Inspection on 20/04/06 for Haversham House

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 25/02/09

Haversham House 11/03/08

Haversham House 24/04/07

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 Andrew Spearing-Brown Unannounced Inspection 10:00 20 April and 5th June 2006 th 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.V290647.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. 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.V290647.R01.S.doc Version 5.1 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 Springlea Limited 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.V290647.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2005 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. The home is an adapted town house, which has accommodation on two floors; the first floor is accessed by a stair lift. Accommodation is provided in 12 single rooms and 2 double rooms. There are a total of three bathrooms, one of which is adapted for use by residents who have mobility needs. A shower facility is available but has a step up to it, which can be difficult for residents to use. There are two separate lounges/dining areas for the residents to choose where to sit. The garden has facilities for residents to sit out in the summer. The manager designate stated on 5th June 2006 that the fees at Haversham House are currently £343 - £400 per week. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over two days lasting a total of around 11 hours. One inspector from the Worcester office of the Commission of Social Care Inspection undertook the inspection. The focus of inspections carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at Haversham House a visit to the home was undertaken. This inspection takes into account any information received by the CSCI since the previous inspection as well as the visit to the home. Since the last statutory inspection two additional visits have taken place. One of the additional visits was undertaken following a complaint received by the CSCI while the second was to assess progress made as a result of the first visit whereby a number of areas were substantiated and associated requirements were made. Prior to this inspection a number of concerns were raised in relation to the running of the home. Some of the more recent concerns were linked to earlier concerns while others were in relation to matters not previously reported to the CSCI and are currently subject to adult protection procedures. Part of this inspection was to assess the progress made in relation to the requirements from the previous inspection as well as in relation to the additional visits. As this was a key inspection the majority of the key standards were assessed, however due to the time spent covering some areas it was not possible nor practical to assess each of the key standards. Those not inspected will be inspector as part of future inspections at Haversham House. The home has not had a registered manager for a considerable period of time. At the time of this inspection a manager designate was in place who is currently applying to the CSCI for registration. What the service does well: Residents throughout the visit raised no concerns to the inspector. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: As highlighted above the registered provider has appointed a new manager. Although some progress was noted the majority of requirements from the previous inspection remain unmet. Information available to potential residents needs to be improved. A new resident was admitted into the home without any documentation from either the purchasing authority or via an assessment carried out by a representative from the home. As a result the home was in no position to ascertain whether they had the ability to meet care needs. Care plans and risk assessments are poor and do not reflect the current care needs of residents. They are in need of urgent review to ensure the health safety and welfare of residents. Concern was also expressed regarding information recorded within the daily notes. A range of training shortfalls became apparent including dementia care and a range of health and safety matters. These all need attending to. Some serious concerns were noted regarding the management and recording of medication. The manager designate took immediate action regarding some matters. Activities are in need of improvement and funds need to be available to facilitate this. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 7 Concerns were in the past as well as during this inspection raised regarding the none payment of invoices and subsequent withdrawal of services. The low stock of food on the first visit was of concern although due to the provision of a supplier this had improved by the time the second visit took place. Telephone services have in the past been disconnected due to none payment. The CSCI was extremely concerned regarding the apparent none reporting of some events within the care home. Vulnerable adult protection proceedings involving the police are currently taking place. Disciplinary action is also taking place regarding staff actions. Serious concern was raised regarding an ongoing lack of suitable bathing facilities. The only accessible bath was out of commission for about 5 weeks during which time nobody was able to have a bath. The laundry contains unsuitable equipment. Staffing levels are at times insufficient and carers have to undertake catering duties, which is inappropriate. A previous complaint alleged that the registered provider ‘pressed to reduce staffing’ levels. A number of health and safety matters were noted and require suitable action. 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 DS0000018486.V290647.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 4. Standard 6 is not applicable to Haversham Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of suitable information and a pre admission assessment results in the care home failing to have suitable systems in place to ensure that identified care needs of potential residents can be met. Care staff have not received the specialist training required to care for older people with a dementia illness. These combined factors place residents at potential risk. EVIDENCE: Since the previous inspection a statement of purpose and service users guide have been prepared. A copy of the service users guide was displayed and reported to have been sent to residents representatives. Although acknowledged that this is an improvement from the previous inspection the documents do not contain the required information and therefore require further amendments. Once the revised editions are produced a copy must be sent to the local office of the CSCI. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 10 The homes conditions of residency was held on one file viewed, this document was signed and dated however it did not contain all the information required such as bedroom number and had gaps regarding absences. On another file the residency document was signed on behalf of the home but not by the resident concerned or their representative. The document also made reference to the National Care Standards Commission (NCSC) the formal regulator prior to the CSCI. A resident was admitted into the care home on the evening prior to the start of this inspection. A Community Care Assessment (CCA) from the placing authority was not available and therefore the home could not indicate how they were intending to meet care needs. In addition the home had not undertaken an assessment prior to the admission. As a result the only information available to staff at the home was gleaned from the hospital discharge letter and directly from the residents family. Haversham House is registered to care for up to sixteen (16) persons. All sixteen residents may, under the registration categories have a diagnosis of dementia. The manager designate confirmed that a significant number of residents have high care needs many of whom have a dementia type illness. The care of older people with a dementia is specialised and therefore the home needs to be able to demonstrate that staff individually and collectively have the skills and experience to deliver the care required. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are insufficient in that they fail to give up to date and necessary detail regarding residents care needs to ensure that staff are able to provide the level of care required. Records seen and practice observed regarding the management of medication gave cause for concern. EVIDENCE: Individual care plans are in place for each resident. A representative sample of care plans were viewed and assessed during the inspection. The dependency levels of residents at the time of the inspection were relatively high therefore requiring suitable and up to date care plans in order that carers are able to provide consistent care. One resident was reported as needing three carers at one point. The majority of care plans viewed were very poor in their content and failed in the overall aim to safeguard residents. The manager designate has introduced an ‘overview sheet’ covering some key areas of care need. One care plan Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 12 contained a copy of a recent review undertaken by a social worker. The main care plans are on a new format introduced by the manager designate, they failed to give suitable details to equip carers with the information needed. One care plan stated that a resident used a hearing aid, however it did not indicate which ear, who fits it, who orders spare batteries or when it is serviced. The same care plan indicated that a resident had a poor sleep pattern but failed to give any indication as to why this could be or the action to be taken by carers. A resident with a document saying ‘high risks of fails’ was signed as read by 2 carers therefore it could be assumed that the majority of the staff had not read it. A falls risk assessment was poor in content. Care plans were not reviewed following residents having a fall and no systems for monitoring falls were in place. One care plan stated ‘please weigh weekly’ – this was not done for a period of time. Care plans seen made no reference to dietary needs. One care plan was blank and therefore staff were working with a care plan drawn up a number of years ago. Care plans that were in place failed to show any resident involvement. As major areas of the care documentation were either none existent or very dated it was not possible to assess them in any detail. The manager designate is aware that care plans and risk assessments are in need of significant input and improvement. This must be done as a matter of urgency. The daily notes were insufficient in some of the details recorded and did not show that suitable follow up action had taken place. Events were not transposed onto the care plans. No pressure relieving policy is in place and nutritional screen was not taking place. It was evident that staff were using a runner in order to administrate medication. Therefore a different member of staff was administering medication to residents to the person who was signing the Medication Administration Record (MAR) sheets. This can be potentially dangerous practice and the practice was required to cease immediately. Following the inspection the manager designate confirmed that a runner system would not operate and that training for senior staff would be provided. The majority of MAR sheets were in good order however a small number of concerns were brought to the attention of the manager designate. It was noted that the MAR sheet of a newly admitted resident was handwritten, any handwritten entries must be double signed to ensure accuracy, the MAR sheet seen was not double signed. The MAR sheets had a number of gaps upon them whereby staff had failed to sign that the medication was given. On one occasion a gap was in relation to a drug, which controls anxiety. Another tablet was found to be missing; although a senior member of staff knew this fact no suitable action had taken place regarding this event. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 13 Prescribed cream was found within a communal toilet, the prospect of creams used communally introduces a risk of cross infection. Another tub of cream was found within a residents bedroom which was 6 months past its expiry date. The inspector did not observe any signs of poor practice during the time spent within the home. It has however recently become apparent that some areas of concern have in the past gone unreported. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are able to see visitors, which can add to their quality of life. Activities are insufficient, the provision, range and frequency of activities needs to be developed further to occupy and stimulate residents. The availability of food within the home was a matter for concern. EVIDENCE: Haversham House does not have a dedicated activities coordinator although one member of the care team is currently taking a lead. It was stated that staff are working on preparing an activities plan and that a number of items have been purchased. Each afternoon some games were taking place involving a small number of residents. As the majority of residents at Haversham House have a dementia type illness activities must be meaningful and suitable to encourage residents to partake. Suitable funding for activities needs to be available. A minister from a local church was reported to visit the home although no church service takes place. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 15 As reported earlier within this report residents care plans are weak. Care plans need to include suitable sections regarding the meeting of residents individual social, religious and cultural needs. Only one visitor was consulted throughout this inspection however there are no concerns regarding open visiting. Residents can choose to see their visitors in their bedroom, the lounges or the dining room. The home has no links with the local community. At the start of this inspection it was of serious concern that the inspector was informed that food had to be purchased via petty cash. It was worrying that the manager designate had to use her own bank account to undertake the system and that money for the month was limited. Food stocks were low and the cook had to prepare dishes depending upon what she was able to find within the kitchen. The manager designated was heard to say to head office ‘ We have no food’. The registered providers have failed to provide the CSCI with receipts for food purchased during February 2006 as requested, this requirement remains in place. A number of different menus were viewed and it was difficult to establish which, if any were going to be used. Prior to the conclusion of this inspection the registered provider had changed the system whereby the cook was able to order food direct from a supplier and did not have a budget to adhere to. Food ordered via this means does not include fresh vegetables. No fresh vegetables were seen during either of the two visits to the home. Milk is provided via the supplier as well as directly from a local provider, this follows concerns about the payment of accounts in the past. One resident described the food provided as ‘ very nice’. It was however noted that one resident was given her sweet while still eating her main course, sometime afterwards the dish was still in place and clearly getting cold. Food provision and availability of a genuine choice will be monitored as part of future inspections. In the meantime the registered persons must ensure that residents are provided a nutritious and varied diet that is able to met individual and collective care needs. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Procedures for notifying authorities of concerns regarding the protection of vulnerable adults remain insufficient and can leave residents at risk. EVIDENCE: Shortly prior to the commencement of this inspection the newly appointed manager designate brought to the attention of the CSCI and Worcestershire Adult Services – adult protection a number of serious previously unreported matters. These are currently under investigation by a number of different agencies, including the police, due to the seriousness of the issues identified. Following the realisation by the manager designate of the above matters members of staff received training on adult protection. The manager designate has furthermore produced procedures regarding staff responsibilities. In addition information produced by both Worcestershire County Council and the CSCI was available. The content of the training was not assessed. Disciplinary action is currently taking place regarding one employee. It was however of further concern that following the seriousness of concerns currently under investigation as well as following training provided an incident noted within a residents records had not been brought to the attention of the manager designate and no suitable care plan or management strategy put into place. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 17 The previous inspection report noted that the homes complaints procedure was not available. The manager designate has now taken suitable action in that a procedure was available. The homes statement of purpose, which needs to be revised, makes comment to complaints however the actual procedure was not included. Due to the mental capability of the majority of residents it was not possible to establish any feedback from residents regarding complaints. One visitor consulted was confident that she could discuss any concerns with staff. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some improvement has taken place since previous visits to the home however further refurbishment and replacement of current equipment is necessary to ensure that residents have a safe and comfortable place in which to live. EVIDENCE: Haversham House is an adapted modern house, which is able to accommodate 16 residents. Bedroom accommodation comprises of 12 single rooms and 2 double bedrooms. As part of this inspection many areas of the home were viewed. Bedroom accommodation on the first floor consists of 2 doubles and 6 singles; the remaining bedrooms are on the ground floor. The carpet in the lounge was stained in places. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 19 The manager designate was not aware of any reports following visits from the Environmental Heath Officer or Fire Safety Officer. The laundry comprises of a small narrow room on the ground floor. Comments were raised recently from a number of different sources regarding the availability of suitable washing machines within the home. The industrial washer and drier were reportedly disconnected and removed from the home prior to the first visit of this inspection. The laundry contained a domestic white goods machine brought down from the staff flat area. The manager designate intended to bring to the attention of the registered provider that the domestic machine was unsuitable. On the 5th June 2006 the domestic type machine was still in place. This machine is not suitable or sufficient for the task in hand. No hand washing facilities are located within the laundry. Haversham House has no sluicing facilities; no risk assessment is in place regarding the cleaning of commodes. A mobile hoist is available within the home, however due to the layout of the home and the lack of a passenger lift the hoist is seldom used. Suitable equipment needs to be available to staff to ensure the health and safety of residents and staff while meeting individual care needs. Although the number of bathing facilities within Haversham House is acceptable the style and design of them is not suitable to meet the care needs of currents residents. One bathroom is not used due to its shape and design, and is now used as a storage facility. A shower room on the ground floor is also inappropriate as it has a high step to be negotiated to get into it. As a result the remaining bathroom is the sole bathing facility available for use. Over recent months a number of different sources have voiced concern to the CSCI regarding the inability to bath residents due to some continual difficulties obtaining a battery for the bath hoist. The outcome for residents of not having bathing facilities was one of serious concern and the registered provider must now provide the CSCI with an action plan as to how the shortfall in facilities is going to be addressed. One bath for up to sixteen residents is not acceptable. The bathroom contained a pile of worn towels; it was stated that they belonged to the hairdresser and that they were not used for daily living The manager designate has fitted soap dispensers within toilets as well as hand gel dispensers in corridor areas as means to improve the infection control measures in the home. A formal programme of routine maintenance and renewal needs to be developed further rather than one of reacting when repairs are necessary. A previous requirement to fit covers to radiators and restrictors to windows has received suitable attention. Some pipe work still requires boxing in. A vanity Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 20 unit in one bedroom was damaged and the extractor fan was loud. A commode was rusty. The rear garden can be reached by means of a level access path. The garden consists of a large lawn, which was well maintained. No raised flowerbeds are provided to encourage residents to partake in some gardening activity. Some tall weeds were in place near to the building. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Insufficient staff are on duty at certain times of the day which is a source of serious concern. The homes recruitment procedures and a lack of training are further areas of concern, which can potential place residents at risk. EVIDENCE: The staff rotas for the weeks commencing 8th May 2006 until the week of the final visit of this inspection were viewed. A number of random days were examined in detail to ascertain the staffing levels on duty. The rotas show the job role undertaken. A number of serious concerns regarding staffing levels were noted at the time of the inspection. Following an additional inspection carried out on during March 2006 the registered provider was required to ensure that a minimum of four persons are on duty at all times throughout the waking day. Despite the assurances given following the additional visit the rota showed that on certain days only three persons are on duty. It was evident on the 9th May three carers had been on duty during the morning shift. Rotas evidenced that at weekends three carers are on duty throughout the waking day. In addition Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 22 it was evident that carers had to finish the preparation of residents tea. Not only does this reduce the number of carers available to meet the care needs of residents but it also introduces a risk of cross infection. It was noted that on days when only three persons are on duty one of the afternoon cares commences work at 12.00 mid day therefore providing a full complement of staff over the lunch period. Two wakeful members of staff cover the night shift. The manager designate recently undertook a trial of night staff coming on duty at 9.00 pm as opposed to 8.00 pm. It was reported that due to transport difficulties experienced by staff without their own transport this arrangement had not proven successful. Despite these difficulties the registered provider must be able to demonstrate that sufficient and suitable staff are on duty at all times with additional staff at peak periods such as bedtime. A domestic member of staff is employed 7 ½ hours per day. The domestic member of staff works alternatively on either Saturday or Sunday each week. On the domestics days off as well as at other times of the day domestic duties are carried out by care staff. No laundry staff are employed and therefore all laundry tasks have to be carried out by care staff. One member of night staff recently worked 70 hours during the course of a week. One member of staff occasional works a 12-hour shift during the daytime. The practice of working long hours can be unsafe and have a detrimental impact on the care delivered. A previous complaint to the CSCI stated that the home was ‘pressed to reduce staffing’ by the registered provider. Staffing levels must be sufficient to meet the care needs of residents and therefore must be maintained at the agreed level. Any shortfalls in staffing cover must be reported to the CSCI as an event which effects the well being of residents. Currently none of the carers hold an NVQ (National Vocational Qualification). Although staff are now registered to commence this training all care homes were expected to have 50 of staff qualified by December 2005. At the time of the second visit to the home the manager designated was about to embark upon compiling a staff-training matrix. As a matrix was not available it was not possible to fully assess the training undertaken by each employee. Therefore the training records of a representative number of staff including those on duty were viewed. The training records seen highlighted a number of shortfalls, which need urgent input. One member of staff last received moving and handling training in September 2001 and had no evidence of receiving suitable fire safety training. The registered provider must ensure that all staff receive mandatory training as required to ensure the health safety and welfare of residents and staff. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 23 Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Significant improvement is needed regarding the management of the home to ensure health and safety practices are promoted and that accurate records are maintained. Quality assurance systems are weak and fail to assist in promoting good practice. EVIDENCE: The newly appointed manager designate has applied to become the registered manager of the home. This standard will therefore be assess as part of that process and as part of forthcoming inspections. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 25 Quality Assurance documentation within the home is dated (1993) and therefore not relevant to current standards and regulation which were introduced in 2002. Significant improvement is necessary to seek the views of residents, relatives and other stakeholders. The results of any surveys should be published and a copy of the results made available to residents and other interested parties including the CSCI. The CSCI have recently had cause for concern regarding the financial management of the home. It was recently reported to the CSCI that following none payment of a telephone account the service was discontinued for the second time. Staff needed to use their own mobile ‘phones to contact relevant persons in order to have the service reinstated, this clearly placed residents at risk. The CSCI is also aware that tradesmen have refused to continue to supply provisions or continue with work within the home due to unpaid accounts. The manager designate has not seen any business or financial plan regarding Haversham House. A certificate showing suitable employees liability insurance was in place. A small but representative sample of residents money held in safe keeping was checked and found to be in order. The manager designate has commenced upon a programme of formal staff supervision. This needs to cover a number of areas including: • • • Aspects of practice Philosophy of care in the home Career development needs Copies of a number of test certificates were forwarded to the CSCI as recently requested. 1. The stair lift was described as ‘lift worn but serviceable’ on 31/01/06. Under the Lifting Operations and Lifting Equipment Regulations (LOLER) 1998 all lifting equipment must be serviced every 6 months, therefore this equipment will be shortly due for a re-service. Documentation following that service must be forwarded to the CSCI along with details of any parts needing replacement. 2. The bath hoist passed a LOLER examination on 27/01/06 3. Gas equipment was serviced on 06/03/06 – this is an annual examination. The health and safety poster in the hallway requires details adding to it. The manager designated has placed a copy of the homes health and safety policy on the notice board. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 26 As reported elsewhere within this report the laundry is unsuitable for purpose. A cupboard within the laundry was unlocked and contained cleaning items and nail varnish remover. Shortfalls were identified in training including a range of health and safety matters such as infection control, safe storage of chemicals, moving and handling and fire safety. The manager designate stated that she had recently had the fire extinguishers serviced; a system of monthly visual checking must be set up. On the first day of this inspection clothing was hanging from door closures to dry. Door closures are in place to ensure that fire doors close on the sounding of the fire alarm, this could not happen if items were hanging from them. Furthermore having weight suspended from the closures could potentially damage them. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 27 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 2 2 1 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 2 1 1 3 2 2 1 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 1 3 2 1 1 Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 28 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 OP1 Regulation 4(1)(2) Requirement A statement of purpose must be available in the home for prospective service users. (The document prepared since the last inspection does not met the requirement. A revised and extended timescale is given) 2. OP1 5(1)(2) A service users guide must be made available for all service users. (The document prepared since the last inspection does not met the requirement. A revised and extended timescale is given) 3. OP2 5 (1) (b) Residents must receive a statement of terms and conditions covering all required areas. A copy of the document signed by both parties must be held and available for inspection. (The wording in this requirement is slightly different to that within previous reports – however the previous timescale of 31/10/05 not met) Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 29 Timescale for action 31/07/06 31/07/06 31/07/06 4. OP3 14 A full assessment of prospective 20/04/06 service users must be undertaken prior to them moving into the home and to include all aspects of their needs. Specialist training must be provided to staff to ensure that service users needs are understood and fully met. (Previous timescales of 31/10/04 31/05/05 and31/10/ 05 not met. A new and extended timescale is given by which time suitable training must of taken place) 31/08/06 5. OP4 (18) (1) a,b,c 6. OP7 15 31/07/06 Each resident must have a comprehensive care plan in place which is regularly reviewed and updated and reflects all aspects of their needs. (Previous timescales of 04/04/04 31/05/05 and 31/10/05 not met. A new and extended time scale is given by which time all and comprehensive care plans must be in place for all residents) 7. OP7 15 Residents care plans must be signed, dated and, where possible, the signature of the service user or representative included. (Previous timescales of 31/05/04 and 31/10/05 not fully met. A new and extended time scale is given for full compliance) 31/07/06 Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 30 8. OP8 12 Nutritional and skin care risk assessments must be carried out. (Previous timescales of 31/05/04, 31/05/05 and 31/10/05 not met. A new and extended time scale is given by which time full compliance must be achieved) 31/07/06 9. OP8 12,13 Moving and handling risk assessments must be reviewed and kept up to date. (Previous timescales of 31/05/04, 31/05/05 and 31/10/05 not met. A new and extended time scale is given by which time full compliance must be achieved) 31/07/06 10. OP8 12,13 Individual risk assessments must be carried out for residents displaying challenging and aggressive behaviours. (Previous timescales of October 2004 and 31st October 2005 not fully met. This requirement must be met in full immediately) 05/06/06 11. OP8 17 (1) (a) Schedule 3 (p) A pressure relieving policy and associated procedures must be in place and understood by all members of staff. Falls risk assessment must be undertaken and understood by all members of staff. Information must be included within the care plan and both must be reviewed regularly and after further falls. 31/07/06 12 OP8 12 31/07/06 Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 31 13. OP9 13 (2) Medication Administration Record 20/04/06 (MAR) sheets must be signed by the person who administered the medication. No ‘runner systems’ are to be in place. The MAR sheets must not contain any blanks. Each space must be either signed to show that medication was administered as prescribed or a code must be in place to demonstrate the reason for the omission. In the event of any drug errors or mishaps suitable action must be taken including notification to the CSCI when required and fully recorded. 20/04/06 14. OP9 13 (2) 15. OP9 13 (2) 20/04/06 16. OP9 13 (2) All prescribed creams must be held securely. Items must be used for the person named on the prescription and suitable procedures must be in place to ensure that items used are in date. Following consultation with residents to devise a programme a record must be kept of meaningful and purposeful activities, which take place within the home. Meals provided must be nutritious and varied. A fully menu must be provided. 20/04/06 17. OP12 16 (2) (n) 31/07/06 18. OP15 16 (2) (i) 05/06/06 Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 32 19. OP18 13(6) Risk assessments and management procedures must be put in place to ensure that service users are not placed at risk by behaviours displayed by other service users. (Previous timescales of May 2005 and 31st October 2005 not fully met. This requirement must be met in full immediately) All areas of the home must be well maintained. Sufficient and suitable bathing facilities must be maintained and be available to met care needs. Sufficient and suitable bathing facilities must be maintained and be available to met care needs. Exposed pipe work must be boxed in to prevent accidental scalding. Suitable facilities must be provided within the laundry. This must include suitable washing machines with disinfection programmes and in line with water regulations. In addition suitable hand washing facilities must be provided. A risk assessment must be carried out regarding the handling of soiled linen, the disinfection of commode pans etc. and a sluicing facility provided, if necessary. Sufficient staff must be on duty throughout the day to meet the care needs of residents. 05/06/06 20. 21. OP19 OP22 23 (2) 23 (2) (j) 31/08/06 20/04/06 22. OP21 23 (2) (j) 20/04/06 23. OP25 13 (4) 31/07/06 24. OP26 13 (3) 30/06/06 25. OP26 13 (3) 30/06/06 26. OP27 18 05/06/06 27. OP27 12 (1) Staff must not be working DS0000018486.V290647.R01.S.doc 05/06/06 Version 5.1 Page 33 Haversham House excessive hours 28. OP29 19 Staff employment files must contain all the required information as specified in Regulation 7, 9 , 19 and Schedule 2. All staff must have individual training and development assessments and profiles. A quality assurance system must be put in place in order to audit the service provided by the home. (Previous timescales of 30/06/04, 30/07/05 and 31/10/05 not met) 30/06/06 29. OP30 18 31/07/06 30. OP33 24 31/08/06 31. OP33 26 The registered providers must ensure that they visit and report on the conduct of the home on a monthly basis and provide accurate feedback to the acting manager as to all aspects of the service provided by the home. (Previous timescales of 30/09/05 part met) 31/07/06 32. OP34 25 (1) The registered providers must be able to demonstrate that the care home is financially secure. Care staff must receive formal supervision at least six times a year that includes all aspects of practice, philosophy of care in the home and career development needs. All records must be kept in accordance with the regulations. DS0000018486.V290647.R01.S.doc 31/07/06 33. OP36 18 (2) 31/08/06 34. OP37 17 31/07/06 Haversham House Version 5.1 Page 34 (Previous timescales of 31/10/05 not met) 35. 36. OP38 OP38 13 13 All hazardous substances must be held securely at all times. All staff must receive adequate and up dated health and safety training, to include fire safety, moving and handling, first aid, food hygiene, infection control and basic health and safety. (Previous timescales of 31st December 2004 not met) Door closures must not be used as a means of hanging clothing to dry. Regular fire safety check must be carried out and recorded. (Previous timescales of immediate on 09/09/05 part met) 05/06/06 31/07/06 37. 38. OP38 OP38 13 (4) 23 (4) 20/04/06 05/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The newly appointed manager designate should ensure that there are no outstanding issue following earlier visits from both the local Environmental Health Office and Fire Oficer. Haversham House DS0000018486.V290647.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 DS0000018486.V290647.R01.S.doc Version 5.1 Page 36 - 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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