Inspection on 10/11/05 for High Haven

This inspection was carried out on 10th November 2005.

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

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

Other inspections for this house

High Haven 18/01/08

High Haven 18/08/06

High Haven 15/06/05

High Haven 09/11/04

High Haven 25/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE High Haven High Haven Howdale Road Downham Market Norfolk PE38 9AG Lead Inspector Mr Jerry Crehan Announced Inspection 10th November 2005 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 High Haven DS0000035183.V254959.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. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service High Haven Address High Haven Howdale Road Downham Market Norfolk PE38 9AG 01366 382205 01366 385586 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) Norfolk County Council Position Vacant Care Home 38 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (30) of places High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To register for 38 Service Users who are Older People. People who need wheelchairs to assist with independent mobility at point of admission should not be accommodated in rooms numbered 2, 3, 8, 101, 102, 107, 138, 139, 140, 148, 150 and 151 (as at 31 March 2003). 15th June 2005 Date of last inspection Brief Description of the Service: High Haven is a care home providing personal care and accommodation for up to 38 older people including eight people who have dementia. It is a local authority home owned by Norfolk County Council. The home is located in the market town of Downham Market, close to the shops, pubs, the post office and other amenities. High Haven is an established two storey, purpose built home. The home’s bedrooms are all single except for one double room. There are five day rooms, a visitor’s room and an activities room. There is a passenger lift. There is a small garden at the front of the building and a large well laid out garden at the rear of the building. A large car park lies to the side. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours. Opportunity was taken to tour the premises, look at care records and policies, and communicate with many of the nineteen service users in addition to visiting relatives, staff and the temporary and newly appointed managers. Two comment cards were received from visiting G.P’s prior to the inspection. These expressed satisfaction as to the care provided at the home. As no other comment cards were received prior to the inspection, the new manager is advised to consider ways in which comment cards can be made more accessible to relatives and others. What the service does well: What has improved since the last inspection? The privacy of service users and the security of their belongings are more satisfactorily addressed, as each bedroom at the home is now lockable, and service users are provided with lockable cabinets. Medication records and practices were good, though the use of risk assessment (where appropriate) must be introduced. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. High Haven DS0000035183.V254959.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 High Haven DS0000035183.V254959.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, 2, 3 The information provided by the home that would assist service users in making an informed choice as to the home’s ability to meet their needs requires updating. The needs of prospective service users are adequately assessed. EVIDENCE: The home has clear written information available to prospective service users, which would provide them with a good understanding of the home’s capacity to meet individual need, including needs arising from dementia. The home has a Statement of Purpose and a Service User Guide that contains the information required by regulation, and is available, alongside other information, in the entrance foyer to the home. The documents are also offered in large print, audio and Braille on request. This is commended. As a consequence of the establishment of a new and nearby ‘housing with care’ resource by the proprietor earlier this year, many service users have moved from the home. The information the home provides to prospective service users (including the Statement of Purpose) will therefore need to be amended to reflect the current situation and services offered at the home. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 9 Either service users or their relatives sign terms and conditions for their accommodation at the home. These appeared to reflect services provided. The relevant documentation was seen and adequately meets the standard required. There is an admission procedure that adequately guides the manager, and care coordinators responsible for assessment, as to actions to be taken to ensure service users needs are assessed prior to a move to the home. Evidence of this was seen in files reviewed and confirmed by service users. High Haven DS0000035183.V254959.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, 9, 10, 11 Service users health and personal care needs are well attended to, though further improvements required. Use of risk assessment should be expanded where service users self medicate. EVIDENCE: Sample care plans and accompanying risk assessments reviewed set out care requirements in satisfactory detail, and where possible service users sign these. Evidence of the regular review of care plans was seen. The recording of information in respect of service users falls must provide more detail of the time and circumstances of the fall in order that appropriate interventions can be carried out. There are currently service users accommodated at the home who take responsibility for administering some of their own medication including service users admitted for periods of short-term care. Risk assessments have not yet been completed in each of these instances. All arrangements where service users retain responsibility for their own medication should be the subject of risk assessments to assist in ensuring safe management. Medication records and storage were reviewed and were found to be satisfactory. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 11 Comments from service users and observation during the inspection showed that staff had an understanding of how to promote service users privacy and dignity. Communication between staff and service users observed was sensitive to the individual needs of service users. A number of service users indicated that staff always respond very quickly to call bells if used. Service users spoken to were exclusively complementary about their staff and the quality of the care they receive at the home. The home consults with relatives and local services for support in the event of deterioration in the health of any service user living at the home, in order that they may remain there. This is supported by information gathered as to the wishes of service users in the event of their death. The managers indicated that relatives are enabled to stay with service users for as much as they would wish at this time. High Haven DS0000035183.V254959.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 & 14 Service users experience a variety of formal and informal social activities in conducive settings, activities for service users with dementia are in the process of further development. Visitors are encouraged and made welcome. EVIDENCE: Service users confirmed that a number of organised activities are arranged regularly including a visiting entertainment, and trips into the local community. However, it was acknowledged by several people during the inspection that pavement access near to the home makes it difficult for service users with restricted mobility, and for service users who require wheelchairs for mobility. The manager indicated that this issue may be taken up by the home with the local council. The managers and staff at the home described a current process of reviewing and developing activities at the home. This review includes looking at developing the range of stimulation available for service users with dementia and looking at appropriate current research. Progress will be followed up at future inspection of the home. It was evident at the time of the inspection that service users experienced and enjoyed discussions with staff. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 13 Service users indicated that their visitors were made welcome at the home at any time of their choosing, and that they usually saw visitors in the privacy of their own rooms. High Haven DS0000035183.V254959.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): 17 There are good arrangements for protecting service users legal rights. EVIDENCE: The managers described the use of independent advocates to support service users in financial affairs. It is also evident that advocacy services were commissioned by the home and used to the benefit of service users deciding whether to remain at the home or move to the newly established housing with care scheme operated by the proprietor nearby. The home is commended for ensuring these services are available to service users. Service users are able to take part in the political process, voting by postal ballot. High Haven DS0000035183.V254959.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): 19, 20, 21, 22, 23, 24 Service users live in a comfortable and safe environment, though there are recommendations to improve general maintenance matters. EVIDENCE: The home is well maintained internally. Externally it is recommended that window frames are either cleaned or repaired if necessary, to ensure the home is maintained to a standard in keeping with others in the community. It is also recommended that encroaching shrubs be cut back from pathways around the home to enable easy access to the fire assembly point. Service users benefit from a variety of communal areas available within the home. The majority of these areas were in use at the time of the inspection for different purposes. However, communal spaces within the part of the home providing care to service users with dementia are limited to a combined lounge/dining room. The new manager indicated that this area would be given consideration for further development and improvement. Consideration should also be given for service users in this area to comfortable and safe access to outdoor areas. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 16 There are suitable and adequate toilet and bathing facilities throughout the home. There is also sufficient specialist equipment available within the home to meet the assessed needs of service users. It is recommended that faulty wheelchairs, or wheelchairs identified for external use only are clearly labelled as such. All of the bedrooms at the home are designed for single occupancy. Many service users bedrooms were clearly personalised with their own furniture and possessions, creating a homely feel within their individual rooms. All bedrooms are now lockable and each room benefits from lockable storage space for service users to store their personal belongings. High Haven DS0000035183.V254959.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, 29, 30 Service users are largely, though not fully supported or protected by the home’s recruitment practices. The staff induction and training programme addresses service user needs. EVIDENCE: Staff morning handover arrangements in the part of the home offering care to service users with dementia are not satisfactory. Currently staff are required to hand over to a colleague and maintain care of service users at the same time. The hand over takes place between the night carer and a carer from the main part of the home, who an hour later has to hand over to the oncoming morning care staff for the dementia care unit. Clearer hand over arrangements are needed between outgoing and incoming care staff with dedicated rostered in time. Sample files reviewed included evidence the recruitment of care staff prior to obtaining two satisfactory written references. Other records reviewed were satisfactory. It is acknowledged that the temporary manager has made considerable and successful efforts to re-establish a new staff group at the home and provide continuity of care to service users. It is evident from staff spoken to and from some training records seen that staff have access to induction training and a full range of mandatory training. Training in dementia awareness has been made available to staff carrying out this care. The existing and new staff group appeared to show interest and enthusiasm in their role. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 18 Service users spoken to were satisfied with the care provided and indicated that they felt well looked after at the home. This was supported in comments made by relatives spoken to. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 19 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): 31, 32, 33, 35, 36, 37, 38 The home is well managed by an experienced temporary manager who is well regarded by service users, relatives and staff alike. The home is run in the best interests of service users. EVIDENCE: The registered manager left the home in July to manage the proprietor’s new housing with care project nearby. An experienced temporary manager from another of the proprietor’s homes has managed the home from that time until the week of this inspection when the new manager for High Haven was being inducted into the home. Both service users and staff spoken to spoke in favourable terms about the manager’s approach and leadership since July. The manager is commended for the way in which she has managed the home, in particular for assisting service users and their relatives in making independent and appropriate choices as to their care provision, ensuring that they were in High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 20 possession of the information they needed to make choices, in providing continuity of care and in re-establishing a staff team. It is expected that this management approach will continue with the appointment of the new manager. They indicated that they are familiar with, and have had experience of, operating systems to ensure that the home continues to be run in the best interests of service users. It is expected that the proprietor will support the new manager in seeking registration with the Commission. Service users financial interests are safeguarded by the home; their relatives manage the vast majority of service users financial affairs. Staff are appropriately supervised and service users further supported by the home’s policies and record keeping. The manager should seek clarity from the fire officer as to the appropriateness of the home’s designated fire assembly point, as this area is secure and to the rear of the home. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 3 3 3 3 3 X X STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 3 2 High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(b) Requirement The registered person must ensure that appropriate interventions be carried out in respect of service users identified at risk of falls. The registered person must undertake, record and review risk assessments for service users who retain control and administer their own medicines. This Requirement Is Repeated The registered person must make suitable arrangements for the care of service users during staff hand over periods. The registered person must ensure that new staff are confirmed in post only following satisfactory checks set out in Schedule 2 of the Care Homes Regulations 2001. The registered person must consult with the fire authority with regard to the suitability of the fire assembly point. Timescale for action 10/11/05 2 OP9 13(2) & 14(2)(a) 30/11/05 3 OP27 18(1)(a) 30/11/05 4 OP29 19(1)(b) (1) 10/11/05 5 OP38 23(4)(b) 30/11/05 High Haven DS0000035183.V254959.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. 1 2 3 Refer to Standard OP19 OP19 OP22 Good Practice Recommendations It is recommended that window frames are either cleaned or repaired if necessary, to ensure the home is maintained to a standard in keeping with others in the community. It is recommended that encroaching shrubs be cut back from pathways around the home to enable easy access to the fire assembly point. It is recommended that faulty wheelchairs, or wheelchairs identified for external use only are clearly labelled as such. High Haven DS0000035183.V254959.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 High Haven DS0000035183.V254959.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. 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