Inspection on 12/07/05 for Haversham House

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Haversham House 23/01/07

Haversham House 25/01/06

Haversham House 12/10/04

Haversham House 18/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Haversham House Longton Road Trentham Stoke-on-Trent Staffordshire ST4 8JD Lead Inspector Norma Welsby Uuannounced 7 September 2005 1:45 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 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 E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Haversham House Address Longton Road Trentham Stoke-on-Trent Staffordshire ST4 8JD 01782 643676 01782 643674 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Medichoice Ltd Mrs Ann Hill CRH 33 Category(ies) of DE(E) Dementia - over 65 (18) registration, with number MD(E) Mental Disorder - over 65 (2) of places PD(E) Physical disorder - over 65 (6) OP Old age (33) MD Mental Disorder (2) DE Dementia (3) Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 MD - to be minimum of 55 years on admission 2 DE - to be minimum of 55 years on admission Date of last inspection 12 October 2004 Brief Description of the Service: Haversham House is a private residential care home registered for up to 33 older people, some of whom may be mentally frail or physically frail. At the time of this Unannounced Inspection, Haversham House was fully occupied and had also received several recent enquiries and had a waiting list. The home has a specialist Elderly Mentally Infirm (EMI) unit on the first floor, which can accommodate up to eight residents, while the remaining residents, who have mixed dependency needs, occupy the ground floor communal areas that have been significantly improved during the past couple of years. Haversham House is located off the busy Longton Road in Trentham and as such provides good access to a wide rang of community resources. The property provides an attractive and well maintained appearance with good car parking facilities. The large open plan lounge on the ground floor leads to a patio and enclosed garden. In total there are 31 single and 1 shared bedroom, which is used by a married couple. While there are an ample number of toilets throughout the building, the home currently has a shortfall of assisted bathrooms, but this is due to be addressed with the building of a two storey extension that had already commenced at the time of this inspection. Haversham House has submitted an application to register an additional 10 bedrooms, all of which will have an en suite. Other facilities will also be provided and it is hoped that work will be completed in January 2006. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place on the 7th of September 2005, between 1.45pm and 6.15pm and the findings were very satisfactory. The home was being managed by the former Deputy Manager, Mrs Janet Picken, who had recently been promoted following the promotion of the Registered Manager, Mrs Ann Hill to Managing Director. Mrs Picken has worked at Haversham House for several years and has many years of appropriate experience as well as having recently completed NVQ Level 4 and Registered Managers Award. Mrs Picken has submitted an application to be approved as the Registered Manager of Haversham House and this is being processed by the CSCI. During this inspection the Inspector set a date for interview on the 27th of September 2005. Mrs Hill is still very involved in the running of Haversham House, visiting daily to provide support and was on site during this unannounced inspection. A wide range of Standards was examined during this inspection and each of these was satisfactorily met. There were no new requirements made as a result of this inspection. In respect of the two requirements from the previous inspection, both of these, while not entirely complied with, were in hand. Neither the home nor the CSCI had received any complaints since the last inspection. Throughout the period of the inspection, both staff and residents provided helpful assistance. There was a very pleasant and friendly ambience in the home and the inspection was positively received. What the service does well: Haversham House provides a very comfortable and homely environment. Many of the staff have worked at the home for several years and as such have developed a good level of expertise and established a very friendly rapport with residents and visitors. Senior staff have a very good working rapport with a wide range of health care professionals and commend the ongoing support that they provide. The staffing structure of the home has been steadily Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 6 improved over recent years to ensure that there is always at least one senior carer leading each shift, both day and night, many throughout the day also being supported by the manager or deputy. The very recent promotion of the Registered Manager to Managing Director further enhances the senior structure and support available to the home. 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. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 &3 . Standard 6, Intermediate Care was not assessed as this service is not provided at Haversham House. The Inspector found that the home has comprehensive pre-admission assessment procedures and appropriate documentation. Dependency levels were found to be commensurate with the home’s Categories of Registration. EVIDENCE: Haversham House has a Statement of Purpose and Service User Guide, the format of which allows information to be easily amended or added. At the time of this inspection the home was fully occupied with a long waiting list. Discussions with the home’s manager and other staff confirmed a very thorough approach is taken in respect of pre-admission assessment, including home/hospital assessment, visits to Haversham House and admission on a trial basis. The home uses a written format for the purposes of its own assessment, which compliments the social workers’ assessment/care plan information. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 The Inspector found care planning to be of a good standard. The health and personal care needs of residents were being met appropriately. The home had comprehensive policies and procedures in place for the management and administration of residents’ medication. EVIDENCE: The Inspector examined a 15 sample of care plans and found these to be satisfactory. The format is simple, information is accessible and was found to be up-to-date. The manager and deputy oversee the quality of the care plans, but the responsibility of reviews lies with the senior staff that support and supervise a team of carers within the home. Appropriate arrangements were in place for residents to receive a broad range of health care treatments and support. Evidence of this was found in care plans and also apparent from discussions with staff and residents. When asked senior staff commended the excellent support they received from a wide range of health care professionals. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 10 The Inspector was advised that at the time of this inspection, none of the residents were self-medicating. The deputy manager has responsibility for the management of medication and senior carers administer to residents. The Nomad Monitored Dosage System of Medication is used and during this inspection, the Inspector was able to observe the teatime medication being administered and this was found to be satisfactory. When asked it was confirmed to the Inspector that all staff who administer medication to residents had undergone medication training. Controlled drugs held on the premises were found to be appropriately stored and correct records maintained. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Haversham House provides a very good range of social, religious and recreational activities and opportunities. Contact with families is promoted. Residents are extensively consulted and encouraged to make choices that determine personal routines and activities for daily life. The quality of meals continues to be of a very good standard. EVIDENCE: The Inspector found that Haversham House continues to provide a wide range of activities and opportunities to residents. Since the last inspection, the former activity assistant has left, but has been replaced by another activity assistant and a driver. Also since the last inspection the home has purchased an adapted minibus, which it shares with its neighbouring sister home. On the day of this unannounced visit two residents were on a trip out of the home with three residents from the sister home and in this respect closer links have been forged which is a positive development. Closer links have also been established with a local church, with friends of the church visiting residents at Haversham House. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 12 An open visiting policy exists and every encouragement is given to families and friends to maintain contact, but unfortunately during this inspection, the Inspector did not have the opportunity to consult with any visitors. However several residents did confirm that they were able to receive visitors whenever they liked and that they were always made to feel welcome. Throughout the period of this inspection, the Inspector made several observations of staff responding to needs and generally interacting with residents and it was apparent that residents were being encouraged to exercise personal choice and autonomy. When asked, residents confirmed to the Inspector that they were able to pursue flexible daily routines suited to their needs and preferences. Without exception, all residents who were consulted confirmed to the Inspector that they were very satisfied with the quality, quantity and variety of meals provided. Special diets are catered for as required; at the time of this inspection, just 2 diabetic menus were provided. Five residents were in need of some degree of assistance at mealtimes, but this varied from day to day. The daily menu was found to be on display and several residents confirmed that they had been satisfied with the provision of meals that day. One resident was celebrating her birthday and at teatime a large homemade birthday cake was provided and much enjoyed by residents. The four weekly menus are regularly reviewed in consultation with residents and adjusted to incorporate seasonal variations. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Haversham House has an established complaints procedure. There are written policies and procedures in place in respect of protecting residents from abuse, along with associated staff training. EVIDENCE: The home’s complaints procedure was seen on display in the home and a copy is also included in the Statement of Purpose and Service User Guide. During the past year the home has not received any internal complaints, nor have any been received by the Commission for Social Care Inspection. When asked a couple of residents confirmed to the Inspector that they were aware of their right to complaint if dissatisfied and would feel comfortable about raising matters directly with senior staff. Staff have been provided with information, guidelines and training in respect of vulnerable adults and correct procedures to follow, including whistle blowing. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 26 The location and layout of Haversham House is suitable for its stated purpose. The home provides a comfortable and homely environment and there is an attractive enclosed garden/patio that provides residents with opportunities to sit outside in pleasant weather. EVIDENCE: At the time of this inspection, building work to provide an additional 10 places had just commenced, with foundations being dug. The home has greatly benefited from already opening up and extending the ground floor communal facilities, providing residents with a lighter and better ventilated sitting area. There is also an activity room and depending on the nature of the activity taking place, this is in regular use. Regular risk assessments/audits are routinely carried out and the home employs a full time handy person to undertake routine repairs and maintenance. The programme to guard all radiators throughout the home had nearly been completed; with agreement reached during this inspection that outstanding work would be completed by the 31st of October 2005. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 15 The provision of additional bathroom facilities will be addressed alongside the aforementioned building work. A random sample of bedrooms was examined during this inspection and for the most part was found to be satisfactory, but three had an odour. Some carpets were also quite badly stained, for example in the reception area and adjoining dining room, which presented a poor impression. This finding was fed back to the Home’s Manager and Managing Director. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The Inspector found that Haversham House was adequately staffed with a range of staff who are suitably trained, experienced and competent to meet the varied needs of residents. EVIDENCE: Haversham House has a good staffing structure enabling every shift, both day and night, to be covered by a senior carer, who is often supported by the manager or deputy also being on duty. Satisfactory numbers of catering and domestic staff, an activity assistant and driver, an administrator and handyman also compliment the care team. Observations of staff throughout the period of this unannounced inspection, confirmed to the Inspector that staff were professional and caring in their duties and care of residents. When asked, several residents were also very complimentary about staff and told the Inspector that they felt well cared for and supported by the home. The home’s manager advised the Inspector that staff turnover continues to be minimal and the benefit of having a stable and experienced staff team was seen as a very positive feature of the home. It was also confirmed that thorough recruitment procedures were pursued when new appointments were made. POVA and CRB checks were in place, with just 2 CRB’s awaited. Training remains a high priority at the home, with a rolling programme of mandatory and specialist courses pursued. NVQ has developed very well, with 6 staff having NVQ level 3 and three more staff working towards it, while all other care staff, with just one exception, either have level 2 or are part way Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 17 through it. The Inspector commended the home and staff for such a commitment to NVQ training. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 Since the last inspection the Registered Manager has been promoted to Managing Director and the former deputy manager has become the Home’s Manager. EVIDENCE: The recently promoted Home’s Manager Mrs Janet Picken has worked at Haversham House for several years as the deputy. Mrs Picken has submitted an application to approved as the Registered Manager and a date for interview was made during this inspection. Mrs Picken has also recently completed NVQ level 4 in Care and the Registered Managers Award. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x x Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 20 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 25 Regulation 13 & 23 Requirement To complete the programme of guarding radiators in residents bedrooms. In the meantime to ensure that risk assessments are updated. To comply with expected ratio of bathrooms. Timescale for action Agreed timescale 31/10/05 Agreed this would be done alongside extension 2. 21 23 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 26 Good Practice Recommendations A review of current arrangements should take place to ensure that bedrooms are odour free and any carpet stains treated effectively. Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Haversham House E51-E09 HAVERSHAM HOUSE UI S8235 V248446 7.09.05 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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