Inspection on 05/01/06 for Havering Court Nursing Home

This inspection was carried out on 5th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Havering Court Nursing Home 09/10/07

Havering Court Nursing Home 20/03/07

Havering Court Nursing Home 31/05/06

Havering Court Nursing Home 30/07/05

Havering Court Nursing Home 24/03/05

Havering Court Nursing Home 17/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Havering Court Nursing Home Havering Road Havering-atte-Bower Romford Essex RM14 4YW Lead Inspector Ms Edi O`Farrell Unannounced Inspection 5th January 2006 11:00 Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 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 Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Havering Court Nursing Home Address Havering Road Havering-atte-Bower Romford Essex RM14 4YW 01708 737 788 01708 740 783 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) BUPA Care Homes (BNH) Limited Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (16), Physical disability (36) of places Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 16 BEDS FOR ELDERLY FRAIL 36 BEDS FOR PHYSICALLY DISABLED MINIMUM STAFFING NOTICE Date of last inspection 30th July 2005 Brief Description of the Service: Havering Court is a purpose built residential care home with nursing, which is operated by BUPA, a large private company that runs similar homes across the UK. The home is registered for 36 younger adults (18 to 65) who have a range of physical disabilties, and 16 older people (over age 65). It is situated in Havering - atte - Bower, a semi-rural area, which is an approximately 15 minute bus journey from the nearest rail link in Romford Town Centre. The home is set in spacious ground and woodlands, which provide pleasant views from bedroom windows. The accomodation is spread over a ground and a lower ground floor, with access via a lift and stairs. The lower ground floor has 14 bedrooms of varying sizes, bathrooms and showers, and a large lounge with french windows onto a pleasant patio and garden. The main kitchen, laundry, and staff rooms are also on this floor. The remaining bedrooms are on the ground floor, along with a large lounge/dining area, staff offices, bathrooms, and communal sitting areas. Many of the service users have very high dependency needs due to the level of disability, and some have additional learning disabilities. Nursing and personal care are provided on a 24 hour basis. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday from late morning to late afternoon. It was the second statutory visit in the inspection programme for 2005/6. Over the course of the two visits all core standards have now been assessed. The focus of this inspection was to check on progress in relation to 17 Requirements set at the previous inspection, several of which had been restated from previous inspections. Some of the Requirements have still not been met, and have been again restated in this report with a new timescale for compliance. Further information about each Requirement can be found under the relevant standards. Unmet Requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The building was toured, some service users were asked for their views, and key staff were asked about such things as finance, medication, and health and safety. The findings of the inspection were discussed with the manager. Some information from the previous visit has been used in writing this report, and where standards were assessed as met at the previous inspection they were not covered on this visit. What the service does well: What has improved since the last inspection? Some bedrooms have been redecorated, and an action plan for other necessary redecoration, such as repairs and painting of damaged doorframes, is being developed. A permanent manager has now been appointed, and she has lots of good ideas on how to improve the service. This includes a ‘resident of the day’ initiative, which takes a holistic approach to each individual, and a staff training programme focused on how staff can offer the best possible Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 6 service. A staff supervision programme has been planned, and a survey of service users has resulted in some changes to the menu. 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. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Prospective service users have the information they need to make an informed choice about where to live. Their needs are fully assessed prior to admission. EVIDENCE: The Statement of Purpose has been amended since the last inspection, and is now very clear as to which categories of service users can be admitted. A copy is prominently displayed in the entrance hall, and a copy of the service user guide is stored outside each bedroom. Two care files were examined, and these demonstrated that full assessment takes place prior to admission, and that the information gathered is then used to develop comprehensive care plans. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Standards 6 to 9 were not tested on this visit. However evidence from the last inspection was that management and staff had put a considerable amount of work in over recent months in re-assessing and reviewing needs. Care plans are comprehensive and regularly reviewed. Service users are helped to exercise choice and to make decisions about their lives, within a risk management framework. Where possible they, and their representatives, are consulted on, and participate in, the life of the home. Confidential information about service users is now being stored correctly. EVIDENCE: Standards 6 to 9 were not specifically tested on this visit, as there were no outstanding requirements. At the time of the last inspection all of the Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 10 outcomes were assessed as met. These standards will be re-tested at a future inspection. Care plans are now kept in bedrooms, rather than in the corridors, and there has been an increased emphasis on the security of confidential information. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA11, 12, 13, 14, 15 & 16 and OP 10, 12 & 13 The home gives a high priority to meeting social and leisure needs, by the provision of both group and individual activities. EVIDENCE: Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 12 The activity programme was discussed with one of the activity co-ordinators, and with some service users. The visit was unannounced and started with an unaccompanied tour of the building at 11.00am. A group discussion about how Christmas had gone was taking place in the upstairs lounge, and this was followed by a quiz. During the afternoon one of the activity co-ordinators went to the pictures with two service users. Comprehensive records of all activities are maintained, including where service users choose not to take part. The home caters for the needs of both younger adults and older people, and this is taken account of in the activity programme. Attention is also paid to meeting individual as well as group needs, for example, one service user is attending a local collage, and swimming and walks are arranged for other service users. All activities outside the home are risk assessed. Service users are regularly consulted about the range of activities, and the timetable is kept as flexible as possible, so as to respond to changing moods. Where service users have creative talents, this is actively encouraged, for example, they made Christmas cards by hand. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA 19, 20 & 21 and OP 8, 9 & 10 Health, personal, and social care, needs are identified in the care plans, and are met on a day-to-day basis. The practices in relation to medication are still not fully protecting service users, and put the home at risk of enforcement action by the Commission. Staff need support and training in approaching service users and their relatives regarding dying and death. EVIDENCE: Several service users were visited in their rooms, and their care plans were compared to the care being provided. The new manager is in the process of introducing a ‘resident of the day’ system. This is a holistic approach to care, where all aspects of the service as they relate to each individual service user Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 14 are examined in detail. The Commission looks forward to seeing the result of this new system at the next inspection. As part of the last inspection one of the Commission’s specialist pharmacist inspectors carried out a detailed review of the home’s medication policy, procedure, and practices. Particular concerns were raised regarding inadequate records for the medicines received into the home, and carried forward to the following four week prescribing cycle. This meant that it was not possible to carry out a full audit. It is a matter of concern to the Commission that the limited audit carried out on this visit highlighted continuing inaccuracies. These included, PRN medication in the cupboard, where there was no prescription, yet the nurse reported that it is currently prescribed; a Depixol ampoule being in the carton, when according to the MAR chart eight had been received and eight given, so none should have been remaining; and pain relief tablets not corresponding with the numbers received and given. Requirement 1 has been brought forward from the previous inspection, and must be complied with, within the new timescale. In discussion during the inspection the manager agreed to contact the home’s pharmacist to request an urgent review of medication practice, in particular audit and control. Following this a report must be forwarded to the Commission detailing the steps taken by the manager to ensure that correct practice is followed at all times. This is Requirement 2. A Requirement has been set at previous inspections in relation to illness, dying and death. This was discussed with the manager during this visit, who reported that action is in hand. Requirement 3 has therefore been brought forward with a new timescale, which must be achieved. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA22 & 23, and OP16 & 35 The manager takes complaints seriously, and listens to, and acts on, the views of service users, and their relatives. Service users’ financial interests are safeguarded. EVIDENCE: The record of complaints was examined, and discussed with the manager, and some service users were asked for their views. Service users were clear who they would complain to, and the records were comprehensive. The home’s records of dealing with service users’ finances were examined, and discussed with the staff member who is currently administering them. Where possible service users retain responsibility for their own money, or relatives, with power of attorney, or enduring power of attorney take control. Where this is not possible the local authority or Public Guardianship Office are involved. Where staff at the home handle any money there are both manual and computer records, which are regularly audited by external officers. One bank account is used, but interest is allocated out to each service user. Just prior to the last inspection adult protection training had been provided for many of the staff, who on that visit ably demonstrated how this had impacted on their practice. This training is to be repeated, so that all staff will have attended. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 16 Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA24,29 & 30 and OP 19, 22, 25 & 26 The initial impression is of a homely, comfortable, environment, but repair and redecoration of paintwork has still not been carried out. Some service users still do not have the specialist equipment they need to maximise their independence, and comfort. The home is clean and hygienic. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 18 EVIDENCE: Six Requirements were set at the previous inspection, some of which have been partly actioned, but others not. Whilst some bedrooms have been redecorated skirting boards and doorframes remain damaged and need to be repainted. This is Requirement 4 restated from the last two inspections. Failure to meet the new timescale will result in the Commission taking action. At the last inspection it was queried if the doorframes were too narrow for some of the larger wheelchairs. During this visit the manager stated that the doorframes were wide enough, and that staff needed to take greater care when manoeuvring chairs through the doors. She also reported that she intended to have the doors and frames strengthened to reduce the possibility of damage. Seven specific changes to the environment were covered by one Requirement in the last report. Four of these have been actioned but the others remain outstanding. These are Requirements 5, 6 and 7. The home provides a service to adults of all ages, who have a wide range of disabilities, many very severe. At the last inspection it was noted that one service user, who has to sit in a wheelchair for most of the day, looked very uncomfortable. At that stage staff had contacted the wheelchair service with little result. During this visit staff reported that the service user had been visited, but that they were still waiting for new equipment. Another service user still has to sit in a wheelchair all day because a special easy chair has still not been purchased. This was discussed in detail with the manager during this visit. The needs of this service users appear to be being given a lower priority than discussions as to who should pay for the equipment. Requirement 8 has been brought forward from the previous inspection. Where service users are assessed as needing specialist furniture or equipment it must be provided. All areas of the home were clean, and no offensive odours were noted. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, 34, 35 & 36 and OP 28, 29, 30 & 36 Service users are supported by competent staff, but the deadline for at least 50 of care staff to have achieved NVQ Level 2 by 31/12/05 has not been met. Service users are protected by the home’s recruitment policies and procedures. Staff still need training in dealing with dying and death. EVIDENCE: Staff were observed carrying out their duties, recruitment files were examined along with minutes of staff meetings, and training records. Supervision was discussed with the manager. Both nursing and care staff are knowledgeable about the needs of the service users, and the case records, such as daily logs, show that they are being met on a daily basis. Recruitment files held all Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 20 required documents. In response to previous Requirements five staff have attended a course on meeting the needs of people with learning disabilities. Training in dealing with dying and death remains outstanding and has been brought forward as Requirement 9. Some care staff have achieved NVQ Level 2 but the home has not met the target date of 31/12/05 for this to be 50 . They now need to negotiate with the Commission for a revised timescale. This is Requirement 10. Once the proposal is received an additional requirement will be set by separate letter, so as to ensure that the new timescale is met. A programme of structured supervision has been planned, but the manager reported that the home is not currently achieving the six sessions per year that the Standards state. This is Requirement 11. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA37, 38 & 42 and OP31, 32 & 38 The home has suffered from the lack of a permanent manager for a considerable period of time. Service users, their relatives, and staff should benefit from the recent recruitment of an experienced manager to this post. The healthy, safety and welfare of service users and staff are promoted and protected. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 22 EVIDENCE: The new manager is in the process of being registered by the Commission. She is suitably qualified and experienced to manage the home, and has lots of ideas for improving and developing the service. She demonstrated a sound knowledge of the needs of both younger adults and older people, and of the specific needs of the current service users. She was observed to have a good relationship with staff and service users, and has responded promptly to any concerns raised by relatives. A survey of service users has recently been carried out and changes made, for example to the menu, based of their views. Health and safety records were sampled, and discussed with the handyman, who has lead responsibility in this area. All records were up to date, with regular in-house checks, and maintenance contracts. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 1 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 X 40 X 41 X 42 3 43 x X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Havering Court Nursing Home Score X 3 1 2 DS0000015593.V276252.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? 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 OP9YA20 Regulation 13 (2) Requirement All Requirements set by the specialist pharmacist inspector in the letter of 05/08/05 must be actioned. Previous timescale of 30/10/05 not met. The manager of the home must forward a report to the Commission setting out what steps have been taken to ensure that all medication is always accounted for, and that there is a clear audit trail. Service users’ wishes in relation to dying and death must be recorded in their care plans, for all staff to refer to when needed. Previous timescales of 23/07/05 and 31/10/05 not met. The home must have a regular programme of maintenance to repair areas that are run down, such as flaking paintwork, and scraped woodwork. Previous timescales of 23/07/05 and 30/11/05 not met. The carpet in the bedroom where there was a fire must be DS0000015593.V276252.R01.S.doc Timescale for action 31/03/06 2 OP9YA20 13 (2) 31/03/06 3 OP11YA21 12 31/03/06 4 OP19YA24 23 (2) 30/04/06 5 YA24 23 31/03/06 Page 25 Havering Court Nursing Home Version 5.1 6 YA24 23 7 YA24 23 8 OP22YA29 23 9 OP30YA35 18 & 19 10 YA35OP30 OP28YA32 18 (1) c 11 OP36YA36 18 (2) replaced. In consultation with the service user this may be carpeting or any other suitable floor covering. The outer doors to the kitchen must be replaced, or redecorated, as they are badly dented and scuffed. The broken bath hoist in the pink corridor, and the broken shower cap in the orange corridor must be repaired. Where specialist equipment, including furniture, is assessed as needed, it must be provided. Previous timescale of 31/08/05 not met. Training and support must be provided for all staff in dealing with dying and death. Previous timescale of 31/12/05 not met. The Registered Person must provide the Commission with their proposals for a new timescale for at least 50 of care staff to achieve NVQ Level 2 or above. Timescale of 31/12/05 for achieving this was not met. Once the new timescale has been agreed an additional Requirement will be set, which must be met. The Registered Person must ensure that staff are appropriately supervised. 30/03/06 30/03/06 28/02/06 30/04/06 28/02/06 30/06/06 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 DS0000015593.V276252.R01.S.doc Version 5.1 Page 26 Havering Court Nursing Home Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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. Havering Court Nursing Home DS0000015593.V276252.R01.S.doc Version 5.1 Page 28 - 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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