CARE HOMES FOR OLDER PEOPLE
Havengore House 27 Fairfield Road Eastwood Leigh On Sea Essex SS9 5RZ Lead Inspector
Mr Trevor Davey Unannounced Inspection 8th November 2005 10:00 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 Havengore House DS0000051663.V263527.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. Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Havengore House Address 27 Fairfield Road Eastwood Leigh On Sea Essex SS9 5RZ 01702 529243 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) Mrs Anne Sik Yee Shum Mr Cheuk Wah Shum Zoe Benedetti Care Home 20 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (20) of places Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Number of service users to whom personal care is to be provided shall not exceed 20 (twenty). Accommodation and personal care may be provided to no more than 20 older people over the age of 65 years (OP). Accommodation and personal care may be provided to no more than 4 service users over 65 years with Dementia (DE(E)). Total number of persons over 65 years to be accommodated must not exceed 20. 07/06/2005 Date of last inspection 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 Rayleigh and Southend. The building is a converted and 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 DS0000051663.V263527.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 8 November 2005 lasting 6.25 hours. The inspection process included discussions with the Registered Providers and manager, six staff, eight residents and one relative. A tour of the premises took place and a sample of policies and records were inspected. Thirteen 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?
Since the last inspection, staff vacancies have been filled and induction has taken place as well as arrangements for ongoing training. This has brought stability and balance to the staff team who understand their roles and responsibilities in the home. The management have completed or are in the process of implementing requirements and recommendations identified during the last inspection. This includes improving security in the home by installing additional door alarms and safety rails. Considerable progress has been made in staff attending training courses and seminars including infection control and diabetes. This has resulted in improved knowledge, skills as well as bringing confidence to the staff team. Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 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 DS0000051663.V263527.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 Havengore House DS0000051663.V263527.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): X EVIDENCE: Havengore House DS0000051663.V263527.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&9 Care plans and risk assessments are in place but some information had not been updated to reflect changes, which had occurred in the required delivery of care. Guidance as to how identified needs should be met was not always specific or sufficiently detailed. Medication record sheets did not always include printed prescription details. EVIDENCE: Residents spoken to, confirmed that the staff responded well in meeting personal care needs and that doctors, district nurses and the chiropodist visited the home as required. Information relating to visits by health care professionals and treatment given was shown in personal-care records. A sample check of care plans revealed that more explicit information was needed in relation to the assistance and support required/special requirements, to ensure guidance was clear to enable staff to be able to appropriately meet identified needs e.g. eating and drinking dietary needs. The pressure area care plan for one resident had not been updated since August 2004 and did not reflect the current moving and handling arrangements which are now in place to assist the resident at mealtimes. A sample check was made of the medication administration records and entries, storage and disposal arrangements were being maintained in accordance with standard procedures.
Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 10 It was noted that several prescription entries had been written on to the M.A.R. sheets by staff, as these had not been printed out by the pharmacist. This is not acceptable practice and the Registered Provider is in touch with the pharmacist to ensure that all prescribed medication (including repeat prescriptions), are detailed and printed on to the M.A.R. sheets. Havengore House DS0000051663.V263527.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 & 15 The lifestyle within the home and daily living reflects the preferences and choices made by residents. The meals in the home are good offering both choices and variety as well as catering for special dietary needs. EVIDENCE: Some other residents spoken to spoken about outings, which had been arranged for them in the local area, which included visits to shopping centres and tearooms. Some of the social activity and ideas had come as a result of meetings with residents, which take place on a regular basis. Sometimes relatives are also able to join in to give added support. Positive comments were made regarding various outside entertainers who visit the home and other staff encourage residents in games and social activities. Staff have also begun assisting residents on a one-to-one basis, where this is required, with reading and letter writing. Residents spoken to said that staff respond positively to their needs and they are supportive whilst at the same time, enabling residents the freedom and choice to follow their preferred daily routines and wishes. If residents needed to get up at night, staff offered cups of tea and spent time talking to them. Residents mentioned that wine with cheese and biscuits are offered Friday evenings and there was a good choice and variety of meals. The cook said that vegetarians and diabetics are catered for and records of meals served, showed the alternatives and variety of meals which had been prepared in accordance with residents choice. Many of the meals had been homemade and prepared on the premises.
Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 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 the following standard(s): 16 There is an established complaints procedure of which residents are aware and any concerns are able to be discussed with the management. EVIDENCE: Since the last inspection, no complaints have been recorded. Residents spoken to felt they were able to discuss any issues of concern with the management and staff team. The Registered Providers regularly call into the home and talk to the residents and the management were said to be approachable and available to discuss either in residents meetings or on a one-to-one basis, any matters regarding personal care and daily life in the home. Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 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 the following standard(s): 19, 21 & 26 The overall standard of furnishings, decor, cleanliness and fitments within the home is of a satisfactory standard but the communal bathroom facilities lack the space necessary for wheelchair users, equipment and supporting staff. EVIDENCE: Since the last inspection, security devices have been improved to make the building more secure and safe for residents. Residents spoken to said that their rooms were cleaned regularly and there were no unpleasant odours in the building. Some of the staff spoken to were aware of infection control procedures as well as the control of substances hazardous to health regulations. Senior staff had attended a training session provided by the Essex Health Protection Unit. Communal bathrooms are provided on the ground and first floor levels but because of limited space, these facilities are not sufficient for residents who may be wheelchair dependent neither could these areas easily accommodate more than one member of staff and other supporting equipment. The home needs to have a variety of bathing facilities, which are suitable for frail and very dependent residents.
Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 14 At the time of inspection, residents were able to be assisted by staff in the use of the communal shower facility on the ground floor. However, this area is also used for hairdressing facilities which is not ideal. Havengore House DS0000051663.V263527.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, 29 & 30 Given the dependency levels of residents in the home at the time of inspection, the levels and experience of staff was acceptable. Residents are supported and protected by the homes recruitment policy and practices as well as a systematic programme of training. EVIDENCE: Staff rotas were available to show that sufficient care staff were on duty during the waking day plus supervisory staff which included the manager, deputy manager and senior care assistants who between them, covered the morning, afternoon and evening periods. There were also cooks and domestics as well as part time staff who assisted with social activities. Two awake care staff were on duty at night. A sample check was made of recruitment records which included proof of identity, references, Criminal Record Bureau checks and application forms. In addition, job descriptions, letters of appointment and contracts were on file. Records of induction training were available as well as courses attended and other training which had been planned for the future. The management have done well in improving the training of staff and ensuring that relevant courses are attended. Dementia training has been planned which includes twelve sessions in-house to be provided by a N.V.Q. Assessor. Records are also available of training completed which includes moving and handling, medication administration and diabetes training. Havengore House DS0000051663.V263527.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): 33 & 38 The home is run in the best interest of residents and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: From conversation with residents, staff, relatives and observation during inspection, the home has demonstrated its willingness to take into account the wishes and aspirations of residents and to meet these expectations so far as it is possible. The management has also taken on the responsibility for ensuring that staff training is updated and supervision is provided in order to provide a caring and professional service in the interests of residents. Health and safety issues have been addressed and ongoing servicing and maintenance takes place. As already mentioned in the report, additional security measures have been put in place which includes warning alarms to the front door and exit door giving access to the fire escape on the first floor. Additional handrails have been installed and made secure a long the first floor corridor. Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 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 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 1 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 14 & 15 Requirement Timescale for action 15/12/05 2 OP9 13 & 17 3 OP21 23 The registered person must ensure that all care plans and risk assessments are kept under review in sufficient detail to show the action by care staff in meeting the health personal and social needs of residents. 01/04/06 The Registered Person must ensure that correct arrangements are in place for the recording, handling, safekeeping and administration of medicines received into the care home. This is in particular reference to details of medication on the M.A.R. sheets, which must be completed but the pharmacist. The Registered Person must 01/04/06 ensure that the premises are suitable for the purpose of achieving the aims and objectives set out in the Statement of Purpose. This includes providing suitable space to allow highly dependent residents to be bathed, with the assistance of staff and any appropriate equipment, which may be required.
DS0000051663.V263527.R01.S.doc Version 5.0 Havengore House Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. N/A Refer to Standard N/A Good Practice Recommendations N/A Havengore House DS0000051663.V263527.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South Essex Local Office 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
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