Inspection on 24/04/07 for Haversham House

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Haversham House 25/02/09

Haversham House 11/03/08

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 Andrew Spearing-Brown Unannounced Inspection 24th April 2007 09:00 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.V334370.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.V334370.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.V334370.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. 5th February 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. Accommodation is provided in 12 single rooms and 2 double rooms. There are a total of two bathrooms, one of which is adapted for use by residents who have mobility needs. A shower facility is available on the ground floor. 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 recorded within the pre-inspection questionnaire that the fees at Haversham House were £420.00 per week including top ups. Addition charges are made for items such as hairdressing, private chiropody, toiletries and newspapers. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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 14.00 hours. The focus of inspections carried out by the CSCI is to assess the outcomes for people who use the service. This inspection takes into account any information received by the CSCI since the previous key inspection including two random inspections as well as the visits to the home. The commission has over the last 12 months received a number of concerns and complaints regarding the service offered at the home. Some of these complaints related to the running and financial management of the home. A number of concerns were brought to the attention of the commission shortly before this inspection. As a result of the earlier complaints Haversham House was subject to adult protection procedures. In addition the commission and the local social services department had serious concerns regarding the lack of suitable action in relation to previously issued requirements. Due to the concerns the registered providers agreed to a voluntary suspension on admissions until such time that these issues could be satisfactorily addressed. The suspension was lifted during February 2007. This inspection was to assess the progress made in relation to the requirements from the last key inspection as well as 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 fully; these will be assessed as part of a forthcoming visit to the home. Prior to the first visit a pre inspection questionnaire was posted to the registered provider requesting certain information. The manager designate handed the completed document to the inspector on the first day of the inspection. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the provider for residents, relatives and other persons to complete. A small number of completed surveys were returned to the commission. 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. Since the inspection but prior to the completion of this report this person has left the employment of the provider. The home has had two manager designates over a period of the last 12 months neither of whom became registered as manager. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Despite the reassurances given by the owners of Haversham House and despite the improvements noted in some areas the Commission for Social Care Inspection continues to have concerns regarding Haversham House. Further significant improvement must happen in order to safeguard the health, safety and welfare of residents. The information available to residents and their representatives needs to be improved. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 7 Care plans and risk assessments continue to fail to ensure that care needs are identified and demonstrate how needs are to be met. Care plans were not sufficiently up to date to evidence that care is given in a consistent manner. Although improvement has occurred regarding the management of medication this needs to continue. Changes to the shower room have brought about an improvement in bathing facilities however overall bathing facilities remain a concern. Other environmental concerns include a lack of hot water supply to a wash hand basin in a bathroom, the lack of refurbishment in some bedrooms and some health and safety shortfalls. The deployment of staff and recruitment procedures continue to be insufficient. The home lacks quality assurance systems. 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.V334370.R01.S.doc Version 5.2 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.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Information available to potential residents and their representatives needs to be developed to ensure that they are able to make an informed choice regarding their future care. Developments in the training provided assists in making sure that staff have the specialist knowledge required to provided care for people with a dementia. The improvements in pre admissions assessments which needs to continue provide information to ensure that care needs are able to be met. EVIDENCE: Previous inspection reports have acknowledged that amendments have taken place to the homes service users guide. The previous key inspection report Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 10 concluded that the document continued to fail to meet the required standard and therefore required additional amendments. Over recent months the registered providers have employed a management consultant who has undertaken some work on their behalf to address the shortfalls identified within Haversham House over continual inspection reports. It was noted that the current service users guide was displayed within the entrance hall as well as within bedrooms. The manager designate confirmed that work was still taking place upon the service users guide therefore the document displayed was not read. The homes statement of purpose was not sought on this occasion. Once these documents are completed a copy needs to be forwarded to the commission. Standard two, which covers the provision of written contracts / terms and conditions, was not assessed as part of this inspection. Previous inspection reports noted that the terms and conditions needed to be amended however a copy was held on individual’s files. Compliance with the associated regulation will be assessed as part of a future inspection visit to Haversham House. Due to a voluntary ban on admissions, which lasted from August 2006 until early February 2007, no new residents were admitted to Haversham House during the above 5 months. Since the removal of the voluntary ban a limited number of admissions have taken place. The manager designate mentioned further possible admissions into the home. The pre admission assessment seen was of a reasonable standard however further evidence is necessary. The registered persons must ensure that staff have the necessary skills and abilities as well as the home having the required registration prior to making future admissions. Previous inspection reports have highlighted that Haversham House is registered for up to sixteen persons all of whom may have a dementia type illness. As the care of persons with dementia is specialist carers need to be suitably qualified. Since the last key inspection a team manager from Worcestershire Adult Services has provided training for staff, this training now needs to be built upon. The manager designate as well as two carers are due to undertake further training in the foreseeable future. The training of staff in conditions associated to old age and good practice matters needs to be developed in order to evidence that potential residents and their representative can be confident that care needs are to be met. Haversham House does not provide intermediate care therefore standard six is not applicable. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Despite some improvement care plans and risk assessments remain insufficient and fail to support the care needs of residents potentially placing them at risk. Earlier improvements in the management of medication have continued, some further improvement is necessary. EVIDENCE: The standard of care plans at Haversham House have caused great concern in the past. These concerns were shared by both the commission for social care inspection and social services who fund the majority of places at the home. Over the past 12 months a number of different formats have been introduced and then replaced with something else. It is acknowledged that a limited number of staff have made some progress in care planning however further improvements must take place in order for the regulations to be met. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 12 Some of the terminology used within care plans was generic and failed to be person centred for example ‘ encourage to keep social interests and hobbies and religious / cultural needs if ** has any.’ A major concern over the past year was the high level of falls occurring at Haversham House and the poor documentation in relation to risk assessments and care planning. Due to changes with the residents residing at the home the level of falls has reduced however the recording remains to be a concern. One care plan stated ‘no further falls’ on 20th April 2007. The plan was reviewed on the 5th May with no additional information. Despite the above comments it was evident elsewhere that falls had taken place both before the 20th April and between the April date and the May date. It was a further concern that the falls had happened at a similar time, this was not reflected in the care documentation and no strategies were in place to try and reduce the risk of falling. Another care plan made no reference to two falls which occurred on one day. One care plan was seen in some detail. The care plan showed that it was reviewed on a monthly basis and therefore it could be assumed that the plan of care would be up to date. The assumption would be incorrect as the plan failed to demonstrate that the resident had recently become poorly and clearly needed additional support while still trying to retain as much independence as possible. The last entry on one care plan stated ‘ physical health has improved ’ when this was not the case. Care plans did not exist regarding the implementation of fluid charts. Fluid charts gave no indication to the required intake. Pressure relieving equipment was seen to be in use within the home. Risk assessments were in place but if they highlighted a risk no evidence of strategies to reduce the risk existed furthermore no professional intervention such as a dietician was recorded. The recording of residents weight was not up to date. The standard of the daily notes was satisfactory in the majority of cases however some concerns were noted such as the lack of follow up information. Previous key inspection reports have highlighted some serious concerns regarding the management of medication within Haversham House. The last report following the random inspection (February 2007) stated that the random report in November 2006 ‘ noted that improvement had taken place.’ As part of this inspection the management and administration of medication was assessed. The current MAR (Medication Administration Record) sheets were viewed as were a random sample of items within the drugs trolley including items within the MDS (Monitored Dosage System). Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 13 The majority of the MAR sheets were completed satisfactory however a number of shortfalls were brought to the attention of the senior member of staff accompanying the inspector. The vast majority of medication was booked into the care home. The inspector became aware of the fact that some medication was not available due to an apparent mix up which was out of the hands of the home. It is vital to be able to easily recognise whether or not each resident has any known allergies; this information was not always recorded upon the MAR sheets. An audit of antibiotic medication did not balance it that the signatures on the current and previous MAR sheets totalled 19. Therefore as the course consisted of 21 doses a total of 2 tables should of remained. However 3 tables were within the drugs trolley therefore it was evident that one dose was missed and one member of staff had clearly signed for medication that was not given. From observations made the inspector has no reasons to suspect that residents privacy and dignity is not up held by staff. The majority of residents looked well-attired wearing clothing suitable for the time of year. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are able to make some limited choices about their life style. Social and recreational activities have improved. EVIDENCE: A visitors book is available in the entrance hall. In order to be able to account for all persons within the home in the case of an emergency visitors should be encouraged to complete this book. Information was displayed along the corridor and within the lounge regarding a forthcoming trip to a local garden centre, a barbeque and the summer fete. Fund raising takes place to fund outings and entertainment. It was reported that a range of activities are available such as planting seeds, making cakes as well as sing songs and manicures. The manager designate has no budget available from the registered provider for the provision of entertainment. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 15 A number of photographs were on display showing residents partaking in parties within the home such as Christmas and Valentines. Pictures showed a recent Easter party including the outcome of the Easter bonnet competition. Two residents were reported to attend church outside of the home. The weeks menu is displayed near the entrance hall. The days menu can also be displayed on a white board within the back lounge / dining room. The menu on the second day of this inspection stated that the meals would consist of lasagne, salad and pitta bread or fish pie, carrots and broccoli. This was to be followed by rice pudding and jam or crème caramels. The meal served consisted of all the above with the exception of the caramels where an alternative was offered. The portions of food served were plentiful. A drink was served with the mid day meal, the plastic beakers used looked scratched and were unattractive. Fresh fruit was available within the main lounge. Fresh fruit and vegetables were also seen within the kitchen. Residents sat within the dining area only needed minimal assistance with eating however when this was required staff carried out this role with dignity and respect. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and staff have sufficient knowledge to protect residents from abuse. EVIDENCE: The Commission has previously received a number of complaints regarding the service provided at Haversham House. The number of complaints / concerns has reduced recently although some concerns were raised shortly prior to this inspection, these concerns were taken into account as part of this inspection. The manager designate described one complaint received since the previous inspection. Records were available to evidence that the matter was addressed satisfactorily. The complaints procedure was seen during this inspection and it was noted that it made reference to the CSCI. The procedure is not available in any alternative formats. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 17 A small number of comment cards were received from relatives / visitors the majority of them confirmed that they were aware of the complaints procedure within the home. Staff were aware of the complaints procedure as well as procedures for safeguarding people living within the home. Voting cards for forthcoming local elections were noted to be within the downstairs office however this standard was not assessed any further. Following serious concerns in the past staff have received training in relation to safeguarding vulnerable adults. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 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. Further progress to improve the environment has taken place but this is insufficient to provide residents with a safe place to reside where care needs can be met. As a result of the shortfalls identified residents are placed at potential risk. 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 some areas of the home were viewed including communal areas / facilities and bedrooms. Bedroom Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 19 accommodation on the first floor consists of 2 doubles and 8 singles; the remaining bedrooms are on the ground floor. Although the number of bathing facilities within Haversham House is acceptable the style and design of them remains unsuitable to meet the care needs of residents. One bathroom is not used due to its shape and design. Following the removal of a high step the shower room on the ground floor has improved, as it is easier for residents to negotiate. The only usable bath is located on the ground floor. The fabric cover on the bath hoist is ‘grubby’. This was identified in previous reports when it was stated that a replacement cover was on order. The registered provider has in the passed submitted a number of plans to improve bathing facilities but these have not always proven to be practical. Despite the improvement to the shower room the commission continues to have concern regarding bathing facilities. The previous key inspection report stated: ‘ It was evident that the wash hand basin within the downstairs bathroom had no hot water. The fact that water was running cold appeared to of been known prior to the inspection highlighting concerns such as the inability for residents and staff to suitably wash their hands.’ The random inspection report following a visit on 5th February 2007 stated: ‘ The hot water supply to both the wash hand basin and bath in the downstairs bathroom was found to be cold.’ The water was tested as part of both visits to the home and found to be cold on each occasion. Liquid soap and paper towels were available within toilets as part of the homes infection control procedures. During the first visit to the home an offensive odour was detected within the downstairs bathroom; it is believed that this was due to items within the hazardous waste bin needing to be removed to outside storage. One bedroom was in particular need of refurbishment. The vanity unit was damaged, wallpaper was peeling off the wall, the carpet was stained and the hem was hanging from the curtains. It was however noted within the same room that window restrictors were in place and the freestanding wardrobe was secured to the wall. Another bedroom was viewed and also found to have some need for refurbishment / improvement. The paint on the window ledge was peeling off, Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 20 the curtains were poorly hung, the en-suite vanity unit was damaged, the ensuite floor was stained and some damage was evident to the furniture. A window restrictor in one bedroom gave cause for concern as it appeared that it could potentially be unscrewed therefore the possibility of it fully opening. Bedroom furniture in a number of bedrooms is damaged or has handles missing. The wallpaper or carpeting in some bedrooms need replacing. Lockable furniture is not provided in every bedroom therefore not providing residents with a suitable place to secure valuables. The carpet grippers leading into some bedrooms and communal facilities from the corridor were loose causing a potential trip hazard. The devise to secure a freestanding wardrobe had been detached in one bedroom. An emergency call system is in place however the cord was not within easy reach of the bed in a number of rooms. Residents must have assess to summons assistance as required unless a risk assessment can demonstrate why this is not the case. The décor along the stairway near to the dining room and some landing areas is stuffed and appeared ‘tired’ in appearance. The previous key inspection report (November 2006) mentioned glass patio doors leading from the back lounge to the outside. Since that visit safety film has been applied in case of the window shattering. The previous report stated that the glazing had no motifs applied to it as a visual aid; the windows remain to have no motifs fitted. Low level glazing in other parts of the home including some bedrooms need to be risk assessed and suitable action needs to be taken to ensure residents safety. One bedroom window did not fully close into the frame. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area was poor This judgement has been made using available evidence including a visit to this service. The suitability of staff on duty needs to be taken into account to ensure care needs can be met and the smooth running of the home. Staff training has improved however recruitment practices remain insufficient. EVIDENCE: At the time of this inspection two carers were on duty for the morning shift. The manager designate stated that three carers are on duty at peak times. It was evident from the rota that the home had recently experienced a number of staff shortages. The home does not use agency staff. Concern was expressed regarding the staffing deployed over a recent night shift. Suitable and sufficient risk assessments need to be in place regarding junior staff. The cook has recently moved on to nights as a care assistant. As a result the former domestic was working as the cook, without a basic food hygiene certificate. The files appertaining to some new employees were viewed. Although it was evident that a PoVA (Protection of Vulnerable Adults) check was obtain for each person prior to the start of their employment other concerns were noted. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 22 A CRB (Criminal Records Bureau) disclosure was held for one person; it was reported that the other one was held with the umbrella body (the organisation who carried out the check on behalf of the home). The application forms completed by two employees were incomplete, it was evident that this was not raised as part of the interview process. The references held were not sufficient. One had a page missing and was not signed, another was headed ‘To Whom It May Concern’ and not to the person who had requested the information. The CRB disclosure and files appertaining to two young employees working within the kitchen were reported to be held at the homes head office in London. It was stated during the last key inspection that the registered provider was reviewing staff contracts. This remains to be the case some 5 months later. One comment received by the commission stated that former staffing problems ‘seem to have resolved.’ Some improvement has taken place regarding training. It was stated that everybody has completed moving and handling training with the exception of a new employee. In addition all employees have, it was stated, undertaken training regarding the protection of vulnerable people. Currently five out of thirteen carers have completed National Vocational Training (NVQ) accounting for 38 of carers. The home should of achieved 50 by the end of 2005. Additional carers are working towards this level of training and therefore the standard should be achieved in the near future. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Little progress has taken place to improve the overall performance of the home especially in relation to management. The shortfalls in management potentially leave residents at risk. Quality assurance systems are lacking and financial concerns remain. EVIDENCE: Following the departure of the previous manager designate the registered provider appointed another person working within the home to undertake this role. At the time of this inspection and prior to the production of this report Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 24 the manager designate needed to submit an application to the commission to apply for registration as registered manager. Prior to the completion of this report the inspector was informed of a further change of manager designate within the home. It is of concern that the home has had frequent changes of manager as the home is in need of suability. As reported previously within this report a management consultant has worked along side the most recent manager designate. The previous key inspection report noted that a commercially produced quality assurance manual covering the National Minimum Standards had been purchased. Since the key inspection (September 2006) two random visits to Haversham House (November 2006 and February 2007) have taken place. Both of the random visits concluded that no progress in using the manual had taken place; this remains to be the case. There was limited evidence of consultation taking place with residents and or their representatives regarding décor and bedding. A recent in house newsletter was on display. Although the progress is noted it remains insufficient and needs to be developed. The required reports following visits undertaken by the registered provider had commenced to be undertaken and were available to the commission. These reports are to be undertaken on a monthly basis therefore as the most recent report was dated February 2007 the frequency is not in line with the required standard. No business, financial or development plans were available within the home during this inspection. Both the Commission for Social Care Inspection and Worcestershire Adult Services have in the past had cause for concern regarding the financial management of the home. Issues around the non-payment of invoices or refunding of residents money were discussed as part of the vulnerable adult procedures. The registered providers assured the above agencies that improvements would take place, these improvements were acknowledged as part of the last key inspection. Petty cash procedures have improved, it was evident that sufficient funds are available to fund provision shopping much of which is done locally. Following the assurances it was of some concern to discover that another residents representative had to chase up money by contacting the homes head office. The registered providers were present within the home during part of the second visit and gave a verbal assurance that they would personally ensure the money was refunded. Prior to this inspection the commission received an anonymous concern that invoices were not getting paid on time, as this was part of recent vulnerable adult procedures it would be of serious concern were this to be the case. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 25 A small representative sample of resident’s money held in safekeeping was checked. The amount of cash held corresponded with the records maintained; receipts were not checked on this occasion. Nobody working within the home acts as an appointee or agent for any of the residents The manager designate reported that a staff meeting is going to be arranged in the foreseeable future as the last one was in February. It was evident that the formal supervision of staff is improving and it is anticipated that the associated national minimum standard should be able to be met. A health and safety poster is on display in the hallway. The information upon this poster needs up dating. This shortfall in information was highlighted within two previous key inspections and the random inspection carried out in November 2006. Evidence of suitable testing under LOLER (Lifting Operations and Lifting Equipment Regulations) was faxed over to the commission following the random inspection during February 2007. The document showed that the hoist over the bath is next due to be serviced during June 2007. The gas safety certificate was also seen during a previous inspection and therefore not needed as part of this visit. The label on the television in the main lounge evidenced that suitable testing of portable electrical equipment takes place. The previous key inspection highlighted the need for an asbestos risk assessment. Prior to the random visit in November 2006 the commission received a copy of a type 2 survey with a summary stating ‘no asbestos containing materials (ACM’s) were found. The fire log was briefly viewed as part of this inspection. Both the last key inspection report and the random report dated November 2006 stated that the fire alarm was not tested in sequential order. Although the testing of the fire alarm is taking place on a regular (almost weekly) basis it contains to be in non-sequential order. Records regarding the visual checking of fire fighting equipment were not seen. Records following the testing of the emergency lighting were insufficient. Fire signage around the home has improved. The manager designate was aware of the Fire Safety Order mentioned within the last random report but did not have a copy of it. Since the inspection the manager designate has advised the inspector that she has downloaded a copy of the fire order. The previous recommendation to use guidance issued under the previous regulations by Hereford and Worcester Fire Authority continues; a copy of this guidance was left with the manager designate. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 26 No procedures were in place regarding the isolation of utilities such as gas, water and electricity in the event of an emergency. All persons who are in charge of a shift within the home need to be aware of the actions to be taken and the location of stop taps and isolators. Records regarding fridge and freezer temperatures were available within the kitchen. Records regarding hot food at the time of serving were not available. It was noted that packets such as food mix and flour were open therefore the possibility of flying insects or other items getting into these items. The hob and microwave over were both clean. Some previously issued requirements from the previous inspection were found to be met. The remaining unmet requirements have been revised and grouped into a more limited number in line with CSCI policy. Therefore the reduction in requirements does not therefore indicate improvement in all standards. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 1 X X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 1 3 2 2 2 Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 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 The statement of purpose must be reviewed in line with the regulation and schedule 1. A copy of the revised document must be sent to the commission. The previous timescale of 31/03/07 not met. A new timescale is given. 2. OP1 5(1)(2) The service users guide must be reviewed in line with the associated regulations and made freely available to all residents and their families / advocates. A copy of the revised document must be sent to the commission. The previous timescale of 15/01/07 was extended to 31/03/07. This was not met. A new timescale is given. 31/07/07 Timescale for action 31/07/07 Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 29 3. OP2 5 (1) (b) The homes terms and conditions document must be reviewed in line with the associated regulations. This document was not viewed as part of this inspection. The date given as a timescale is the date of this inspection. 24/04/07 4. OP3 14 A full assessment of prospective residents must be undertaken prior to them moving into the home and must include all aspects of their care needs. Due to the voluntary restricted suspension no admissions took place for a period of time. In order to assess this requirement as met further evidence is needed. 24/04/07 5. OP7 15 Each resident must have a 31/05/07 comprehensive care plan in place which is regularly reviewed and updated and reflects all aspects of their care needs. Previous timescales of 04/04/04 31/05/05, 31/10/05 31/07/06 30/11/06 05/02/07 were not met. This requirement must now be met in full with immediate Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 30 6. OP8 12 Risk assessments including falls must be carried out and understood by all members of staff. The information from the risk assessment must form part of a comprehensive care plan and be regularly reviewed This requirement replaces a number of similar requirements, which was not met. Some of the requirements have previous timescale as follows: 31/05/04 31/05/05 31/10/05 31/07/06 31/10/06 05/02/07 The new timescale must be fully met. 15/06/07 7. OP19 13 (4) Assess and ensure suitable safety measures are in place regarding the patio windows and any others below waist height. Previous timescale not met 15/06/07 8. OP19 23(2) All areas of the home must be well maintained. Previous timescales of 31/08/06 30/11/06 and 31/12/06, 30/04/07 were part met. A revised timescale is given. 31/07/07 Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 31 9. OP22 23 (2) (j) Sufficient and suitable bathing facilities must be maintained and be available to met care needs. Part met – further action to provide suitable bathing facilities must be taken within the revised timescale. 31/08/07 10. OP19 OP25 13 (4) (c) OP38 11. OP24 23 (2) (j) The registered providers must ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated. Sufficient supplies of hot water must be available delivered at a safe temperature. The previous timescale of 05/02/07 not met. 25/04/07 30/06/07 12. OP29 19 (1) Suitable and robust recruitment procedures must be implemented to safeguard vulnerable people. All staff must have individual training and development assessments and profiles. Previous timescale of 31/07/06 and 31/01/07 not met. Not assessed during this inspection 31/05/07 13. OP30 18 30/06/07 14. OP33 24 A quality assurance system must be put in place in order to audit DS0000018486.V334370.R01.S.doc 31/07/07 Haversham House Version 5.2 Page 32 the service provided by the home. Previous timescales of 30/06/04, 30/07/05 31/10/05 not met The timescales of 31/08/06 31/12/06 31/03/07 part met. A revised timescale is given 15. OP37 17 All records must be kept in accordance with the regulations. Previous timescales of 31/10/05 31/07/06 30/11/06 31/03/07 not met. A new timescale is given 30/06/07 25. OP38 23 (4) The registered person must ensure that the requirements made under the Fire Safety Order 2005 are met. Previous timescale of 31/12/06 and 31/03/07 not meet. A new timescale given. 30/06/07 Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 33 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 It is recommended that the guidance issued by Hereford and Worcester Fire Authority is used. Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 34 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haversham House DS0000018486.V334370.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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