Inspection on 15/06/05 for High Haven

This inspection was carried out on 15th June 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 10/11/05

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 Howdale Road Downham Market Norfolk PE38 9AG Lead Inspector Jerry Crehan Unannounced 15 June 2005 10:00 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. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service High Haven Address Howdale Road Downham Market Norfolk 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) 01366 382205 01366 385586 Norfolk County Council Position Vacant Care Home 38 Category(ies) of Dementia - over 65 years of age (8), registration, with number Old age, not falling within any other category of places (30) High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 accomodated in rooms numbered 2, 3, 8, 101, 102, 107, 138, 139, 140, 148, 150, and 151 (as at 31 March 2003) Date of last inspection 9th November 2004 Brief Description of the Service: High Haven is a care home providing personal care and accommodation for 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 I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Opportunity was taken to tour the premises, look at care records and policies, and communicate with many of the thirty-three users accommodated at the time of the inspection. A visiting relative, staff members and the manager were also spoken to. The inspection took place at a time of change and uncertainty for service users and staff at the home. The manager, a significant proportion of staff, and a significant number of service users will be moving in July to a new ‘housing with care’ resource newly built nearby. Consequently the proprietor is undertaking a recruitment programme for new staff, and a new manager will also need to be appointed. CSCI will liaise with the proprietor throughout this process. What the service does well: What has improved since the last inspection? Improvements in care planning have been noted, particularly in regular reviewing of care plans, which was an issue identified at the last inspection. The standard of internal decoration has improved significantly since the last inspection. The home looks much brighter as a consequence. Measures have been taken to improve the safety of service users by regulating hot water temperatures and covering radiator surfaces. Significantly, the home now provides two staff throughout the day in the part of the home offering care to service users with dementia. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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 I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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 High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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) 3 & 5 The home has an adequate admission procedure, providing prospective service users with the opportunity to visit the home where possible. EVIDENCE: 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 spoken to. The admission procedure is further supported by assessments by referring agencies. Service users indicated that the opportunity to visit the home prior to admission was made available, one service user indicated that their ‘daughter came to look around as I was in hospital’. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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, 9 The care planning system is clear and adequately provides staff with the information they need to meet the health and care needs of service users. Medication practices are confused and may place service users at risk. EVIDENCE: Sample care plans and accompanying risk assessments reviewed set out care requirements in reasonable detail, where possible service users sign these. Improvements in the reviewing of care plans since the last inspection was noted. Evidence of monthly and three monthly reviews was seen. Care plans refer to the involvement of a variety of community health professionals. Service users confirmed access to, among others, the GP, district nurse and chiropodist. Medication procedures and records were reviewed and found to be reasonable. However, it was apparent that recording on medication charts sometimes departs from the system used by the home with confusion about use of two of the authorised codes. There were two instances where medication had been signed for though could not have been administered. On discussion with the care coordinator it is apparent that at least two service users have responsibility for looking after, and administering their own asthma medication. This arrangement should be the subject of risk assessments to High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 10 assist in ensuring safe management. It is recommended that photographs of service users accompany medication records. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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) 13 & 15 There are regular visitors to service users at the home who are made welcome. Meals in the home offer choice and variety and are served in pleasing surroundings. EVIDENCE: Service users indicated that their visitors were made welcome at the home, and that they usually see visitors in the privacy of their own rooms, or in quieter lounge areas available. Some service users indicated their appreciation that staff would offer their visitors a cup of tea. There were relatives visiting the home at the time of the inspection. One relative spoken to confirmed that they were made welcome with a cup of tea each time they visit the home. Service users gave a mixed response as to the quality of the food at the home. One person indicating that the meals ‘could be better’, another that ‘the food is quite decent’. All service users spoken to agreed that meals were served in good portions and that there was always choice available on the menu. This was reflected in the menu seen at the time of the inspection. Meals seen looked appealing and were served in the homes large dining area for the majority of service users. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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 Arrangements for dealing with complaints and protecting service users are satisfactory. EVIDENCE: Service users spoken to indicate that they would speak with the manager or a care coordinator if they had a complaint or concern, and that they felt they would be listened to. This was also reflected in comments by a relative spoken to. There has been one complaint in the last twelve months that was dealt with by the Commission. There was accessible information available in the home as to how to make a complaint. The home has a procedure for responding to allegations of abuse, including ‘whistle blowing’. Staff spoken to are aware of these procedures and their function, and have had access to appropriate training. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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) 19,24,25,26 The standard of the environment is good, providing service users with an attractive and particularly homely place to live. The absence of bedroom door locks compromises service user privacy. EVIDENCE: The home is well maintained internally and stands in reasonable wellmaintained grounds. The standard of internal decoration has improved significantly since the last inspection. The home looks much brighter as a consequence. There is varied and substantial communal space available. Bedroom doors are not lockable and therefore do not support the privacy of service users and the security of their belongings. However, the manager advised that locks have been ordered and that they would soon be fitted. Service users bedrooms appeared comfortable and homely. A service user spoken to indicated that they had ‘got quite a few things of my own on my room’. Radiators have been guarded and water temperatures in hand basins and baths regulated since the last inspection, thereby providing a safe environment for service users. The home appeared clean, pleasant and hygienic at the time of the inspection. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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 Staff at the home are employed in sufficient numbers to comfortably meet service users needs, and have a good understanding of service users support needs. EVIDENCE: There were five members of care staff supporting the thirty-three service users living at the home, (including two staff in the part of the home providing care to service users with dementia) providing a staffing level above the minimum standard required. Service users indicated that there was sufficient staff available to meet their needs (and this was apparent at the time of the inspection) and felt that they were in safe hands. The manager advised that there is currently thirteen staff that have achieved NVQ level 2 training or above, which is over 50 of the care staff compliment. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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) 31,34,38 The manager is experienced and competent to run the home, and demonstrates the leadership necessary in managing the home. The home is run in the best interests of service users, despite the prospect of significant change. EVIDENCE: The registered manager has considerable experience in the role, and clear that service users and staff have confidence in her capacity as a manager. However, the manager indicated that she had resigned from her post and would be replaced within the next month. She explained that she would be taking up another management post nearby, which will support a significant number of the service users currently living at High Haven. She explained that on site management cover would be provided at the home until a permanent replacement appointed. As indicated in the summary of this report CSCI will liaise with the proprietor throughout this process. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 16 Service users financial interests are safeguarded by the home; their relatives manage the vast majority of service users financial affairs. Records of financial transactions involving service users monies were reviewed. These were satisfactory and accurate. It is recommended that monthly audits that are currently completed be verified by a second person. The home seeks to promote the health, safety and welfare of service users, though issues identified concerning medication compromise this. High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x 3 x x x 2 High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 18 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. 2. Standard 9 9 Regulation 13(2) 14 Requirement The registered person must keep full and accurate records for the administration of medicines. The registered person must undertake and record risk assessments for service users who self-administer inhaled medicines in order to assist in ensuring such medicines are safely managed. The registered person must ensure that the home provides locks on bedroom doors to support the privacy of service users and the security of their belongings. THIS REQUIREMENT IS REPEATED Timescale for action Immediate and Ongoing 31st July 2005 3. 24 12(4)(a)& 23(1)(a) 31st July 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 9 34 Good Practice Recommendations It is recommended that photographs of service users accompany medication records. It is recommended that monthly audits of service users monies be verified by a second person. I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 19 High Haven High Haven I55 s35183 Highhaven v233438 150605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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. 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