not been dated or signed and a risk assessment for the use of the hoist had not been completed. Details of healthcare as well as visits and treatment provided by other healthcare professionals was recorded. Key workers are involved in completing and updating care plans which is monitored
Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 10 by senior staff. Log sheets for day and night had been completed on a regular basis. An occupational therapy assessment was also in place as well as turning and fluid charts where required. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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) 13 ,14 & 15 Residents are enabled to maintain regular contact with family/friends or representatives. They are actively involved and are consulted regarding their individual preferred daily routines and lifestyle in the home. EVIDENCE: Residents confirmed that they were involved in selecting meals for the menu and that alternatives were available. Some of the staff spoken to stated that residents were asked in meetings and also on a one-to-one basis regarding their preferred choice. On the day of inspection, there was a choice of three alternative meals for lunch. Records of meals provided were available for inspection. A number of the residents are taken out regularly by family and friends and a variety of social activities also take place and details were available on the notice board. Relatives meetings take place every six months, which are well attended, and copies of the minutes were made available for inspection. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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) 16 & 18 There is an established complaints procedure of which residents are aware. Policies are in place for the protection of residents from abuse, which includes the staff whistle blowing procedure. EVIDENCE: There have been no complaints recorded since the last inspection. A copy of the homes complaint procedure is included in the Service User Guide, copies of which had been given to all residents. Some of these copies were seen in residents bedrooms. A copy of the homes Prevention of Abuse Policy and Whistle Blowing Procedure was made available for inspection. Records were available to show that eight staff had received training in the prevention of abuse to vulnerable adults. The manager stated that these issues are also covered in staff induction and supervision. Residents spoken to stated that they felt safe in the home. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 & 22 The overall standard of furnishings, decor, cleanliness and fitments within the home is of a satisfactory standard, although some areas are required to be made safe and secure for residents. EVIDENCE: Ongoing internal decoration takes place within the premises and on the day of inspection, a new carpet was being laid in the main lounge. The management are in the process of creating more accessible areas in the grounds for the use of residents. Given that some of the residents have been diagnosed with dementia and are liable to wander, the management must ensure that the grounds and the buildings are secure. On the day of inspection it was noted that the side gate was left open which poses a risk to residents who may leave the home unnoticed. In addition, the front door has no alarm fitted to alert staff should a resident leave and expose themselves to danger on the main road. It was also noted that the door on the first floor leading to the external fire escape had no warning alarm which could endanger a resident who may try to negotiate the external fire escape unsupervised. Since the last inspection, handrails for the corridors had been delivered and were waiting to
Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 14 be fixed to the wall. One of the handrails had been installed but this was unsafe and the inspector advised the Registered Provider and manager that this should be made safe in order minimise the risk of residents falling. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 & 30 Given the dependency levels of residents in the home at the time inspection, the levels and experience of staff was adequate. EVIDENCE: A staff rota was available which showed three care staff, including the person in charge, on duty for the early and late shifts respectively. The manager is supernumerary for three days per week from 8 30 a.m. to 5 p.m. or 9 a.m. to 4 p.m. A deputy manager is also available to cover for the manager. In addition, the Registered Provider is in the home on a regular basis. There is two ‘awake’ staff that covers the night duty. Two domestic staff and Cooks are also employed. The inspector advised the manager that as dependency levels increase, additional care hours may have to be provided. Records were available of courses and training, which had been completed by staff, which included first aid, food hygiene and awareness of dementia. There was no recent training, which had been undertaken by staff in respect of moving and handling and the correct use of a hoist. The manager is to make arrangements for staff to receive refresher training as soon as possible. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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) 35 & 38 There was an awareness of the importance of safeguarding residents interests and financial arrangements. Appropriate health and safety arrangements for the welfare of residents were in place but moving and handling training needs to be updated as well as infection control procedures. EVIDENCE: A record of transactions in respect of residents personal allowances were made available for inspection and sample checks made, showed that balances were correct. Two staff signatures had been recorded and receipts were available. Residents have lockable drawers in their rooms and families also safeguard money on behalf of many of the residents. As already mentioned in this report, staffs needs to be updated in moving and handling techniques . Although the home does have policies on infection control procedures, it was recommended to the manager that contact be made with the Essex Health Protection Unit to review procedures and update practice where this may be necessary.
Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x 2 x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 2 Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 18 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 7 & 38 Regulation 13(5)(4) 15(2) Requirement Timescale for action 20/07/05 2. 19 23(2) 3. 22 & 38 23(2) 13(4) The Registered Person shall make suitable arrangements to provide a safe system for moving and handling service users and ensure that any unnecessary risks are identified and eliminated. Care plans and risk assessments must be kept under regular review. The Registered Person shall 20/07/05 having regard to the number and needs of the service users, ensure that external grounds are safe for use and secure. The Registered Person shall 31/07/05 having regard to the number and needs of the service users ensure that the physical design and layout of the premises to be used as the care home meet the needs of the service users. All parts of the home to which service users have access are so far as reasonably practicable, free from hazards to their safety. This includes the fitting of suitable support rails along the corridors and providing an alarm device on the front door and the door on the first floor leading to the external far escape.
Version 1.30 Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Page 19 4. 30 18(1) The Registered Person shall, 1/09/05 having regard to the size of the care home, the statement of purpose and the number and needs of service users, ensure that the persons employed at the care home received training appropriate to the work they are to perform. Updated training must be provided for moving and handling techniques, including the use of the hoist. 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 38 Good Practice Recommendations Contact should be made with the Essex Health Protection Unit for up-to-date advice on infection control procedures within the home. Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Havengore House I56 - I06 S51663 Havengore House V231884 070605 Stage 4.doc Version 1.30 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
