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

This inspection was carried out on 9th January 2008.

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 08/01/09

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Haverholme House Care Home Broughton Road Appleby Scunthorpe North Lincolnshire DN15 0AD Lead Inspector Stephen Robertshaw Key Unannounced Inspection 9th January 2008 09:15 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.V357578.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.V357578.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) Ancyra Health Ltd Position 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.V357578.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. 15th January 2007 Date of last inspection Brief Description of the Service: Haveholme 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 ranged from £341.94 to £388 per week plus a nursing supplement if required of between £101 and £139 a 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 acting 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.V357578.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 09th of January 2008 and was unannounced. The inspector was in the home for approximately 7.5 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. Before the visit took place surveys were sent out to people that live at the service, their relatives, outside professionals and care staff that work at the home. 19 of the surveys were returned to the Commission this included: 3 from care managers, 2 from relatives, 1 from a service user and 13 from people that work at the home. The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to then during the inspection visit. Their comments and input have been a valuable source of information, which has helped inform this report. 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: People that live in the home say that the staff are ‘very friendly’ and ‘look after us well’. The inspector observed staff and people living in the home, it was clear that they have very good relationships with each other and that they all get along. The health care needs of the people living in the home are well met and staff are provided with training to make sure that they understand the needs of the service users and that they can do their jobs well. Service users are provided with meals that they choose and like, however they are encouraged to follow a healthy diet including lots of fresh fruit and vegetables to try and maintain their health. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. This is what people staying in the home experience. This judgement has been made using available evidence including a visit to this service. This means that the people that live at the home receive a full needs assessment before admission. However these assessments are very basic and do not include any detail of how individuals needs affect their daily lives. EVIDENCE: Since the last inspection the homes statement of purpose and service user guide have been updated and now identify the services that are provided at the home and that are included in the service users fees. Detail is also provided giving information in relation to the proprietors, manager and carers and nurses available through the service. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 9 New contracts have been issued to all of the people that live at the home, however the manager stated to the inspector that most of these had not yet been returned to the service, however she would ensure that they are followed up. The inspector observed the care files for five 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 assessments were very basic and did not give any clear indication of how individual needs affected the daily lives and activities of the people involved. The new manager showed the inspector a new assessment process that she is hoping to introduce to the home. This appeared to be more appropriate to the pre-admission process and if used correctly would include the information that would be required. People that live at the home who received nursing care had had a health care assessment completed by an NHS registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual and to determine the amount of financial support they would receive. The home currently 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 deliver their care. All of the surveys returned to the Commission were very positive in relation to the services ability to meet the needs of the people that live at the home. One service user stated to the inspector ‘you could not want anything else, everything you need is here, this is not a care home it is home!’. People spoken with by the inspector said that they were given the opportunity to visit the home before they moved there on a more permanent basis. One person told the inspector that ‘I came here even though I didn’t live close or have a trial visit, I had known the home for a long time and knew that if I needed to go anywhere I would come here’. The home does not provide intermediate care. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 10 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, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: The inspector observed the case files for five of the people that were living at the home. All of these files included a care plan provided through their funding authorities and also care plans that had been developed by the home. The care plans looked at by the inspector 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 recoded to be implemented by the staff. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 11 Risk assessments were in place to cover a wide range of areas 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. The recording of information in the care plans and risk assessments was very basic and did not give detail of how individuals needs affected their daily lives and the level of support they required to carry out specific tasks. An example of this is a care plan that was observed stated that the person needed support with having a bath, but it did not detail the actual support that was required. There was evidence that local authority funded service users and others that self funded had a minimum of an annual review of their assessed needs. The majority of the care plans included people that use the service or their representative’s agreement to the care plans. This helps to ensure that people that live at the home have had input to their plans and agreed to the contents. Not all of the documents that had been completed included full dates and signatures of the people that had completed them. Some only included initials. This could cause difficulties at a later stage if the person needed to be recognised and shared the same initials as somebody else that was working at the home. One person that lives at the home stated to the inspector ‘you get well looked after here, the staff are very hard working and are very good at their jobs’. The records seen by the inspector provided evidence that the people that live at the home all had good access to outside professionals to support them with their healthcare needs and this included: GP’s, chiropodists, dentists and optician services, with records of their visits being written into their care plans. Individuals spoken to by the inspector stated that they were very happy with their access to healthcare services. One person stated that ‘I can go to the doctors surgery, but if I am really unwell the doctor comes to see me here’. The individual care plans identified where individuals had specific nutritional and dietary needs, including PEG feeding, food supplements and soft diets. People that live at the home have their weight recorded on a monthly basis to support the evidence from their diet plans and personal health records. Since the last inspection improved records are made in the home in relation to individuals fluid intakes for people that are supported with PEG tubes. The keeping of detailed records of all feeds (including batch numbers) and flushes administered via the PEG tube is standard nursing practice. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 12 A new policy and procedure had been develop in the home to support the care of people with PEG feeds. Qualified nurses in the home administer medication to individuals with nursing needs and senior care workers administered medication to non-nursing residents. Records and interviews with staff showed that these staff had completed appropriate medication training. Checks on the medication records showed that overall these were well maintained and kept up to date, however there were a few areas where they needed to be improved. These included; The medication records observed by the inspector were up to date and had been accurately recorded and were appropriately stored. This included the controlled drugs that were held in the home. However neither of the two medication rooms in the home were locked when nobody was in them and the ground floor windows were open and there were no restrainers on them. This means that it would be possible for someone from outside the home to access the medication room. Direct observations supported that service users dignity and respect is upheld at all times in the home. However if the CCTV cameras in the corridors were operational then privacy and dignity would not be supported. One person stated to the inspector ‘you are well looked after here, you can be on your own or you can see other people around the home, sometimes I like to be on my own and other times I like to be with other people’, another individual stated ‘ I haven’t been here very long, its very different to living in your own home, but the staff are good and look after you well, I couldn’t look after myself at home. All of the care files seen by the inspector included the individuals last wishes in the event of their deaths and identified who would be responsible for making any of the arrangements including family, legal representatives and the home itself. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 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 daily lives and social activities are limited in the home. People that live there are only offered a limited range of activities and there is not appropriate transport available to allow people in wheelchairs to be transported. EVIDENCE: The manager of the home stated that an activity co-ordinator is employed to work at the home three days a week. The homes rotas and interviews with the staff including the co-ordinator confirmed that this takes place. Direct observations supported the evidence that individuals can choose what they become involved in at the home. On the day of the site visit people that live at the home were observed playing dominoes and Scrabble. The activity co-ordinator was seen talking to the individuals over lunch to determine what activities they wanted to become involved in. People spoken to stated that ‘we have more activities now. At Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 14 Christmas we had a pantomime, and several choirs visited to sing to us’. People that are fully mobile have more opportunities to attend activities in the community, as the homes transport does not accommodate people in wheelchairs. The manager of the service stated to the inspector that a new bus has been requisitioned and that this would make transport available to anyone at the home that required it including those people that use wheelchairs. The activities are restricted and do not necessarily meet the needs of all of the people that live at the home. One service user stated ‘the activities are more regular now, but you don’t have to do them if you don’t want to’. The activity co-ordinator would benefit from accessing specialist training in relation to activities for older people. This would help to develop activities with a wider scope and interest for the people that live at Haverholme House. The activity co-ordinator records her involvement with individuals in their personal care files and in an activity log that she maintains. This is widely a duplication of information and the service users would benefit from only record being made as this would allow the activity co-ordinator to spend more time with them developing stimulating activities. All of the service users that were spoken to by the inspector stated that they could have visitors at any reasonable time. The manager and care staff also confirmed this information. No visitors were available at the time of the site visit to confirm this, however surveys returned from families said that they were always made to feel welcome at the home. Care plan information included the likes and dislikes of individuals and their religious preferences. We participated in lunch with five 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 also said that ‘a full cooked breakfast is available on two days a week’. All of the people spoken to stated that the quality of the meals in the home was very good. One person said ‘the meals are much better now and if you don’t like what is on the menu than you will be offered an alternative. One person was given an alternative meal, as they did not like what was on the menu. The person involved said that they were ‘happy’ with the alternative that was provided for them. There had been no regular meetings held with the people that live at the home and their representatives to determine what their likes and dislikes are, or to help to identify what activities they would like to become involved in. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 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 people that live in the home have their rights protected and there is a clear complaints policy and procedure. EVIDENCE: The home 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. The reference to the Commission has been amended to relate to the new North Eastern region. No formal complaints had been recorded at the home since the last inspection. Service users spoken to by the inspector stated that they were confident that if they made a complaint that it would be listened to and be acted on appropriately. Care files observed by the inspector clearly identified who was responsible for dealing with individual’s finances. This included the supporting paperwork from the Court of Protection and the appointed representatives. Since the last inspection almost all of the care staff had received safeguarding adults training. The training was provided though the local authority and took place within the home itself. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 16 Interviews and discussions with care staff supported the evidence that they understood what could be constituted as abuse in the home and what they would be required to do if they suspected that any abuse was taking place. At the last inspection it was recognised that one referral had been made to safeguarding adults. Since this time the home have been involved in a safe guarding reference as in line with local authority policies and procedures. At the time of this site visit the outcome of the investigation had not been resolved. It was stated to the manager that it was a priority to conclude this as soon as possible in the best interests of all parties involved. Examination of a sample of staff 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.V357578.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 23, 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. The environment generally requires a lot of improvement to create a homely atmosphere for the people that live there. EVIDENCE: We made a tour of the premises to see if the environment was suitable to the needs of the people who use the service and the staff. The corridors of the home were very dimly lit. The strip lighting was old and the covers were tarnished and this reduced the amount of light that passed through them. This means that the corridors are dull and this could cause people to trip or fall. Several of the light bulbs in one of the main dining rooms were out, and no replacements were available in the home. This meant that people that live in Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 18 the home could have difficulties seeing correctly at mealtimes and for any activities being held in the room. The handyman stated to the inspector that a supply of the appropriate bulbs had been ordered and should be arriving at the home very soon. One area of the home had recently had a damp problem. The walls were back to bare plaster and the carpet was damaged. The manager stated that when the walls had dried out they will be re-decorated and then a new carpet that has been ordered will be fitted to the corridors to replace the damaged or old carpets. One of the bathrooms in the Grove area of the home was being used as a storage area and had linen towels and blocks of soap left out openly. The inspector also observed linen towels and blocks of soap in several of the other bathroom and toilet areas. This could cause infection control problems in the home. The bath in the same bathroom is very close to a bidet; this makes it difficult for the carers when they need to use a hoist to assist individuals in to the bath. The inspector was also informed that the bath unit had a crack in it. This area does not have a shower room available to the people that live there the management of the home should consider how to make this a more accessible/usable area. A wet room has already been developed in the other half of the home and the staff reported that this had made a big difference stating that the service users now had a choice of having either a shower or a bath. 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. 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. 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. As stated earlier in the report the management of the home must ensure that the medication areas of the home are correctly and safely secured. 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 servicing. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 19 All of the rooms in the home are for single occupation and 19 of the rooms include en-suite facilities. This means that all personal care and treatments can carried out in private ensuring the privacy and dignity of the people involved. The manager of the home must review the CCTV cameras in the corridors of the home and the current infringement they cause to privacy, dignity and respect of the people that live there. A relatives survey commented in their returned survey ‘they offer a home from home environment’. There had been a long period in the home when the call bell system was not fully operational. Recently a new call system had been fitted throughout the home and the staff confirmed to the inspector that this had much improved the response times in the home. Haverholme House Care Home DS0000002789.V357578.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 have the necessary knowledge and skills to be able to care for the service users, however some of their training needs to be updated. EVIDENCE: The residential side of the home always has a minimum of three staff on duty. This evidence was supported through the homes rotas. The nursing side of the home calculates the staffing hours in relation to the nursing hours required in 2002. 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. Only five of the care staff have so far completed NVQ 2 in care or equivalent, the manager of the service must ensure that a minimum of 50 of the care staff have achieved NVQ2 or equivalent in care. The manager of the home has only been in position for a very short period of time, however she has already established a clear training matrix for the staff. Approximately 50 of all of the mandatory training had recently been Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 21 completed by the staff working at the home. This was confirmed through observation of staff training records and interviews with staff. People that live in the home were very positive ion relation to the abilities and skills of the staff one person stated ‘the staff are very good, and know how to look after you properly’, a relative commented in their survey that ‘the staff are very friendly’, another stated ‘all staff who I have come in to contact with have been very helpful and polite, and transport is provided for relatives to visit due to the isolated area Haverholme is in’. Most of the questionnaires returned to the Commission believed that there was enough staff on duty to meet the needs of the people that live at the home on all shifts, however they mostly commented that it would benefit the service from having more staff available to allow more individual time to be available to people that would benefit from this. The inspector spoke with ten people that were living at the home and they all stated that that there were always enough staff available to meet their needs. As identified at the last inspection of the service the care plan records did not provide clear information on dependency levels for specific individuals it was therefore not possible to check whether existing staffing levels are appropriate. A review of staffing needs to be carried out based on assessment of the dependency levels of residents, using a recognised dependency tool, this will enable more accurate judgements to be made about the homes staffing needs. Staff personnel files that were observed by the inspector supported that equal opportunities are followed in employment of staff at the home. They also supported the evidence that the appropriate safety vetting had been completed before the staff had any access to the people that live at the home or the records that were associated with their care. The manager of the service stated that all new staff had a formal induction and a pro-forma for recording induction training was in place. However there had been no new staff employed to the home since the last inspection. An annual appraisal system was in place in the home and records showed some staff had had an annual appraisal, however some of these were over due. It is important that annual reviews are kept up to date, this is needed to ensure the homes training plans and priorities accurately reflect the needs of the staff team. 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. Individuals spoken to by the inspector stated that they knew most of the staff names, but they couldn’t remember some of them, particularly when new staff begin to work at the home. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 22 Several staff commented to the inspector that the service would benefit from the use of transport that people in wheelchairs could access; this would make activities available to a wider group of people at the home. The manager confirmed to the inspector that the outside management of the service had approved a new minibus with wheelchair access. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 23 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, 34, 35, 36, 37 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 now has stability in the management and this now needs to develop the processes for the service to run appropriately to meet the needs of the people that live there. EVIDENCE: Up until recently the home has been without a formal manager for over 12 months. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 24 The newly appointed manager 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, however she has not yet made an application to be registered with the Commission. This must be undertaken as a priority especially in relation to the length of time that the home has been without a registered manager. Staff and service users spoken to by the inspector stated that things had improved at the home since stability had been introduced to the internal management of the home. As the manager has only been in position for a limited amount of time the inspector was unable to determine their management approach to the home and their openness and availability. However on the day of the site visit the positive impact of the influences of the manager were evident. This included improved paper records for the home and in establishing appropriate training for all of the staff. The home did not have a formal effective quality assurance and monitoring system. It is very important that this is developed as a priority. This would allow the home to gather views from different people including outside agencies and professionals on how services are provided through the home. This would then allow the management to establish systems to maintain the quality of what is already being provided and how to improve any areas of need. However to support the quality of care provided through the home North Lincolnshire Council had awarded the home its Gold Standard for Quality Assurance. The inspector observed the homes finances and sampled two of the people that live at the homes personal finances. All of threes records were up to date and had been accurately recorded. The only improvement in the records was that full signatures should be used and not just initials. A staff supervision programme was in position and each staff member had an allocated supervisor. Five of the staff supervision records that were observed showed that staff are not in receipt of regular supervision. This is an outstanding requirement from the last inspection. The manager of the home stated to the inspector that supervision for the homes staff was being reestablished at the home and all staff had already had an annual appraisal planned. The manager of the home also needs to be provided with formal recorded and structured supervision to support her in her role and the development of the service. All of the records that are required by regulation were kept by the home and were stored in accordance with the Data Protection Act 1998 and other associated other legislation and good working practices. However some of the records required greater detail and full signatures instead of initials. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 25 General health and safety shown to be supported and maintained in the home. This was supported through the homes policies and procedures, staff training and the maintenance of equipment. The home had up to date safety certificates for the gas and electric systems. Information seen by the inspector also supported that moving and handling equipment was regularly serviced and maintained. General risk assessments for people that live at the homes were seen in their individual files including those for moving and handling, bed rails and daily activities of living. However these were very basic and could be developed further to state how the risks affect individual s lives and what can be done to reduced the risks to the individuals involved. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 2 X 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 3 3 1 2 3 Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation 5 (1c) Requirement The registered person must make sure that all of the people living at the home have a contract that details the care that they receive for the fees that are paid. This is to make sure that they understand if they have to make any contributions and if so how much. The registered person must make sure that the preadmission assessments include detailed information of how prospective residents needs affect their daily lives and identify the support that they require to meet these needs. This will make sure that the home understands how a persons difficulties affect their daily lives.. The registered person must ensure that the individual care plans and risk assessments for people that live in the home identify the level of the support that they require at the home and how it must be delivered. This will help the staff to understand how individuals in DS0000002789.V357578.R01.S.doc Timescale for action 10/03/08 2. OP3 14 (1, 2) 29/02/08 3. OP7 15 (1,2) 29/02/08 Haverholme House Care Home Version 5.2 Page 28 4. OP8 OP19 16 (2j) 5. OP9 OP19 6. OP10 OP19 7. OP12 8. OP19 9. OP19 OP20 the home need to be cared for. The registered person must make sure that all bathrooms and toilets do not include linen towels and blocks of soap to support the homes infection control policies and procedures and to ensure the health and hygiene requirements al of the people at the home. 23 (2i) The registered person must make sure that the medication rooms in the home are kept secure. This includes the windows and doors to make sure that no unauthorised entry can be made to the rooms. 12 (4a) The registered person must review the CCTV coverage in the homes corridors and how this infringes on the privacy, dignity and respect of the people that live at the home. 16 (m) The registered person must 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. 23 The registered person must (1a,b,2a,b make sure that the damp areas ) of the home are appropriately repaired and decorated and the damaged carpets are replaced to create a more homely atmosphere for the people that use the service. 23(2b,p) The registered person must improve the lighting in the corridors of the home to create a more homely environment and DS0000002789.V357578.R01.S.doc 14/01/08 14/01/08 29/02/08 30/04/08 29/02/08 07/03/08 Haverholme House Care Home Version 5.2 Page 29 10. OP19 OP20 OP26 23(2b,p) 11. OP19 OP21 23 (2b) 12. OP19 OP26 16 (2j) 13. OP27 18 (1a) 14. OP28 18 (1a) 15. OP31 8 and 9 to make the corridors safer for people to use. The registered person must make sure that there are adequate stocks of appropriate light bulbs in the home to replace bulbs when they are no longer suitable for use. This will make the rooms lighter and safer for the people that use them. The registered person must replace the missing tiles in the identified toilet to maintain health and safety in the home. The registered person must evaluate the condition of the kitchen floor and provide a surface that supports health and safety in the kitchen. The registered person must ensure that all of the staff complete their mandatory training to ensure that they have the knowledge and skills to care for the people that are living at 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. The registered person must 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 ensure that the home has an effective quality assurance and monitoring system. This must show how residents, relatives and other key people are DS0000002789.V357578.R01.S.doc 14/01/08 14/02/08 30/03/08 30/05/08 30/06/08 29/02/08 16. OP33 24 (1,2) 30/04/08 Haverholme House Care Home Version 5.2 Page 30 17. OP33 24 (1) 18. OP36 18(2) 19. OP37 17 consulted about services provided by the home and any action taken to address any issues raised by these individuals Previous requirement of 31/03/07 was not met). The registered person must 31/03/08 develop regular service user and family meetings to gain their views on the services that are provided in the home and to allow them to offer opinions on how the service needs to be developed. The registered person must 30/06/08 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 requirement of 31/03/07 was not met). The registered person must 14/01/08 ensure that all records completed by the staff include full dates and signatures. This makes it easier at a later date to identify who completed them if required. Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 31 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 OP19 Good Practice Recommendations The registered person should consider making a change to the bathroom in the Grove area to make it more accessible and to offer choice to people that live at the home to have a bath or a shower. The registered person should provide the activity coordinator with specialist activity training to help them to develop the range and interest of the activities that are made available to the people that use the service. 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 should make sure that the programme for completing the staff appraisals is completed for all staff working at the home. 2. OP27 3. 4. OP27 OP36 Haverholme House Care Home DS0000002789.V357578.R01.S.doc Version 5.2 Page 32 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.V357578.R01.S.doc Version 5.2 Page 33 - 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. 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