CARE HOMES FOR OLDER PEOPLE
Haverholme House Care Home Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD Lead Inspector
Theresa Bryson Unannounced Inspection 20th October 2005 09:30 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 Haverholme House Care Home DS0000002789.V261134.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. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Haverholme House Care Home Address Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD 01724 862722 01724 870887 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) Ancyra Health Limited Undergoing Registration Process Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (45), Physical disability of places over 65 years of age (45) Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd February 2005 Brief Description of the Service: Haveholme House Care Home is set on the outskirts of the village of Appleby near Scunthorpe. It is an older style mansion house, retaining many original features, with a modern extension to the side. The home is registered to care for 52 older people. The home has been divided into two facilities: service users with nursing needs are located in the main building, which is called Pine Tree Court and based on two floors, access is via a lift. The service users with residential care needs are accommodated in the newer purpose built extension, which is called Grove Court and is on the ground floor of the purpose built building. These units although joined are managed separately. The majority of the rooms offer lovely views of the surrounding countryside. The grounds are extensive and always well cared for; there are a variety of sitting areas, all accessible for wheelchair users. There is a large car park at the front of the building. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day in October 2005. To find out how the home was run and if the people who lived in the home were pleased with the care they got, the inspector spoke to the manager, 6 service users and 6 staff. Paperwork kept in the home was also seen to make sure that the checks to make sure staff are safe to work in the home had been done, and that they had been trained to do their job safely. Records were also looked at to make sure the home and the things in it were safe and checked often. The manager Mrs.Rosemary Wright accompanied the inspector through out the visit. The delay in this report going out was due to managerial problems in the local office. What the service does well:
The staff looking after the people in the home were very friendly and knew a lot about each person. They showed dignity and respect to each person when they approached and assisted them through out the day, in a variety of tasks. The home was clean and tidy and had lots of space where people sit and relax and eat. The information given to each person before they come to the home was clearly written and informed each person about different aspects of living in this home. The records for giving medication had been clearly written and a sound system was in place to enable staff to complete this task safely. A varied menu was provided each day and individual needs could be catered for by the kitchen staff. Meals were taken in a relaxed atmosphere and staff seen to assist the people who required it with dignity and care. Paperwork seen for looking at complaints and for protection against abuse was clearly written and people said they felt confident that concerns would be dealt
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 6 with well. Training schemes were in place to make sure staff working with the people who lie in the home had the latest knowledge to be able to deal with any need as it arose. Safety checks were in place to ensure that the environment the people live in and for staff to work is safe. What has improved since the last inspection? What they could do better:
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 7 The records kept on the people who live in the home needs to be up to date and include all aspects of their care on a daily basis. This is to ensure that all needs are met at all times. This remains outstanding from the last inspection. The registered persons must ensure that wedges are not used to keep open doors and suitable mechanisms are in place, this will ensure all people are safe in the event of a fire. This remains outstanding from the last inspection. The company must ensure that all people who live in the home are asked whether they would like a privacy lock on their bedroom door. This remains outstanding from the last inspection. The manager must ensure that water outlets in areas used by the people who live in the home meet the recommended temperatures so they are not harmed or in any discomfort. The manager must ensure that linen is provided for the people who live in the home in adequate supplies and is in a good state of repair. The company must ensure that all staff have signed a contract of employment. The company must provide a five-year electrical wiring certificate to ensure the home is safe. This remains outstanding from the last inspection. 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. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 8 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 Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 9 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): 1,2,3 and 6. Service users are provided with comprehensive documentation before entering the home, to enable them to make informed choice. Staff are given preadmission paperwork to enable them, to adequately prepare for a person’s admission. EVIDENCE: The statement of purpose and service users guide was offered to the inspector to see and included all items listed under Schedule 1 of the Regulations. This is placed in each new person’s room on admission, but is also sent out and offered to those making general enquires about the home. Copies were also on display at both entrances to the home. The documents gave a good overview of the home and would enable prospective service users to have informed choice about the stay at the Care Home. The pre-admission documentation has now been replaced since the last inspection and is in a much simpler format. This enables the Manager or her
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 10 deputy to make a comprehensive record of their findings prior to a person’s admission. This document then forms the basis for the first care plan and gives an holistic background for the admitting care worker to plan initial care needs. The home does not provide intermediate care and therefore Standard 6 is not applicable. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 11 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 and 11. The home provides comprehensive care documentation to enable all service users needs to be monitored and assist staff to deliver the appropriate care to each person. This documentation had not been completely up dated. The home has a robust system for administering drugs. EVIDENCE: The staff at the home were currently revising all care plan documentation to a new format. There were mixed comments made to the inspector by staff concerning how they felt about the difficulties and positives of completing this documentation. 8 care plans were tracked during the course of the inspection, covering both residential and nursing service users’ needs. These showed that some parts are not being consistently recorded. For example; - weight and dependency charts were not up to date, when tracked by the inspector. The daily report sheets were also spasmodically written and it was difficult to ascertain a true picture of the actual delivery of care given to each person on a daily basis. Staff were reminded that this paperwork is a legal document and should reflect all care given and be up to date to evidence all needs are being met.
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 12 Medication records were checked and the storage of all medication was neat and tidy. All administration records were checked and recording appeared accurate. The controlled drugs were checked and all items neatly recorded and corresponded to actual drugs in the cupboards. Staff when questioned had a good knowledge of service users needs regarding administration of medication and which medication was required. This has resulted in a safe system being in place to meet service users needs. The care of the dying policy was seen and this has now been revised to include current legislation and local guidelines. The Regulation 37 notices received by the local CSCI office arrived promptly after a person’s death and appeared to accurately record events. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 13 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): 15. The home provides a varied menu to meet service users needs and all parts of the kitchen and storage areas had benefited from an effectual cleaning programme, ensuring food is delivered and presented in a safe manner. EVIDENCE: The inspector was shown around the kitchen and storage areas by the cook. She was able to describe the running of the kitchen, the rota system and how ordering takes place. She also had a sound knowledge of service users needs and was able to inform the inspector which service user was on a diabetic diet and also protein diets. The kitchen receives a notification form from the care staff, but the key workers complete the nutritional assessments in the care plans. She has informed the manager that the kitchen needs to know of changes to diet promptly to meet needs of service users, which care staff are sometimes slow to do. The cook stated she was happy with her suppliers and there was evidence of good stock and temperature control. The storage areas were clean and tidy. The cleaning programme was in place and all areas very clean and free from hazards. Ensuring a safe system is in place for preparing and delivery of meals.
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 14 The home offers a 4-week cycle of menus, which includes a hot choice at teatime. Individual needs can be catered for and the cook endeavours to speak to a selection of service users each week. The service users made many positive comments to the inspector about the meals provided and staff were seen to offer assistance to those who required it with dignity and respect. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 15 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 and 18. A comprehensive complaints policy was in place for service users and other parties entering the home to see. Service users and their relatives were aware of how to make a complaint, were confident to do so and believed their concerns would be listened to and acted upon. There was a robust policy in place to ensure the service users were protected from abuse. EVIDENCE: The complaints policy was on display and service users and staff spoken to stated they felt confident any concerns would be addressed and dealt with in a confidential manner. A new logbook was seen which recorded 3 complaints since the last inspection. All had outcomes recorded and appeared to have been completed to the satisfaction of all parties. This indicates that all parties are living and working in a relaxed atmosphere and are not concerned about bringing items to managements attention. The home has a robust policy in place to protect service users from abuse. The protection of vulnerable adults first checks had been implemented since the last inspection and a separate file kept for those checks and for the full criminal investigation bururea checks. The 7 staff files tracked showed that references had been taken up and all appropriate identification paperwork recorded as seen. This ensures service
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 16 users that safe checks are made prior to staff being employed to look after them. Training records also showed that staff had received training in the protection of vulnerable adults and could identify problems should the need arise. This ensures that staff are working with service users in a safe manner. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 17 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): 19,22,24 and 26. The home was clean and tidy for this category of service user. A planning and redecoration plan was in place ensuring the maintenance of the building was always suitable for each service user. EVIDENCE: A plan for redecoration of the home was seen to be in place and covered both inside and outside the building. This will ensure that the home is maintained at all times and safe for the service user to live in. The manager accompanied the inspector on the tour of the building. A selection of rooms were seen and all bathrooms, toilets and communal areas. The provision of locks on service users’ room doors and adequate closing mechanisms on bedroom doors, to prevent the use of wedges had still to be completed. Several doors were seen to be wedged open and wedges were removed at the time of the inspection. The staff were reminded of the health and safety hazards of this practise. The home is liaising with the local fire
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 18 brigade over suitable door closing mechanisms and this report has been copied to the inspector by the local fire brigade. Some new equipment such as a hoist and suction machine had been purchased since the last inspection .The manager also showed the inspector the inventory she keeps of all nursing equipment and that on loan from the local Primary Care Trust. This ensures maintenance can be kept up to date. The last room audit was completed in August/September, as recorded in the quality manual. All areas of the home were clean and tidy and service users stated they were satisfied with standards of hygiene kept in the home. There was a great deal of evidence that service users can personalize their own rooms, which they stated had assisted them in settling into the home. The linen cupboards were reasonably tidy, but many items needed reviewing. The manager was to complete a linen audit and purchase new bed linen and towels, to ensure service users are given clean items, which are also not worn. The water temperature logs were seen and temperatures running either very high or very low. As the home has a new maintenance person, it needed to be brought to his attention that variances need to be reported and other agencies employed if he cannot correct the temperatures. This could cause service users to be washed in temperatures too high or too cool and cause them discomfort or actual injury. The garden areas were very colourful and neat and all areas free from hazards and accessible for wheelchair users. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 19 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 and 30. The home has a system in place for staff recruitment and staff training and although checks are made on staff prior to employment the home did not have all the sufficient contracts in place which staff had signed, which could lead to staff being dissatisfied with their work and employment. EVIDENCE: All rotas were seen from all departments. The one for kitchen and domestic, administration staff appeared adequate to the needs of those areas. Staff stated they were happy with their hours and the present schedules set for them. Care staff stated that the amount of hours set on their rota was not adequate to give quality time to the service users. The manager was aware of the importance of keeping up to date dependency levels on each service user, so their needs can be met with adequate staff on each shift. As the levels are calculated at head office level how staffing ratios are worked out was not available on the day and an immediate requirements notice issued to ensure there were adequate staff calculated to be on duty to meet all current needs. The home currently had 42.3 of the care staff qualified to NVQ level 2 and 3 care awards. They also had a further 6 in the progress of obtaining their level 2 awards. The home had two assessors in the home to assist staff. Staff spoke highly of their courses and felt it had enhanced the level of care they give to service users.
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 20 7 staff files were tracked in depth and found to have the necessary documentation in them covering schedules 2 and 4 of the Regulations. The home had an up to date list of their criminal investigation bureau checks, and along with other checks ensures staff are safe to work with service users. The records showed that new contracts, which had been issued, to staff had not all been signed and completed. The manager was asked to make this a priority as this could lead to a breaking of employment law and cause dissatisfaction within the staff group. The training plan for 2005 was in place and identified both statutory and service specific training. A separate sheet is also kept on the actual topics of training which have taken place each month. This ensures that the plan can be updated instantly should the need arise. Examples of service specific training included: - strokes, care plan implementation, pressure sores and nutrition. Some individual staff logs were not quite up to date, but the manager was aware. This ensures that staff have the latest up to date knowledge to enable them to deliver care to service users. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 21 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): 31,35,36 and 38. The home has a robust system in place to ensure that supervised staff working in a safe environment provides the quality of care delivered to service users. EVIDENCE: The current manager has been newly vetted by the CSCI and her curriculum vitae and all Criminal Records Bureau checks completed. She has also enrolled on the Registered manager’s award and could show an up to date programme. Her professional portfolio as a nurse is checked by her line manager, enabling her to maintain a “live” registration with the Nursing and Midwifery Council. This ensures she has the necessary skills to manage the home. The administrator checked over the personal allowance records with the inspector. 3 were tracked in detail and found to be correct. The administrator was able to give a good account of the financial control kept at the home for
Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 22 service users’ personal allowances, residents fund and petty cash records. This ensures that all documents are accessed on a need to know basis and service users are secure in the knowledge their finances are well looked after with the home’s, family and other advocates support. The logs were seen of the supervision records for staff and also the list for when sessions are due to take place. The manager was able to explain the system in place and stated that all supervisors had been trained in their role. She also completes a yearly appraisal on each staff member. This ensures all staff are checked to ensure they are safe to work with service users and also that their individual needs as staff are being addressed. Documents were seen to ensure that all safety checks are made in the home for the safe up keep of the environment for service users, staff and visitors. The only item missing was the five yearly wiring check certificate for the home, which remains outstanding from the last inspection. The manager was to make head office aware. The manager, other staff and head office and regional staff also complete regular audits in the home. This includes; -medication, rooms, care plans and complaints. Evidence of these were seen and showed where action had been planned. Since the last inspection the manger has ensured that all fire and manualhandling training has been up dated for staff and that bed rails now have protectors in place. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 X 2 Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 24 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 15.1. Requirement The registered person must continue to develop the care programmes documentation to ensure all problems are clearly identified with associated care interventions. (Previous time scale of 07/03/05 not met). The registered person must ensure that temperature control is kept on all water outlets. The registered person must ensure that adequate linen is provided at all times and that this is in a good state of repair. The registered person must ensure that all staff have completed and signed contracts of employment. The registered person must ensure a five-year wiring certificate is in place for the home. (Previous time scale of 07/03/05 not met). Timescale for action 27/01/06 2 3 OP25 OP26 23.2.j. 16.1.c. 26/12/05 27/01/06 4 OP29 18.1.a. 26/12/06 5 OP38 23.2.b. 26/12/05 Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 25 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 Refer to Standard OP28 OP31 Good Practice Recommendations The registered person should ensure that 50 of care staff achieve NVQ level 2 or above by 2005. The manager should complete her Registered manager’s Award. Haverholme House Care Home DS0000002789.V261134.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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