Inspection on 23/11/09 for Haverholme House Care Home

This inspection was carried out on 23rd November 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Haverholme House Care Home 08/01/09

Haverholme House Care Home 09/01/08

Haverholme House Care Home 15/01/07

Haverholme House Care Home 13/03/06

Haverholme House Care Home 20/10/05

Haverholme House Care Home 02/02/05

Haverholme House Care Home 07/07/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Haverholme House Care Home Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD Lead Inspector Stephen Robertshaw Key Unannounced Inspection 23rd November 2009 08:45 DS0000002789.V378540.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haverholme House Care Home Address Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD 01724 862722 01724 282378 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) www.aermid.com Aermid Health Care (UK) Limited Vacant Care Home 48 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (48), Physical disability (45) of places Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 48 PD, Physical disability - Code PD, maximum number of places: 45 2. Dementia - Code DE, maximum number of places: 1 The maximum number of service users who can be accommodated is: 48 8th January 2009 Date of last inspection Brief Description of the Service: Haverholme House Care Home is situated 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 people. The home has been divided into two facilities: people that use the service with nursing needs are located in the main building, which is called Pine Tree Court and service users with residential care needs are accommodated in the newer purpose built extension, which is called Grove Court. All bedrooms are single occupancy and most offer lovely views of the surrounding countryside. The grounds are extensive and 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. The current weekly fees range from £343.05-£362 per week for residential care and £341.94-£388 per week for nursing care plus an agreed nursing supplement if required. People that live at the home will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these can Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 5 be obtained from the acting manager of the home. Information on the service is made available to prospective and current residents through the homes statement of purpose, service user guide and previous inspection reports. Copies of these documents can be obtained from the management at the home. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the service was unannounced and took place on the 23rd November 2009. The Commission was in the home for approximately six and a half hours. This report has been written with the information gained on this day and from the Annual Quality Assurance Assessment that had been completed by the management of the service and had been sent in to us before the site visit took place. We also spoke with nine of the people that use the service, one visiting professional and five relatives. The information that they gave to us has also been used to help to write this report. The Commission also case tracked four of the people that use the service. This included looking at all of the assessments and care plans that had been written about them. The quality rating for this service is 1* star. This means the people who use this service experience adequate quality outcomes. We would like to thank the management and staff working for the home and the people who we met at the site visit for their hospitality and friendly welcome. What the service does well: The home provides a very friendly and relaxed atmosphere, the people that use the service also said that their families and friends could visit them ‘anytime’ and that their rooms were ‘comfortable’. People said that that there was always a good choice of meals at the home. The staff receive lots of training and support to make sure that they have the skills and knowledge to be able to understand people’s individual needs and how they would like to be looked after. The health needs of the people living in the home are well met and staff the staff work well with doctors and nurses to make sure that their health care is well looked after. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 7 The people that live in the home say that they are happy to be living there. They are also given the opportunity to decorate their rooms to their own likes and comforts. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.2 Page 8 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 9 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.V378540.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that people that use the service have their need assessed before they are admitted to the home, however the assessments contain only basic and generic information. EVIDENCE: The Commission observed all of the information held at the home that related to the care provided for four of the people that use the service. All of their care files included an assessment of their needs before they had been admitted in to the home. This included the homes pre-admission assessment of need and assessments provided through the funding authorities including care management and continuing health care. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 11 The homes pre-admission assessments provided very little personal information in relation to the support that individuals would require if they moved to live at the home. An example of this includes people having mobility needs identified I their assessments, but no detail had been included in relation to the support that the person would need and failed to recognise how these needs affected the persons abilities and daily lives. The acting manager of the home stated that the homes pre-admission assessments were going to be changed to provide a more person centred approach to assessment. Observation of staff interacting with the people that use the service, interviews with management, staff and people that use the service all helped to support the evidence that the staff have the necessary knowledge and skills to be able to safely support and deliver care to the people that use the service. The staff training records also showed that there has recently been a great increase in the amount of training undertaken by the staff. This also helps to demonstrate that they have al of the skills and knowledge to care for the people that they are responsible for. The staff that were observed had good working relationships with the people that they were supporting. They communicated well with them and clearly took in to consideration the individuals personal needs and supported their dignity and privacy. The home does not provide intermediate care to the people that use the service. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the individual care plans in the home do not always support the needs of the people that they are intended for. EVIDENCE: The Commission looked at all of the information in the home that related to the care being provided for four of the people that were living at there. Three of the four care files that were observed by us included a care plan provided through their funding authorities. This included care management and continuing health care documentation and two three care plans that had been developed by the home. The fourth care file was in relation to a person that had been admitted to the home on the Friday before the inspection. The home had not yet completed any care plans for this person; however a continuing health care plan was available. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 13 The care plans that were observed had been evaluated on a monthly basis to make sure that they were still appropriate to the needs of the individuals that they concerned and included any changes to the care being given. There was some confusion in relation to some of the care plans as when they had been identified as no longer appropriate they had been crossed out, leaving other areas of the care plan still in use. It would have been more appropriate to rewrite the care plan to avoid any misinterpretations. The care files also included risk assessments that included areas such as skin integrity, nutrition and moving and handling. Observation of these documents identified that they were not always supported by a care plan. This was especially in relation to skin integrity. Two of the care files included high risks in relation to skin integrity; however there were no care plans in position to support these needs. In general the care plans in all of the care files that were observed included very basic information and this was very generic in nature. An example of this was in relation to mobility the care plans said that the person needed support with their mobility but did not detail how the person wanted to be supported with these needs. These documents did not say how many people were needed to help a person to mobilise, or recognise the particular equipment that was needed to safely mobilise them. This means that the people that use the service mat not receive the support that is right for them. This could have implications on their personal health and safety. The acting manager of the home stated that the care plans needed to include more person centered information. He also added that some training has been contracted for the staff group in relation to person centered care, assessment and care planning. Information about individual’s social interests, likes and dislikes and spiritual needs were also included within the individuals care plan. However once again the detail in these recordings was very basic and did not offer any clear indications of how the individuals reacted to the activities that are made available to them. Most of the care plans that were observed by the Commission included the signatures of the people that use the service or their representative’s. This helps to make sure that people that live at the home have had some say in the development to their plans and had agreed the levels of individual support that they required. Individuals care plans supported the evidence that the people who live at the home had good access to outside professionals to support them with their healthcare and social needs. The individual care plans identified where individuals had specific nutritional and dietary needs, including PEG feeding, food supplements and soft diets. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 14 The qualified nurses in the home administer medication to the people with nursing care needs and senior care workers administer medication to nonnursing care residents in the home. All of the medication records in the home were up to date and had been accurately recorded. Observation of medication being administered to people that use the service showed that all good clinical and professional guidelines were followed. The temperature of the medication room and fridge in the nursing area of the home were monitored on a daily basis to ensure the safety of the prescribed medication. The residential medication room had not had the temperatures recorded since the area was re-opened following the flood last year. This record was initiated on the day of the inspection. The controlled medication in the home wads all appropriately stored and recorded. Advice was given to review the prescription for an individuals Temazepam as this hadn’t been required for several months. Direct observations by the Commission at the time of the site visit supported the evidence that people that use the service have their dignity and respect upheld at all times in the home. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the service offers a wide range of activities to the people that use the service, however there are some concerns in relation to the consistency of the quality of food that is provided at the home. EVIDENCE: The acing manager of the home stated that the service employs an activity coordinator and has plans to appoint two more part time activity co-ordinators. This is to make sure that activities are available through the day at the home and this will include activities on evenings and weekends. Direct observations showed that quite a few of the people that use the service became involved in the activities that were available. On the day of the site visit this included watching videos, craft work preparing for the Christmas period and board games. One person said ‘I like playing board games’. The Commission spoke with five visitors to the home and they all confirmed that they are welcome to visit the home at any reasonable time. One visitor stated that ‘the staff are always very friendly and have a lot of patience’. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 16 Several of the people that live at the home made comments to the commission in relation to the quality of the meals that are provided to them There did not appear to be any consistency provided through the two cooks that work at the home. Comments included ‘the meals are very good on some days’ and another person said ‘the Yorkshire puddings were so hard if you dropped them on a plate it would break’. A recent survey sent out by the service in relation to meals identified that ‘food is not always up to standard’ and ‘good food is spoilt by the way it is cooked eg not cooked or overcooked’. Another person that uses the service commented to the Commission ‘the meat was too thick and I couldn’t chew it’. The acting manager of the home stated that the service has developed a new food group that includes people that use the service to help to improve the quality and choice of foods that are made available at the home. The dishwasher in the kitchen has not worked for several months. The people that use the service and the cook stated that this meant that full cooked breakfasts were no longer available as there was not time to hand wash all of the cutlery and crockery before the lunch had to be prepared. Some people stated that they missed the ‘extras’ at breakfast. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that people that use the service understand how to make a complaint to the service if they wish to. EVIDENCE: The service has a clear and easy to follow complaints policy and procedure. A copy of this is made available on the notice board in the entrance of the home. No formal complaints in relation to the care provided by the home had been recorded since the last inspection. However approximately 24 people made formal complaint to the service provider in relation to the homes fees. This will be expanded on further under the management and administration section of this report. People that were spoken to by the Commission said that they were confident that if they made a complaint to the home that it would be listened to and where appropriate actions would be taken to make things right. However they did not have the same faith in the external management of the home. Staff training records and interviews with management and staff showed that they had received appropriate safeguarding adults training. The training was identified as being provided through the local authority, National Vocational Qualifications and other external training resources. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 18 Observation of staff personal files supported that the home followed good working practices when appointing new staff. This included formal applications, references, interview records and appropriate safety vetting before the staff had been employed to have any contact with the people that were living at the home. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the environment at the home has slightly improved, however much needs to be done to create a homely and comfortable environment for the people that use the service. EVIDENCE: The Commission made a tour of the premises to see if the environment was suitable to the meet the needs of the people that live at the home and the needs of the people that work there. The acting manager of the home stated that the proprietors of the service intend to improve the general environment of the home, however an asbestos assessment of the home had recently been completed and no structural Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 20 alterations could be made prior to the report from this assessment being published. The manager’s office in the home has been moved downstairs next to the main entrance for the nursing area. This means that the manager will be more accessible that previously when they were based in an office that was out of the way upstairs. This will also help to identify when people enter and leave the building. On the day of the site visit a visitor to the service said ‘this is a good idea to have the office here now we know where the manger will be if we want them. The acting manager stated that it was difficult to keep a consistent temperature around the home as one of the water pumps was not working to its ‘full potential’. He said that the system had been assessed by an engineer and would be a priority when the asbestos assessment is returned to the home. Recently new equipment had been ordered for the home. This included a new mobile hoist and a new sluice for the nursing area of the home to replace the sluice that had been condemned. New carpets had been fitted in the corridors in the residential area of the home. The joins in the carpet were lifting and could cause trip hazards. This was also identified in one of the bedrooms where the carpet between the bedroom and the en-suite were lifting also causing a trip hazard. The hot water is also difficult to regulate in the same room. On the ground floor of the building there was a walk in area that included the electrical supply and fuse units for the home. This door did not have a locking mechanism and could be a potential threat to any unauthorised people that could enter this area. The Commission also made a tour of the kitchen and found it to be very clean and was well stocked. Concerns remain in the kitchen in relation to the condition of the flooring in the kitchen. The condition of the floor remains a concern. There are areas of the floor that are badly stained and these areas cannot be cleaned properly. The dishwasher in the home had also been condemned and had not been in use for several months. This piece of equipment needs to be replaced with urgency to help to support the health, safety and welfare of the people that use the service. This will make sure that the correct temperatures to sanitise the crockery and cutlery is appropriately maintained. Infection control policies and procedures were also compromised in the upstairs corridor of the home. Linen towels had been left on an open trolley in a corridor. Any person passing this trolley could have contact with the towels and pass on any infections that they may have. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 21 We observed the maintenance records for the home all of the appropriate safety certificates were in position, this included insurance, gas safety systems, safe electrical installations and moving and handling equipment maintenance and service records. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the staff working at the home understand the needs of the people that use the service. They have not all received all of the mandatory training that is required for them to make sure that their work practices are safe. EVIDENCE: Direct observation of the staffing levels at the home suggests that there are reasonable staffing levels at the home at all times. This helps to make sure that the service can meet the care needs for all of the people that live there. The acting manager stated the home has experienced some difficulties in recruiting nurses to work at the home. However he stated that recently new nursing staff had been recruited and the service was waiting for their clearances before employing them to work at the home. The acting manager also stated that when nurses were not available the home used its own nurse bank staff to offer consistent services to the people that live at the home. He also said that this could be achieved without having to access agency staff. Thirteen of the care staff have completed their National Vocational Qualification (NVQ) 2 in care or equivalent. Since the last inspection of the service there has Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 23 been a determined drive by the service to complete NVQ training and this has also been reflected in the staff’s mandatory training. The homes training plan identified that all of the staff should have completed all of the training that they require to make sure that they have the knowledge and skills to safely care for the people that use the service. Interviews with the nursing and care staff supported that the home has provided training much improved on previous years at the service. One person that uses the service said ‘the staff are friendly’, a visitor to the home also stated ‘you can’t ask too much of them they (the staff) are very hard working’. The Commission observed the employment details for three of the staff that work at the home. Their files supported that equal opportunities are followed when employing new staff to work at the home. This included appropriate applications, references and safety vetting. The staff working at the home continues to be inconsistent in wearing their identification badges. This could cause difficulties with some people with dementia being able to recognise them and could also cause problems for people visiting the home and being able to remember who they spoke to. The acting manager recognised that this was an issue in the home and stated that it would be addressed. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This means that the internal management of the home is supportive of the needs of the service; however the outside management of the home has not been supportive to the needs of the people that use the service or their families. EVIDENCE: The service has employed a new manager at the home. At the time of the site visit the home the acing manager had been in position for only two weeks. The service had not had a registered manager for approximately three months previous to him being employed. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 25 The acting manager stated that they intended to submit an application to the Commission to be recognised as the registered manager of the home and also intended to complete the Registered Managers award. The acting manager is a qualified Registered Mental Health Nurse. He has previously had management experience in residential and nursing homes. The home has the beginnings of an appropriate formal effective quality assurance and monitoring system. Recently surveys have been sent out to the families of people that use the service, the staff group and to fifteen of the people that live at the home. These need to be evaluated, an action plan should be produced and these should be published. A recent survey in relation to the meals provided at the home has identified that kitchen staff need to receive more training and a new food group has been set up at the home. This group includes staff, management and people that use the service. The aim of the group is to provide meals at the home that are varied and are acceptable and of good quality to the people that receive them. Staff supervision records and interviews with staff identified that supervision in the home has begun to improve and takes place on a more regular basis than previously. However the homes records showed that they are not receiving the recommended minimum of six formal supervision periods per year (pro-rata). The management of the home must ensure that this position is improved to provide evidence that the staff working at the home have all of the knowledge and skills to be able to safely deliver care to the people that use the service. General health and safety was seen to be to be supported and maintained in the home. This evidence was supported through the homes policies and procedures and the maintenance records for the moving and handling equipment. The home had up to date safety certificates for the gas and electric systems. Concerns were raised with the Commission in relation to the homes finances. This had arisen after the company had sent letters to people that use the service and/or their representatives in relation to unpaid fees. This matter was referred to a debt collection agency. Letters were then sent out to the people that the ‘arrears’ were due from, mentioning the possibility of court action. These arrears were later identified as mostly being up to date and there had been errors in the homes own financial systems. The company management received approximately twenty four complaints in relation to how these accounts were dealt with. One person stated to the Commission that when they queried the account sent to them they phoned the central office and ‘it was a nightmare to get an answer’ and when they did, the management ‘put down the phone on me’. A letter of apology was sent out to al of the people that received the arrears letters and were informed that no further action would be taken. People involved that were spoken to by the Commission felt that this was very poor practice and placed people under a Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 26 great deal of stress and pressure. They also said that this could have had ‘a profound effect’ on the people that use the service who do not have any support outside of the home. One person stated that the fees that they pay contribute to the wider service development. They felt that their fees should be used inside the home that the fees were paid to create a homely, comfortable and safe environment. The service has recently employed a new area manager that is responsible for Haverholme House. It I s important that this person starts to rebuild the relationship between the service, the people that use the service and their families and friends. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 27 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 2 X 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 X X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 1 1 2 X 2 Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 28 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 Requirement The registered person should make sure that the care plans that are developed by the home are person centered and meet people’s individual needs in a way that is safe and is acceptable to them. The registered person must also make sure that where there is an identified need there is a care plan in position to support this need. This includes areas suck as skin integrity where a risk assessment has been completed and identified a risk to the individual. 2. OP15 16 (2b) The registered person must make sure that the quality of the 30/12/09 meals provided in the home is consistent. This will help to make sure that the people that use the service have a balanced and healthy diet. The registered person must evaluate the condition of the kitchen floor and provide a surface that supports health and DS0000002789.V378540.R01.S.doc Timescale for action 30/01/10 3. OP19 16 (2j) 30/01/10 Haverholme House Care Home Version 5.3 Page 29 safety in the kitchen. (Previous requirement of 09/06/2008 was not met). 4. OP26 13(3) The registered person must make sure that the home infection control policies and procedures are followed by all of the staff. This will help to support the health and safety of the people that use the service and the people that work with them. The registered person must make sure that all of the staff working in the home receive the minimum recommendation of six formal recorded supervision sessions per year (pro-rata). This will help to make sure that the staff have all of the necessary knowledge and skills to safely carry out their roles. 30/12/09 5. OP36 18 (1a) and 18 (2) 28/02/10 7. OP31 8 and 9 The registered person must 30/12/09 make sure that the homes manager makes an application to the Commission to be registered and prevent an offence by running a home without being registered. The registered person must make sure that the homes financial arrangements are appropriately managed and processed. This will help to avoid confusion on what fees are due and those that have been paid. The external management of the home need to develop their relationships with the people that use the service and their families. This will help to provide a more trusting and more professional relationship DS0000002789.V378540.R01.S.doc Version 5.3 Page 30 8. OP36 7 (3a) 25 (1) 30/12/09 12 (5a) Haverholme House Care Home 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 OP3 Good Practice Recommendations The registered person should improve the quality of the homes pre-admission assessments. These should be more person centered and this will help to identify if the home is able to safely meet all of their needs. The registered person should make sure that the temperature of the medication rooms and medication fridges are monitored on a daily basis to support the health and safety of the people that receive the medication. The registered person should have the water pump repaired or replaced as soon as possible to create a homely and safe environment for the people that use the service. The registered person should replace the sluice in the nursing area of the home to support the health and safety of the people that use the service. The registered person should make sure that no carpeted areas of the home create trip hazards for the people that use the service. This will help to support the health and safety of the people that use the service. The registered person should supply a locking device to the electrical cupboard to make sure that only people authorised to enter this area can do so. The registered person should make sure that all of the staff working in the home wear their identification badges. This will help people that use the service and their visitors to know who they have had contact with. The registered person should continue with the DS0000002789.V378540.R01.S.doc Version 5.3 Page 31 2. OP9 3. OP19 4. OP19 5. OP19 6. OP19 7. OP27 8 OP33 Haverholme House Care Home development of the homes quality assurance system. This will help to identify how other people view the services that are provided by the home. Haverholme House Care Home DS0000002789.V378540.R01.S.doc Version 5.3 Page 32 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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