Inspection on 09/09/05 for Haversham House

This inspection was carried out on 9th September 2005.

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

Other inspections for this house

Haversham House 25/02/09

Haversham House 11/03/08

Haversham House 24/04/07

Haversham House 20/04/06

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 Annie OMara Unannounced 9 September 2005 09:00 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Haversham House Address 327 Bromsgrove Road. Redditch, Worcestershire B97 4NH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01527 542061 Springlea Limited vacant Care Home 16 Category(ies) of DE(E) Dementia over 65 (16) registration, with number OP Old age (16) of places PD(E) Physical disability over 65 (16) Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection 21 April 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 accommodaton on two floors, the first floor is accessed by a stair lift. Accomodation is provided in 12 single rooms and 2 double rooms. There are no ensuite facilities. 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 seperate lounges/dining areas for the residents to choose where to sit. The garden has facilities for residents to sit out in the summer. The home is generally well maintained and comfortable. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours on a weekday morning. Care records were looked at, staff training files examined and observations made about care practices. Four residents were spoken to and a discussion with staff took place. What the service does well: What has improved since the last inspection? What they could do better: The registered persons have been trying to appoint a suitable manager for over a year and have been let down on several occasions. However during this time the support provided to the existing staff group has not been consistent. Additionally the registered persons have not effectively maintained an overview of the day to day management issues which the existing staff group are not able to manage themselves. This has meant that basic information about the home is not available for prospective residents. Care planning for residents has not been kept up to date, although the staff are aware of individual needs. Staff training records have not been kept current and identified specialist training needs have not been met. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 6 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 E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5. The lack of information about the home does not provide prospective residents and their relatives with the assurance that the home can meet their needs which could lead to residents being placed in the wrong environment. EVIDENCE: The statement of purpose and service users guide was not available and the acting manager was unsure if the most recently admitted resident had been given a copy. A community care assessment had been carried out for the new resident prior to admission and a care plan was in place. The resident had visited the home before moving in and a record of the visit was made. There were copies of the contracts between the home and the residents but none of the three seen had been signed or dated. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11. Care planning systems in the home have not improved since the last inspection, and while staff are aware of individual needs the lack of written information continues to put residents at risk. EVIDENCE: Care plans were in place for the residents but have not been updated since the last inspection. Residents’ files seen indicated that a daily personal care diary had been introduced. These had not been signed every day and the photocopies were poor and smudged making it difficult to read. There was no record of the residents belongings brought into the home. There was no photograph of the resident on file. One care plan had not been dated or signed. Risk assessments for skin care, nutrition or moving and handling had not been reviewed or updated. The care plan for a new resident did not contain any risk assessments in relation to personal care nor were there any in place for challenging behaviours that had been identified by the assessment and previous placement. Discussions with staff indicated that they were aware of the residents’ needs but these had not been included in the records. The daily records kept as to how the new resident was settling in were written in good detail. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 10 Medication administration was not inspected on this occasion. However the deputy manager stated that the senior staff had received training from Boots pharmacy and the home was changing their system to the Boots system the following week. Relationships between staff and residents were seen to be warm and affectionate. Residents spoke highly of the staff and said that they looked after them well. Staff adhered to the principals of privacy and dignity and were seen to be respectful with the residents. Records seen for a resident who had been looked after whilst terminally ill showed that they had received a high standard of care during their illness. The family had been involved and staff had paid attention to maintaining a high level of comfort. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, The activities were repetitive and lacking in variety which was not stimulating for the residents. EVIDENCE: There are no routines imposed on the residents and when they were asked they said that there was enough for them to do during the day. There was a program of activities displayed although this did not change from month to month. There were few opportunities for residents to go out. Staff confirmed that they did have time to spend with the residents undertaking activities but the records kept were sporadic. Staff were seen engaging with residents on a one to one basis throughout the morning. Residents confirmed that visitors were able to come to the home at any time. Due to the lack of availability of the statement of purpose and service user guide, these arrangements were not provided to new residents Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18. The lack of knowledge among staff about the homes policy on abuse and poor training puts residents at risk. EVIDENCE: Residents who were spoken to knew to whom they would address complaints should the need arise. However the complaints procedure was not readily available in the home. The Commission for Social Care Inspection has not received any complaints about the home since the last inspection. The deputy manager and a senior member of staff have attended training on abuse and managing challenging behaviour. The deputy could not confirm that she had seen the homes’ policy and procedures for handling suspected abuse. All staff need abuse awareness training. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were inspected on this occasion. EVIDENCE: Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 30. General health and safety training in the home has improved but the lack of NVQ training for any staff leaves them disadvantaged and puts residents at risk. EVIDENCE: The home has maintained the staffing levels at three on duty throughout the waking day. The home currently has fourteen residents and any further referrals to the home must take into account the needs of the existing resident group. The deputy manager confirmed the following training had taken place although there were no up to date staff training records in place. Infection control Fire training Moving and handling Medication Food hygiene NVQ training which had been started has been suspended. There are currently no staff members with NVQ qualifications. The deadline for 50 of the staff to have received NVQ training is 31st December 2005. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37, 38. The management systems in the home are failing to provide what is necessary to keep the residents safe from harm and free from risk. EVIDENCE: There is currently no registered manager employed at the home although the registered persons are advertising for a suitable person. The current deputy manager is being supported by the registered persons, but this inspection has identified shortfalls in the general management of the home which includes up dating care planning, risk assessments, supervision of staff, training plans and managing health and safety in the home. There is no quality assurance program in operation in the home. Residents personal allowances kept by the home were checked and amounts wee correct. There were no receipts for hairdressing or chiropody appointments paid for by the residents, nor were two signatures sought for all financial transactions. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 16 Staff do not receive supervision for the work they undertake. Records which were not kept in the home included, receipts for residents financial transactions, records of residents belongings and Regulation 26 visits and reports by the registered persons. The deputy manager stated that the registered persons were visiting weekly and had been supportive. However, because there is currently no registered manager the visiting and reporting functions are of vital importance to ensure that they have an overview of the service and how it is operating. The weekly fire alarm tests had not been undertaken at the required frequency. An Immediate Requirement notice was left in respect of this matter. Fire maintenance checks were due to be carried out. There were risk assessments in place for the environment but these had not been signed or dated. There was no plan in place to show how environmental issues were being managed. The gas safety certificate was in place. It was of concern that again there was no-one who was keeping an overview of the health and safety matters in the home. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 2 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 1 x 1 x 2 2 2 2 Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1)(2) Requirement A statement of purpose must be made available in the home for prospective residents. Timescale of 31st May 2005 not met. A service users guidemust be made available for all residents. Timescale of 31st May not met. Statements of terms and conditions between the home and the resident must be signed and dated. Specialist training must be provided to staff to ensure that residents needs are fully understood and met. Timescale of 31st October 2004 and 31st May not met. Each resident must have a comprehensive care plan in place which is regularly reviewed and up dated and reflects all aspects of their needs. Timescales of 4th April 2004 and 31st May 2005 not met. Residents care plans must be signed, dated and where possible the, the signature of the resident or their representative included. Timescales of 31st May 2004 not met. Nutritional and skin care risk Timescale for action 31st October 2005 31st October 2005 31st October 2005 A training plan to be in place by 31st October 2005. 31st October 2005 2. 3. 1 2 5(1)(2) 5(1)b 4. 4 (18)(1) a, b, c. 5. 7 15 6. 7 15 31st October 2005 7. 8 12 31st Page 19 Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 8. 9. 8 8 12, 13. 12, 13 10. 16 22(1) 11. 12. 18 18 13(6) 13(6) assessments must be carried out and regularly reviewed. Moving and handling risk assessments must be carried out and reviewed. Individual risk assessments must be carried out and reviewed for residents displaying challenging and aggressive behaviour. The homes complaints procedure must be freely available and given to all new residents and their representatives. All staff must have access to the homes adult abuse policy. Arrangements must be made by training or other measures to ensure that all staff are aware of all types of abuse. Timescale of 30th November 2004 partially met. Risk assessments and management procedures must be put in place to ensure that residents are not placed at risk from other residents challenging behaviours. Timescale of 31st May 2005 not met. The strip lights in the kitchen to be covered. Timescale of 31st May 2005 not met. Individual staff training plans must be kept up to date. NVQ training for staff must be pursued by the registered persons. Suitable management arrangements must be put in place to ensure that staff receive the support they need to run the home, and that the management functions of the home are fulfilled. A quality assurance system must October 2005 31st October 2005 31st October 2005 30th September 2005 30th September 2005 31st October 2005 13. 18 13(6) 31st October 2005 14. 15. 16. 17. 19 27 27 31 13 18 18 7 31st October 2005 31st October 2005 31st October 2005 31st October 2005 18. 33 24 31st Page 20 Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 19. 20. 35 36 17 18 21. 37 26 (1)(2)(3) 22. 23. 24. 37 38 38 4,17 Schedules 1, 3, 4. 23(4) 13(4) be put in place in order to audit the service provided by the home. Timescale of 30th June 2004 and 30th July 2005 not met. Receipts must be kept for all transactions carried out on behalf of residents. All staff must receive refular supervision by the registered persons. Timescale of 31st May 2005 not met. The registered persons must produce a report as stated by Regulation 26 and a copy must be sent to the Commission for Social Care Inspection. All records must be kept in accordance with the regulations. Regular fire safety checks must be carried out and recorded. The environmental risk assessments must be signed and dated. October 2005 30th November 2005 31st October 2005 30th September 2005 31st October 2005 Immediate 30th September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 12 Good Practice Recommendations A record of activities undertaken by residents should be kept. Haversham House E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 21 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 E52 S18486 Haversham House V246003 090905.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!