Inspection on 08/01/09 for Haverholme House Care Home

This inspection was carried out on 8th January 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 23/11/09

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.

CARE HOMES FOR OLDER PEOPLE Haverholme House Care Home Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD Lead Inspector Stephen Robertshaw Key Unannounced Inspection 8th January 2009 09:00 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 Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 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.V374052.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 Manager post vacant Care Home 52 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (52), of places Physical disability (45), Physical disability over 65 years of age (45) Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration category DE(E) 1 male refers solely to the service user identified in the application V29651. 9th June 2008 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 £349.04 to £416 per week. 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 be obtained from the manager. 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 home. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the service took place on 06th of January 2009 and was unannounced. The inspector was in the home for approximately 7 hours. The evidence included in this report was gathered through all of the information received about the service since the last inspection and the evidence provided through the site visit including interviews and observation of the documentation kept by the home and direct observation of staff interactions with people that live at the home. The Commission would like to thank everyone that took the time to talk to us during the inspection visit. Their comments and input have been a valuable source of information, which has helped inform this report. Although the service remains an adequate service it was clearly identified as being an improving service. The quality rating for this service is 1 star. This means that the people that use this service experience adequate quality outcomes. What the service does well: The staff appeared to be very friendly and had a good understanding of the people that they were caring for and the support that they needed to remain independent. Discussions with people that use the service suggested that the staff know to look after them properly and keep them safe. The staff and the people that live at the home appear to have very good relationships with each other and the atmosphere between them is friendly and relaxed. This helps the people that use the service to feel very settled and this means that they can rely on the staff for any support that they may need. Everyone is provided with meals that they choose and like, however they are encouraged to follow a healthy diet including. The home is very clean and pleasant this means that the environment is comfortable for them to live in. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 6 The people that live in the home say that they are ‘well looked after’ and 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: The management of the home need to ask other people their views of the services it provides to make sure that they can meet the needs of the people that they are looking after. The care and nursing staff must receive all of the training and supervision that they need to make sure that they have the right kills and knowledge to be able to safely look after the people in their care. The management of the home need to make sure that everyone that is admitted to the home has a care plan developed for them soon after they arrive. This will help to make sure that everyone’s needs can be met at the home and will be supported in a way that they are happy with. The manager of the home needs to complete her application to the Commission to be recognised as the registered manager of the home and to be identified as a ‘fit person’. Please contact the provider for advice of actions taken in response to this Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 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.V374052.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live at the home generally receive an assessment of their care needs before they are admitted to the home. This makes sure that they can be appropriately cared for while they are at the home. EVIDENCE: The Commission observed the care files for three of the people that live at the home. These all included an assessment of their needs before they had been admitted in to the home. The standard of the pre-admission assessments had improved since the last inspection. These now provide clearer indications of how individual needs affected the daily lives of the people involved, and the level of support that they required to improve their quality of life. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 10 People that live at the home who receive nursing care had received a health care assessment completed by an National Health Service registered nurse from the local Primary Care Trust, to identify the level of nursing care that is required by each person with nursing care needs and this also helps to identify the level of funding to be provided for the placement. The home employs a small number of male carers. This means that as far as is practicable people that live at the home can have some choice about the gender of staff that delivers their personal care to them. Observation of staff training and supervision records and observation of their practices supported the evidence that the staff have the knowledge and skills to be able to safely support and deliver care to the people that use the service. The home provides people with the opportunity to people to visit it and have trail periods there. This helps people to make sure that the home will be ‘right’ for them and make sure that the home can support their individual needs. One person spoken to by the Commission stated that ‘I dint come to have a look around before I moved here as I was too ill, but my family visited and said that it would be good for me and it is’. The home does not provide intermediate care to the people that use the service. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live at the service have all of their health and personal care needs met there, however the documentation that supports the care of the individuals does not always include appropriate detail of how these needs must be supported and emergency care placement do not always have essential care plans in position within appropriate timescales. EVIDENCE: The Commission looked at all of the services information in relation to three of the people that were living at the home. All three of these files included a care plan provided through their funding authorities and two included care plans that had been developed by the home. The third person had been an emergency admission the previous week and no care plans were in position to identify what needs they had and how they needed to be supported with them. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 12 The care plans that were looked at by us had been evaluated on a monthly basis to make sure that they were still appropriate to the needs of the individuals involved and any changes to the care being given was recorded to. The care plans were supported by risk assessments including, skin problems (pressure sores), nutrition, moving/handling and activities of daily living. Information about the resident’s social interests, likes and dislikes, spiritual needs were also included within the individuals care plan. There was evidence to suggest that the local authorities care pans had not been reviewed as regular as their guidelines determine. The manager of the service stated that she was following this issue up with the funding authorities as this could also have implications as to how care is provided and the level of funding being received. The information that is recorded in the individual care plans and risk assessments has improved since the last inspection and are now beginning to identify a much more person centred approach to care. This process has only recently begun and it will take time to transfer all of the individuals care plans to this format. The manager of the service stated that this was a priority for the home and as care plans were reviewed they would be updated to a much more person centred care plan as opposed to a more generalised care plan. Most of the care plans that were seen included the signatures of the people that use the service or their representative’s identifying their agreement to them. 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. The Commission observed records in individuals care files that 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 and this included: GP’s, chiropodists, dentists and optician services. The individual care plans identified where individuals had specific nutritional and dietary needs, including PEG feeding, food supplements and soft diets. However one person who’s records were observed by the Commission was losing weight but this had not been monitored since September 2008. The qualified nurses in the home administer medication to people with nursing care needs and senior care workers administer medication to non-nursing care people in the home. Staff training records showed that the care staff receive appropriate formal medication administration training before they can administer medication to the people that use the service. 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. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 13 Since the last inspection window opening restrainers had been fitted to the medication room windows. This has helped to support the security of the medication room, and the rooms are now kept locked when they are not in use. 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. The CCTV cameras in the homes corridors that had been observed at an earlier inspection had been removed. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the social activities for the people that use the service are limited in the home. People that live there are only offered a limited range of activities. EVIDENCE: The manager stated that an activity co-ordinator is employed to work at the home. Unfortunately on the day of the site visit they were not available. During the sit visit the Commissions observations supported the evidence that individuals can choose what they become involved in at the home. Individuals were asked what they wanted to involved in. People spoken to by the Commission varied in their opinions in relation to the activities that are available in the home. Some people said things like ‘I don’t like to get involved in activities, I’d rather do things for myself’ while another said ‘ I get bored here, there’s not much to do’. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 15 The activities that are provided are quite restricted and do not necessarily meet the needs of all of the people that live at the home and do not necessarily provide adequate stimulation. Discussions with people that use the service, and their visitors and observation of records held in the home support the evidence that people that live at the home can have visitors at any reasonable time, and confirmed that they are always made to feel welcome. The Commission ate lunch with several of the people that live at the home. A choice of meal was available and the meals were well presented. A three course meal was available to all those that wanted it. One person stated ‘the meals are always very good’ and another person said ‘I enjoy my meals they are always tasty’. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the people that live in the home have their rights protected and there is a clear complaints policy and procedure. EVIDENCE: Haverholme 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 had been recorded at the home since the last inspection. People that use the service that were spoken to by the Commission said that they were confident that if they made a complaint that it would be listened to and where appropriate actions would be taken to make things right. Staff records and interviews with management and staff showed that most all of the care staff had received appropriate safeguarding adults training. The training was provided though the local authority, through National Vocational training and other external training resources. Interviews and discussions with care staff supported the evidence that they understood what could be considered as possible abusive situations in the home and this helped to show what they would do if they suspected that any abuse was taking place in the home. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 17 Since the last inspection the local authority conducted an audit of the home after receiving concerns in relation to the standards of care being provided there. This did not eventually go down the safe guarding adults route, and since their visit and recommendations the standards in the home have improved. 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.V374052.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,24,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the environment of the home has improved since the last inspection, however there are still areas of the home that need to be improved to provide a homely environment for the people that use the service. EVIDENCE: As part of the site visit to the service, the commission made a tour of the premises to see if the environment was suitable to the meet the needs of the people who use and work at the service. The lighting in the corridors of the home had improved since our last visit. The manager stated that there was a programme for the maintenance of the building and this included replacing some of the other existing lighting in the homes corridors. At the last inspection several light bulbs had broken and no Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 19 replacements were available at the home. At this site visit stocks of new light bulbs were observed to be in place at the home. New hand sanitizers had been fitted throughout the home. This will help to support infection control in the home and help to stop cross infection. The areas of damp identified at the last inspection have now been replaced. The manager of the home stated that this had taken a considerable time due to the extent of the damage and stated that the area was now fit for use. During this refurbishment a new wet room was fitted to the home. This helps to offer more choice to individuals on how they want their personal care needs to be met. Two bedrooms also had their en-suite facilities renewed. Also at the time of the building works a new nurse call bell system was fitted in the home. This is a much more up to date system and helps to ensure the health and safety of the people that use the service. At the last inspection it was identified that ‘One of the toilets had tiles missing on the wall. These need to be replaced to provide a safe, hygienic and homely environment. The sluice room doors need to have some kind of lock fitted to them to avoid unauthorised entry to these areas’. The tiles had been replaced and the sluice doors are now lockable. Toilet area 2 had recently been refurbished however the top of the hot tap was missing. This had been reported in the maintenance book and a new tap had been ordered. Bathroom 11 had been refurbished, however the walls had not been finished properly. The manager stated that she would make the builder aware of this. The manager stated that some of the homes thermostatic radiator valves were also going to be replaced to provide a more accurate service. Some of the bedroom furniture in the home was getting very old, and some drawers were seen to be falling apart. The bedding also looked like it was time to be replaced A tour of the kitchen found it to be very clean and was well stocked. The only concern in the kitchen was the condition of the flooring. The condition of the floor remains a concern. ‘Consideration should be given to providing a new floor covering to ensure a safe working environment. There are areas of the floor that are badly stained and these areas cannot be cleaned properly’. A new double fridge had been provided in the kitchen after the last fridge had been condemned. The inspector 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.V374052.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the staff records in the home do not support that they receive all of the mandatory ands specialist training that they require to understand and meet the needs of the people that use the service. EVIDENCE: Since the last inspection and the renovation of the building there had been several concerns raised in relation to the care and nursing staff levels at the home. The management of the service attempted to address some of these issues through inviting people who use the service and their representatives to meetings to air their views and opinions. The staffing levels at the home suggest that there are reasonable staffing levels at the home to be able them to meet the care needs for all of the people that live there. There were no staff working in the home that were under 18ys of age and no staff under 21yrs are ever left responsible for any part of the service. A small number of the care staff have completed their NVQ 2 in care or equivalent. The manager of the service was reminded that the service must Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 21 ensure that a minimum of 50 of the care staff have achieved NVQ2 or equivalent in care. This is an outstanding requirement. The Commissions direct observation of staff training records and interviews with staff identified that they are not up to date with most of their mandatory training. It is important that this training is completed by all of the staff working at the home to make sure that they have all of the necessary skills and knowledge to be able to safely care for the people that live in the home.. People that live in the home were very positive in relation to the abilities and skills of the staff. One person said ‘the staff are lovely, they are always busy, but always make time for you if you need them’. A visitor to the service said ‘the staff are very friendly and know their jobs, they are very busy, but just get on with it without complaining’. Staff personnel files that were observed by the Commission supported that equal opportunities are followed when employing new staff to work at the home. The following statement was made in the last inspection report and the point still remains ‘The staff do not wear any identification in the home. It would benefit some of the people that live at the home and their visitors if they were able to identify who they were talking to at any individual time’. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the home that the management of the home needs to make sure that the care and nursing staff receive the correct training and supervision to make sure that they have the necessary skills and knowledge to be able to safely care for the people that use the service. EVIDENCE: The manager of Haverholme had resigned her position in December 2008, however she was asked to rescind her resignation shortly after and did so returning to the home after a very short absence. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 23 The manager of Haverholme is a qualified Registered General Nurse (2001). She has had previous management experience in another residential nursing home and has worked in residential nursing care for the past twenty years. The manager of the service has completed most of the units required for the Registered Managers Award. The manager of the home has not yet made a request to the Commission to be recognised as the registered manager of the home. Haverholme do not have a formal effective quality assurance and monitoring system in position. It is very important that this is developed as a priority. This would help the service to gain other peoples views in relation to how people’s individual needs are met through the services provided by the home. The homes last quality assurance questionnaire feedback was in January 2008.The corporate body however carry out a national audit for all of their services. Staff supervision records did not support that the care and nursing staff have received the recommended minimum of formal supervision in the last twelve months. 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. This is an outstanding requirement from the last inspection. 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. The manager of the home was reminded that the Commission will no longer accept requirements be carried over to the next inspection without enforcement action being considered. However it was identified that the home has made good progress since the last inspection and appeared to be moving forward in a positive manner, therefore on this occasion enforcement action would not be taken by the Commission at this time. Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X 3 2 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 25 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 must make sure that in all cases individuals should have a care plan detailing how their needs must be met at the home within 48hrs of their arrival at the home. This will help to make sure that the placement is appropriate and can support the individual’s needs. The registered person must make sure that all of the refurbished areas of the home identified in the report have their work completed. This will help to support the health and safety of the people that use the service. The registered person must ensure that all of the staff completes their mandatory training to ensure that they have the knowledge and skills to care for the people that are living at the home. (Original timescale of 09/06/08 was not met) The registered person must DS0000002789.V374052.R01.S.doc Timescale for action 30/03/09 2. OP19 16 30/03/09 3. OP27 18 (1a) 30/04/09 4. OP31 8 and 9 14/03/09 Version 5.2 Page 26 Haverholme House Care Home 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. (Original timescale of 09/06/08 was not met) 5. OP33 24 (1,2) The registered person must 30/03/09 ensure that the home has an effective quality assurance and monitoring system. This must show how residents, relatives and other key people are consulted about services provided by the home and any action taken to address any issues raised by these individuals (Previous requirements of 31/03/07 and 09/06/08 were not met) 30/04/09 The registered person must ensure staff receive formal and recorded supervision as a minimum of six times a year (pro-rata). This is needed to ensure staff receive, necessary guidance and support to carryout their work effectively and to receive feedback on their performance. (Previous timescale requirements of 31/03/07 and 30/906/08 were not met) 6. OP36 18(2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 27 1. OP7 The registered manager should make sure that all of the people that are funded by the local authority have their care plans re-assessed by the local authority within their guidelines. This will help to make sure that the home is able to support their needs. The registered person should make sure that there is a range of stimulating activities that are made available to the people that live at the home and that transport to activities in the community is accessible to all those that would wish to use it including people that use wheelchairs. This will allow people to have more choice in the range of activities that they want to be involved in. The registered person should evaluate the condition of the kitchen floor and provide a surface that supports health and safety in the kitchen. The management of the service should consider replacing the bedding in the home as it is all looking old. They should also consider renewing some of the bedroom furniture and fittings. This will help to provide a more homely and comfortable environment for the people that live at the home. The registered person should make sure that the staff that are on duty are identifiable to the people that live there and to visitors to the home. The registered person must make sure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent in care to support that they have the knowledge and skills to be able to care for the people that live at the home. 2. OP12 3. OP19 4. OP19 5. OP27 6. OP28 Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haverholme House Care Home DS0000002789.V374052.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!