Inspection on 24/01/06 for Hevercourt

This inspection was carried out on 24th January 2006.

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

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

Other inspections for this house

Hevercourt 26/03/08

Hevercourt 28/02/07

Hevercourt 21/09/05

Hevercourt 21/10/04

Hevercourt 11/05/04

Similar services:

Wingham Court

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

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

CARE HOMES FOR OLDER PEOPLE Hevercourt Goodwood Crescent Gravesend Kent DA12 5EY Lead Inspector Ruth Burnham Announced Inspection 24th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 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. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hevercourt Address Goodwood Crescent Gravesend Kent DA12 5EY 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) 01474 363690 Kent Community Housing Trust Mrs Christina Clark Care Home 46 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (21) of places Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Kent Community Housing Trust is a non-profit making Trust. Hevercourt is one of 22 residential care homes owned and run by the Kent Community Housing Trust (KCHT) in the Kent and London areas. It holds Investors in People Award and has an ISO 9002 Quality Standard Accreditation. The general aim of KCHT, as expressed in its brochure, is to provide quality services which are flexible and affordable, meet the needs of individuals, preserve dignity and promote independence, and develop opportunities for fulfilment for people needing housing with care and for those who need care and support within their own homes. Hevercourt is a large detached premises surrounded by lawns and gardens and close to the A2 junction at Singlewell. It offers 37 single and 5 double bedrooms. There is a shaft lift serving all three floors with bedroom accommodation on the ground, first and second floors and other services (i.e. kitchen, lounges, smoking room, visitors room, hairdressing salon, activities room, medical room and staff room) on the ground floor. The Home is registered for 21 Older People and 25 Older People with a Mental Infirmity. Hevercourt is located on the outskirts of Gravesend and is within easy walking distance for most service users of shops and other public amenities. However, service users have good access to a KCHT minibus. There are extensive car parking facilities at Hevercourt and service users have access to two safe enclosed gardens at the rear. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector who was in the home from 09.30 to 16.00, during this time a number of staff and service users were observed and spoken with around the home. Feedback was given to the manager. What the service does well: What has improved since the last inspection? What they could do better: Admission procedures must be followed to ensure that the home has adequate information to ensure that service users are only admitted whose care needs can be met, staff who carry out assessments must be properly trained. The care plan should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the service user are met in a way which takes account of their individuality and preferences. Guidance for staff in relation to risk assessment must be clear and must reflect care managers assessments. Only service users who have made a positive choice to share a bedroom should be required to do so and action must be taken to ensure that requirements in relation to environmental standards, which have been identified in previous reports, are complied with Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 6 without further delay. The registered person shall establish and maintain a quality assurance system for the care provided at the care home and supply to the Commission a report in respect of any review of quality and make a copy of the report available to service users. 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. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 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 the following standard(s): 1-6 People who are thinking about moving to the home and their supporters are provided with sufficient information on which to decide if this is the right home for them however, improvements are needed in pre admission assessments to ensure that all their needs can be met. EVIDENCE: People who are thinking about moving to the home and their supporters are provided with detailed information about what they can expect through a statement of purpose and a service user guide, a copy of which is provided in each bedroom. People who live in the home can be clear about their rights and responsibilities through contracts which are in place and were available for inspection, those seen had been signed by all parties. Records which were examined indicate that people who are admitted to the home cannot always be confident that their needs will be met, a pre-admission assessment of their needs is carried out by the home however not all staff who carry out the assessment have received specific training in this area and there Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 9 was some concern that admission procedures set out in the Trust’s quality manual are not being followed adequately in that the forms provided for assessment are not being fully completed at the pre admission visit. Confusion has arisen for staff because the same needs assessment form used pre admission is also being used as the care plan. There is opportunity for people who live in the home to visit prior to admission and meet the staff and other residents, they are able to spend time at the home and have a meal if they wish. The initial residency is for a trial period of four weeks after admission to ensure that the home was an appropriate place for the service user, this can be extended if felt necessary and unplanned admissions are avoided whenever possible. The home does not provide intermediate care. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 Service users benefit from support by staff who are well informed about them however individual personal care needs may not always be met, their privacy and dignity is not always being upheld and, in some instances, they may be at risk of harm. EVIDENCE: Service users care needs are set out in their needs assessment to enable staff to provide care. Service users’ individual personal needs may not always be met as needs assessments seen are largely set out in a tick box format, with small boxes which allow for minimal comment or observations. These contain limited guidance for staff which takes account of the individuality and personal preferences of residents in how their care should be delivered. Daily records do not reflect the content of care plans and do not reflect the good practice and positive interaction which goes on in the home on a daily basis. Service users benefit from the care provided by the dedicated and committed staff team, interaction observed was warm and friendly and care was provided in a way which respects and protects the dignity and privacy of service users. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 11 Personal records include excellent information about the background and social history of people who live in the home to help staff to communicate with them however, service users could still be at risk of harm in that risk management still does not take account of all aspects of service users lives, for example the risk assessments documented for one new service user did not reflect risks which were identified in the care plan which has been provided to the home by the care manager. Service users who are disorientated and wander at night are still compromising the dignity and privacy of other service users. Given that many service users in this home are suffering from dementia it is clear that those who share bedrooms are not able to make a positive choice to share with full understanding of the implications of this situation for privacy and dignity in that they will be sharing with other service users who are strangers to them. Where people who live in the home are supported with their medication they are safeguarded through good administration practice, safe storage and good record keeping. Medication is administered largely via a monitored dosage system. People who live in the home can expect to be able to remain in the home until death so long as the home is able to continue to meet their needs, and they and their relatives benefit from the support of staff who have received training in bereavement and loss. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 People who live in the home benefit from the wholesome food and flexible routines however, individual recreational interests and needs may not always be met. EVIDENCE: Service users benefit from the flexible routines in the home, they are able to exercise choice in relation to routines of daily living. The home employs an activities co-ordinator who arranges activities for the people who live in the home however, there are no individual programmes included in resident’s care plans for staff to follow and records of activities which were seen did not show that recreational activities are provided for all residents. People who live in the home benefit from the use of a minibus which is used for outings. Service users were are benefiting from increased staffing levels at breakfast time which has improved the service they are offered. Choice at meal times is offered in a way which is appropriate for people who have a diagnosis of dementia in some form. Picture menus have been introduced and the health of residents is promoted through a commitment to providing healthy foods which take account of individual needs. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 13 People who live in the home benefit from the flexible visiting policy in that friends and relatives are able to visit at all reasonable times and they also enjoy some involvement with local community groups such as the local school, and a local minister conducts a religious service monthly for people who wish to take part. People currently living at the home who are unable to manage their own finances, their interests are safeguarded in this area through clear policies and good record keeping. People who move into the home are helped to feel at home by being able to bring personal possessions with them, as long as they do not present a hazard, a record is kept by the home, bedrooms are personalised. - Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): People who live in the home are protected from abuse and they can be confident that they will be listened to. EVIDENCE: People who live in the home and their supporters are provided with a written complaints procedure and are free to offer comment or complaint, the home maintains summary of complaints as required and details are recorded in individual resident’s records. Residents are supported to vote through the arrangement of postal votes which are arranged for those service users wishing to participate in the election process. People who live in the home are protected from all forms of abuse and there are written policies and procedures including a whistle blowing policy to ensure the safety and protection of service users. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 - 24 People who live in the home have benefited from improvements made since the last inspection however, their quality of life is adversely affected by failure to comply with some previous requirements. EVIDENCE: People who live in the home are benefiting from the improvement which have been made in the environment; the dining room floor has been replaced and many areas have been redecorated to provide a pleasant and homely atmosphere. However the quality of life for some service users continues to be affected by the provision of furniture which is not fit for purpose, in that some wardrobes are far too small and new bedroom chairs are not suitable for relaxing comfortably in, should service users wish to spend time in their rooms rather than in the communal sitting areas. Telephone and television sockets are not provided and not all bedrooms have sufficient electrical sockets. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 16 Service users who share rooms are mainly those who have dementia, therefore, it is impossible to make a judgement that it is their positive choice to share. Those who share are also adversely affected by the inadequate size of these rooms, which are too small to accommodate the furniture required within the standard. The quality of life for people who live in the home, particularly new admissions and those with dementia has been improved through the addition of signs on doors which make orientation within the home easier. Previous inspections have identified the need for specialist assessment of the premises by suitably qualified persons who would provide appropriate advice in relation to these issues, the manager confirmed that this is being arranged shortly. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 People who live in the home benefit from the support of carefully selected and well trained staff who understand their needs. EVIDENCE: People who live in the home benefit from the care and support provided by the staff team who are well supervised and have all received specialist training in understanding the specific needs of people who have dementia, they are also benefiting from the increase in staffing levels since the last inspection. People who live in the home are protected through sound recruitment and selection procedures which include taking up 2 written references and carrying out checks with the criminal records bureau prior to appointment, staff records seen are maintained in a way which meets regulatory requirements. Residents also benefit from the opportunities provided to staff to improve their skills through training and access to National Vocational Qualifications, the commitment and enthusiasm of the manager in relation to training is impressive and records indicate that all staff are provided with opportunities to develop and acquire new skills which will continue to improve the quality of life for people who live in the home. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): People who live in the home benefit from an experienced management team who have their best interests at heart however, lack of effective quality assurance systems may hinder future improvements to their quality of life. EVIDENCE: People who live in the home benefit from the qualifications and experience of the manager who managed homes since 1998, she has recently completed the Registered Managers Award. Residents and their supporters benefit from the open door policy of the manager which was demonstrated by the way in which residents felt free to wander in and out of the office for a chat during the inspection. There are clear lines of accountability within the home and the organisation with audit visits by the Registered Provider taking place every month. Responses from relatives received before the inspection indicated a general satisfaction with the overall management of the home. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 19 The quality of life for people who live in the home and their supporters is monitored through annual quality questionnaires, which are sent to all relatives/representatives of the service users. However, the home does not have a continuous self-monitoring system in place, based on a systematic cycle of planning-action-review, which produces a report to the Commission in line with the regulations. The safety of people who life in the home is maintained through periodic routine tests and checks of fire precautions, records seen were in good order. There is a fire safety risk assessment in place however this has not yet been approved by the Fire Safety Officer. Safety is further promoted through the regular maintenance of all equipment and installations; safety certificates were seen and were in good order. Safe working practices also protect residents from risk of harm through training staff in fire safety, moving and handling, first aid, basic food hygiene and health and safety. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 20 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 3 3 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 x x x 2 2 2 x x STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 21 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 OP3OP3 Regulation 14 7 19(5) Requirement Timescale for action 31/03/06 2 OP7OP7 13(4)c 15(1) 12(2&3) 3 OP12OP12 12(1) & 16(2)(n) 4 OP22OP22 23(1)&(2) The registered person shall not provide accommodation to a service user unless the needs of the service user have been assessed by a suitable qualified or suitably trained person – in line with the admission procedures of the Trust. 31/03/06 The care plan should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the service user are met in a way which takes account of their individuality and preferences. Risk assessments should be included in the care plan, which cover all aspects of daily living. The registered person shall make 31/03/06 arrangements for all service users to take part in a programme of activities and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation and fitness. 31/03/06 An assessment of the premises DS0000023955.V269807.R01.S.doc Version 5.0 Hevercourt Page 22 (a) and facilities should be made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for. Specific environmental adaptations should be made to assist service users with sensory loss, dementia or other cognitive impairment. 31/03/06 5 OP24OP24 23(2)(n) Bedrooms must be furnished with at least the minimum requirements as set out in the standard with furniture that is suitable and fit for purpose. 6 OP23OP23 12(3)& (4)a&23 (2)f 7 OP33OP33 24 31/03/06 The size and layout of rooms occupied by service users must be suitable for their needs i.e. shared rooms should sufficient space to accommodate the required furnishings and be occupied by service users who have made a positive choice to share. When a shared place becomes vacant, the remaining service user should be offered the opportunity not to share. Each person should have comfortable seating. The registered person shall 31/03/06 establish and maintain a quality assurance system for the care provided at the care home and supply to the Commission a report in respect of any review of quality and make a copy of the report available to service users. Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Hevercourt DS0000023955.V269807.R01.S.doc Version 5.0 Page 25 - 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!