Inspection on 11/03/08 for Haversham House

This inspection was carried out on 11th March 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Haversham House 25/02/09

Haversham House 24/04/07

Haversham House 20/04/06

Haversham House 09/09/05

Haversham House 21/04/05

Haversham House 01/10/04

Haversham House 05/04/04

Similar services:

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

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

CARE HOMES FOR OLDER PEOPLE Haversham House 327 Bromsgrove Road Redditch Worcestershire B97 4NH Lead Inspector Pat Scott Unannounced Inspection 11th March 2008 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haversham House DS0000018486.V349467.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. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haversham House Address 327 Bromsgrove Road Redditch Worcestershire B97 4NH 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) 01527 542061 01527 544732 Springlea Limited vacant post Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (16) Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named service user between 60 and 65 years of age. 24th April 2007 Date of last inspection Brief Description of the Service: Haversham House is a small home, which provides a service for 16 older people who may have a physical disability and/or a dementia type illness. The home is situated close to Redditch town centre. There is a local bus service available. Car parking is available for visitors and staff. The home is an adapted town house, which has accommodation on two floors; the first floor is accessed by a stair lift. Fees at Haversham House are £420.00 per week including top ups. Addition charges are made for items such as hairdressing, private chiropody, toiletries and newspapers. The inspection report is available in the home. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is *one star adequate service. This means the people who use this service experience adequate quality outcomes. We, the commission, used a range of evidence to make judgements about this service. This includes: information from the provider in the annual quality assurance assessment, staff records kept in the home, medication records, survey results from people who use the service, surveys from the staff team, discussion with the manager, tour of the premises, previous inspection reports, quality assurance processes, Fire Authority reports, Environmental Health Office reports, observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? A manager has been appointed and commenced employment. Staff respect privacy and dignity and are sensitive to changing needs. The service listens and responds to individuals’ choices and decisions about who delivers their personal care. Staff listen to people who live in the home and take account of what is important to them. People are being more involved in decision making. A relative commented: ‘ when I visit they always update me with anything I need to know, also contact me if they need me.’ The fabric and furnishings of the home are starting to be renewed. Some bedrooms have been upgraded. A new stair lift has been installed. New care plans are in place. They are completed in a more person centred way providing staff with clear directions for individual care and demonstrating consultation with people who use the service. They provide a better indication of care provided and progress made by individual people. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 6 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. Haversham House DS0000018486.V349467.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 Haversham House DS0000018486.V349467.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): Key Standard 3. 6 not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records for the admission of new people to the service demonstrate that the process is personalised so that consideration has been given to all aspects of care. EVIDENCE: From records seen, the admission of new people takes into account the individual needs, concerns and anxieties of the prospective person and their families. The manager consults the assessment information to see if the home can meet the person’s needs before they make the decision to accept the application for admission and offer a placement. Evidence shows that prospective people have a needs assessment carried out before they are admitted to the home. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 9 The manager has received copies of the summary, and care plans, from those assessments carried out by social services. Staff training to ensure that they have the necessary skills and ability to care for residents who are admitted is improving. Haversham House DS0000018486.V349467.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): Key Standards 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ care needs and risk assessments are set out in their individual plans of care which ensures that all care needs have been addressed and will be fully met. The manager understands the need to comply with safe medication systems and staff practice has improved so that residents health matters are now more safely addressed. The actions of staff and their approach to care ensures that people who use the service are treated with respect and their right to privacy is upheld. EVIDENCE: Three care plans were examined. The practice of involving residents in the development and review of the plan is clear. The plans include the information Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 11 necessary to plan the individual’s care. There is recorded evidence of updating information and changing actions in the care plans. The manager stated her intention to audit care plans in the future, to assess whether the staff consistently complete and use them. People who use the service have access to health care services that meet their assessed needs both within the home and in the local community. People who use the service have access to dentists, opticians and other community services. The health of residents is monitored and appropriate action taken. The home seeks professional advice on health care issues, acts upon it and generally is able to provide the aids and equipment recommended. There is written evidence in the daily notes of health care treatment and intervention, and a record of general health care information including weight monitoring, and nutritional information. The service has a training plan for medication roles. A new medication policy is to be introduced. Staff are seen to be aware of the need to treat residents with respect and to consider dignity when delivering personal care. There is recorded evidence of updating information and changing actions in the care plans. People who use the service all appeared well groomed with their hair, nails and clothes looking clean. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 12 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): Key Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with social activity and can keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations through assessment, consultation and choice. Residents receive a healthy diet according to their assessed requirement and preference. EVIDENCE: The assessment process demonstrates that social/leisure pursuits are addressed prior to admission in a personalised way for the individual. Once living at the home, social activities are provided based on resident consultation. The manager stated that she has started to hold regular resident and relatives meetings regarding all aspects of living at the home. A returned survey stated: ’they have an information board telling us what events they are holding, also raffles etc.’ Activities are described on a display board. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 13 Menus have been revised and records show that residents are asked what they would like to eat from the menu. Comments received on surveys are very positive about what on offer regarding leisure pursuits at the home. People are aware of the intention to make this even better. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 14 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): Key Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure which is accessible to relatives so that people who visit the service have information of how to make complaints about the home. Adult protection training is provided for staff so that people who use the service are protected from abuse and have their legal rights protected. EVIDENCE: The service has not received any formal complaints recently. The Manager has completed adult protection training and reported that all staff have also been booked on this course. The manager stated the service intends to train staff in how to deal with complaints. Good interaction is observed between staff and people who use the service. They are relaxed in their company and showed no signs of distress. A suggestion box is in the foyer. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 15 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): Key Standards 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the décor and furnishings of the home have improved to enable people who use the service to live in a better-maintained and comfortable environment. EVIDENCE: The manager informed us of some decoration that had taken place. A tour of the home showed that, while looking shabby and a bit worn both internally and externally, isn’t dirty or unsafe. Areas seen around the home are clean and rooms personalised. Call bell systems are working and are within reach of residents. A maintenance person has been employed. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 16 The manager stated that laundry arrangements are inappropriate for the care home. The very small room containing the washing machine is sited off the main corridor leading to the lounge and the driers and storage are on the top floor of the home. There is no dedicated facility for dealing with all laundry and janitorial duties. Staff are aware of the importance of infection control when dealing with and transporting soiled linen. Externally the gardens are in need of attention. Mops are stored outside the back door by a residents seating area. The waste bins are also sited by this seating area. A stair lift is in place which has not been serviced. The manager has reported this to the provider but it has not been completed. Not all bathrooms and toilets have washable flooring. When balancing these pieces of evidence against other more positive parts of this outcome group and improvements made since the new manager took over, an overview of the environment is seen as adequate. Much work has been done but there remains a lot of upgrading to do to make the premises a dignified place to live. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment steps ensure the service secures suitable staff and that people who use the service are in safe hands. Staff in the home are being trained and are in sufficient numbers to fill the aims of the home and meet the changing needs of residents. EVIDENCE: Common induction standards are provided for new staff. Records show that all staff have received medication training, fire, manual handling and food hygiene. Staff are participating in NVQ qualifications and will achieve the 50 level required. Staff files seen of two new recruits showed that all required checks are carried out. Supervision has commenced with a record of those undertaken. The manager records an overall training matrix which includes mandatory and other specialist training. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 18 A keyworker system is in its infancy. Comments returned in surveys include: ‘ always very attentive and always seem to be interested in what they (residents) are thinking and saying.’ ‘they are caring in trying to support my aunt with her problems and try to give her a near as normal day to day life.’ Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 19 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home intends to implement quality assurance systems and audits so that people who use the service are more assured that the service is closely monitoring its own practice and that the overall conduct of the home is being better managed. EVIDENCE: A new manager is in post who has applied for registration. She is keen to improve and develop systems that monitor practice and comply with the plans, new policies and procedures of the home, for example audits for infection control, medication and care plans. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 20 Through discussion, the manager is aware of the need to plan the business activity of the home but does not hold responsibility to manage finances and resources to deliver plans for the service. The manager stated that currently there is no formal business plan. The manager seeks support and supervision from the provider but she reported that this is sometimes difficult to achieve. The manager was open in her wishes and ideas for improvement to the service. There are no formal audits, apart from a recent external health and safety audit, to check whether policies and procedures are being adhered to and that systems are working to achieve good outcomes for people who use the service. The manager acknowledged the need for self assessment to demonstrate how outcomes are achieved. Quality assurance processes are starting to happen. Service user meetings are to be held regularly. Staff have had the opportunity to air their views through meetings. Comments in a survey stated:’ any concerns raised with the manager have been addressed.’’ Feel that the home is better run and families are more involved with the new manager.’ Reports under Regulation 26 reviewing the conduct of the service are not consistently completed. The service does not display the certificate of registration. The manager is training and developing staff with consistency and equality so that they are generally competent and knowledgeable to care for people who use the service. Residents confirmed they are being asked their point of view more than before. They said they are pleased with the new manager and that they are asked if they have any concerns and they are starting to have residents’ meetings. Checks on records show that they are up to date. Records for the management of health and safety are maintained. Fire records show that tests and drills take place. The home has a system for recording personal monies. Relatives commented that they feel a satisfactory system is now in place. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP31 OP19 OP19 OP33 OP26 OP38 OP31 Good Practice Recommendations The provider should provide supervision for the manager, at agreed frequencies and formulate a business plan. The provider should continue with the planned programme of renewal of the fabric and decoration of the premises internally and externally. The provider should provide a plan to upgrade assisted bathing and toilet facilities. The manager should implement her stated intention to audit the new systems and processes of the service i.e medication, infection control, admissions. The provider should review and improve the laundry facilities. The stair lift should be serviced The certificate of registration should be located and displayed. Haversham House DS0000018486.V349467.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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