Inspection on 11/07/06 for The Haven

This inspection was carried out on 11th July 2006.

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

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

Other inspections for this house

The Haven 09/07/07

The Haven 07/10/05

The Haven 18/07/05

The Haven 14/12/04

The Haven 01/07/04

The Haven 15/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Haven, The 218 Worcester Road Droitwich Spa Worcestershire WR9 8AY Lead Inspector Andrew Spearing-Brown Unannounced Inspection 09:45 11 July and 17 August 2006 th th 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 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven, The Address 218 Worcester Road Droitwich Spa Worcestershire WR9 8AY 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) 01905 772240 Mr Simon Greaves Mr Simon Greaves Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (16) Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th October 2005 Brief Description of the Service: The Haven is an adapted care home located on a main road in a residential area close to the centre of Droitwich. The home provides personal care for a total of sixteen people over the age of 65 years. The home is able to provide long term and short-term care for older people who are physically disabled and older people who have a dementia illness. The home is owned and managed by an experienced registered provider. The home’s purpose is to provide a high standard of personal care in a homely environment. Bedroom accommodation is situated on both the ground and first floor. A stair lift is in place to assist residents gain access to both levels. The registered person stated on 13th July 2006 that fees at The Haven are between £390.00 and £430.00 per week. Information regarding additional charges was not sought during this inspection. The ‘Contract of Residence’ states that residents shall from their own resources provide newspapers, clothing and other items of luxury or personal nature. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at The Haven visits to the home were undertaken. The last inspection at The Haven took place during October 2005. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visit a pre inspection questionnaire was posted to the registered person requesting certain information. The registered person stated that he had posted this document unfortunately it was not received by the CSCI. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the home. Seven questionnaires designed for residents were completed and returned to the CSCI prior to the inspection. The majority of these appeared to have been completed by relatives on behalf of residents. Comments from these questionnaires are included within this report. At the time of this inspection the home had no vacancies. In addition to the registered person discussions took place with the deputy manager on the first day of this inspection. On the second day of this visit the registered person was away for a few days and the deputy manager was on duty later in the day. Discussions did however take place during the second visit with a senior carer, a carer, the cook and a domestic who were working the day shift. In addition a discussion took place with a night carer. The opportunity to have discussions with residents while they were sat in the lounge was taken. What the service does well: Information regarding the care home is available to current and potential residents however this as well as the homes terms and conditions need to be amended. Feedback from residents relatives was favourable – comments from relatives are included within this report. One relative commented: ‘it’s like one big happy family.’ Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 6 The registered person is aware of the shortfalls in care planning and risk assessment but is however confidant that the care needs of residents are met. The records regarding servicing of equipment were in order. The audit of a recent questionnaire prepared within the home demonstrated a shortfall in activities provided. A part time activities coordinator has recently commenced employment at the home to start addressing the situation. What has improved since the last inspection? 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. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 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 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 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): Standards 1, 2, 3, 5. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information available to potential residents and their family does not contain all the necessary information to afford them the ability to make an informed choice regarding the home. Visits to the home and a trial period assist resident choice whether the home is meeting their needs. Improvements are needed regarding the initial assessment and care planning stage. EVIDENCE: A copy of the homes statement of purpose was included within the policy manual. It was noted that it stated that it was due to be reviewed in October 2005. Following the visits to the home but prior to writing this report the registered person supplied the commission with a copy of both the statement of purpose and service users guide. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 9 The statement of purpose supplied was dated February 2006 and has a review date of February 2007. The information within this document is set out in a format designed to cover the required areas as set out within the regulations. Some information within the document is however out of date for example reference to staff experience working with the client group did not match the information seen on staff records. The training listed as staff having or due to take does not match the training records on staff files. Reference to the former National Care Standards Commission (NCSC) needs to be amended and reference to the fire precautions needs to be expanded. The service users guide requires a further review in order to met the relevant National Minimum Standard. It was noted that information regarding the payment or not of telephone calls (other than international) differs from the information upon the contract. A blank copy of the contract used was included with the service users guide supplied to the commission. In addition the registered person provided evidence of a recently signed contract. The location of the bedroom was not specified (rooms are not numbered within the home). References within the contract to the NCSC need to be amended to the CSCI. The initial pre admission assessment of a recently admitted resident contained basic details. No initial care plan was in place, while the care plan of another resident was scant in its detail. The inspector saw no evidence that the registered manager confirms in writing that the home is able to meet identified care needs. The registered person confirmed that the initial four weeks of a placement at The Haven are on a trial basis. Feedback by means of questionnaires received at the Commission for Social Care Inspection prior to the start of this inspection showed that all respondents believed they had received enough information before moving into the home. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although feedback from relatives evidenced care needs to be met the care planning and associated risk assessments fail to support care needs due to insufficient detail, which can potentially place individuals at risk. Risk assessments regarding fall prevention were of concern. The management of medication is generally satisfactory although further improvements are needed to ensure the procedures undertaken are consistently safe. EVIDENCE: Individual care plans are in place for each resident. A representative sample of care plans were viewed and assessed during the inspection. A number of concerns were raised with the registered person regarding the care plans and risk assessments viewed. Care plans in place are reviewed on a monthly basis; the deputy manager takes time out on a daily basis to up date one care plan. This can be seen to be good practice. Care plans need to be Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 11 reviewed on at least a monthly basis or more frequently as necessary to support individual residents needs. From other evidence it was apparent that some information needed to be transferred to the care plan prior to the regular monthly up date. Records regarding oral hygiene were insufficient; one care plan stated ‘oral care – has dentures’ therefore providing no indication to the exact care needs of the individual. Records existed evidencing chiropody input however care plans were not detailed other than recognising that a chiropodist was required. One care plan viewed gave no direction or strategies to be followed regarding agitation. Risk assessments were either non-existent or insufficient regarding moving and handling, fall prevention, pressure sore prevention and nutritional screening as a result care plans were also insufficient in these areas. The procedure regarding pressure care prevention was viewed and stated that residents should be assessed upon admission and weekly or more often if condition deteriorates – this was not happening. Weight records were not completed, these need to coincide with nutritional assessments and individual dietary care plans. In addition to ‘significant event’ records are daily handover records. The significant event records are not completed on a regular basis unlike the handover sheets, which are done three times per day. The handover records are on the whole repetitive containing statements such as ‘seems fine’ ‘slept well’ and ‘fine no problem.’ Concern was raised regarding some of the entries made by carers. A number of examples were noted when it was either unclear what had taken place or it could not be evidenced what action took place following an observation. During the second part of this inspection one care plan was re assessed and an additional care plan was viewed; the same concerns as highlighted above were evident. It was noted that although falls were recorded the care plan was not subsequently reviewed in order to prevent further occurrences. Care plans did not provide any strategies to assist carers with identified care needs such as engaging with a resident with poor / limited speech. The shortfalls noted within care plans were discussed with the registered person who accepts that The Haven has room for improvement in relation to the care plan documentation. However he is confident that care needs are met. A number of resident questionnaires were completed and returned to the commission before the inspection; it was evident that relatives or representatives completed these. Comments included: Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 12 ‘The care received at The Haven surpasses any expectations we had . . . The residents are treated with kindness and dignity.’ ‘ I can not fault the care my xx receives at The Haven.’ ‘ I am very happy with everything at The Haven. I can’t thank Simon and his staff enough.’ Feedback on a questionnaire from a GP was favourable. ‘Very happy with The Haven. Provide good standard of care for patients.’ A photograph of each individual resident was attached to his or her care plan. Similarly a photograph was also included with the medication records. As part of the inspection the management of medication was assessed. In order to carry out this assessment the storage and recording of medication was examined. Concerns were noted regarding some elements of recording upon the Medication Administration Record (MAR) sheets, which required improvement. A small number of gaps were evident whereby staff had failed to either sign for medication as given or enter a code to explain why it was omitted. All medication including items within the Monitored Dosage System (MDS) must be recorded if returned to the supplying pharmacy. At the time of the first visit staff were not recording items within the MDS when returned in order that a full drug audit is possible. It was of concern that 28 tablets belonging to one resident could not be found. The registered person was required to carryout a full investigation in an attempt to locate these tablets or report them as missing to the relevant authorities if they could not be sought. An investigation was carried out and no further action was deemed to be required. Staff consulted stated that they had received training regarding medication. A medication round was viewed and seen to be carried out in a unhurried manner. On arriving for the second visit of this inspection it was noted that one resident was at a dining table sat on a wheeled commode chair. This chair was later used to transport a resident from the dining room into the lounge. The use of this piece of equipment should be reviewed as to whether it is best practice and whether it upholds individuals dignity to be sat on this chair as opposed to a traditional wheelchair. A referral for a wheelchair would need to be generated via the GP. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is evident that progress has taken place in relation to the provision of activities within the home. Early morning routines were of some concern although the assurance from the registered person that improvement has taken place is reassuring. EVIDENCE: Visitors are able to visit at any reasonable time. Visitors are able to use communal areas such as the lounge or dining room as well as resident’s own rooms as they wish. The previous inspection noted that a number of residents were up and dressed early in the morning. One visit during this inspection commenced at 7.20 am at which time 14 residents were up and dressed, 3 of whom were sleeping in their chairs. At 9.30 am it was noted that 10 out of 15 residents were sleeping. One member of the night staff reported that they started getting residents up at 5.45 am due to a resident who couldn’t settle. It was reported that all residents were awake when they entered bedrooms and that it was Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 14 very rare for anybody to have a lie in. Residents were reported to be in bed by 9.00 pm. One care plan viewed stated ‘ may occasionally wake in the early hours.’ Although some residents were up before 6.00 am nobody had received a drink when the inspector arrived at 7.20 am. The ‘day girls’ were reported to do breakfast, one resident was heard to say ‘ We want something to eat’ at 7.45 am. Subsequent to this inspection and following a similar observation made by the registered person the inspector was assured that residents now receive a drink upon waking and that the night staff start preparing and serving breakfast. This practice will be reviewed as part of a future visit to the home. A number of residents questionnaires were completed and returned to the commission; it was evident that relatives or representatives completed these. The availability of activities was highlighted as a shortfall. A list of activities was held on each of the files examined within which a few events were recorded. The daily notes/ hand over records viewed contained no indication of any activities. During the first part of the inspection the registered person stated that an activities coordinator was due to commence at The Haven during the early part of August working two hours twice per week. During a later visit a folder set up by the newly appointed organiser who holds a GNVQ (General National Vocational Qualification) in health and social care was viewed. A range of events were noted to have taken place while others were planed for the forthcoming weeks. The records seen were of a good standard. The range, availability and frequency of activities will be assessed as part of forthcoming inspections. In response to the question on the questionnaire ‘Do you like the meals’ the responses were just under 50:50 between the response of ‘always’ and ‘usually’. Nobody replied with either ‘sometimes’ or ‘never’. One additional comment was: ‘My xx is always saying how good the food is.’ While another was: ‘ meal standards are usually very high.’ Other than breakfast no other meals were seen throughout this inspection. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some documentation needs to be improved however it was evident that residents representatives are aware of how to make a complaint should they need to do so. In addition staff have received training and had suitable knowledge regarding adult protection procedures in order to safeguard residents. EVIDENCE: A number of residents questionnaire were completed and returned to the CSCI prior to this inspection. It was evident that relatives or representatives completed these on behalf of residents. All respondents stated that they knew how to complain and who to complain to. One questionnaire contained the comment: ‘never had cause to complain’ The homes complaints procedure was due to be reviewed in November 2005 – this has not happened. It was noted that it made reference to the former regulator the National Care Standards Commission; this needs to be amended to the Commission for Social Care Inspection. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 16 No complaints were recorded within the home and staff consulted were not aware of the home having received any complaints. It was noted that the home had received a number of complements regarding the care provided. The commission has not received any complaints regarding this service since the last inspection. One senior member of staff had no knowledge of a leaflet issued by Worcestershire County Council giving guidance to carers regarding the local adult protection procedures. The in house procedures were in need of reviewing and up dating where necessary in line with Worcestershire County Council procedures. Staff consulted reported that training has taken place within the care home to ensure that staff are aware of their responsibilities regarding the reporting of any actual or potential abusive practices. This training was evidenced within staff files. In addition it was reported that areas around the General Social Care Council code of practice and whistle blowing was discussed as part of a recent staff meeting. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 17 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): Standards 19, 20, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the environment continue to taken place in order to provide residents with a comfortable place to reside where care needs can be met. Some shortfalls were identified during the inspection, which need to be addressed to ensure safety. EVIDENCE: No physical changes have taken place within The Haven since the last inspection. A communal lounge and smaller lounge off are well maintained, well furnished and homely in appearance. The dining area is located within a conservatory. A stair lift is provided giving access to the first floor of the building, a bathroom and small toilet can not be reached via this lift therefore a small number of steps have to be negotiated to reach this area. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 18 The majority of bedrooms were viewed. Following a previous inspection it was noted that one double room has some matching furniture, which looked pleasant. Double bedrooms had matching covers on the beds. As highlighted within the previous report the furniture in some bedrooms needs replacing as it is showing signs of fatigue. Lockable furniture was not available in every bedroom. It was reported that nobody holds a key to his or her bedroom. The upstairs bathroom was refurbished during 2005 and is a great improvement to the previous provision. The toilet seat was missing and therefore needed to be replaced. The toilet next to the bathroom is not ideal as it is small had has a concertina door, one of the door knobs was missing therefore a screw was protruding from the door. The wallpaper needs replacing as it is stained. One downstairs toilet was missing a shade over the ceiling light. The previous inspection report showed that the registered person was aware of the need to have environmental risk assessments. The previous report stated that once available they would need to be readily accessible to staff. The senior on duty was not aware of any such document and therefore it was assumed that no further progress has taken place. The registered person confirmed that these assessments have not as yet taken place. Wardrobes remain unsecured to the wall the securing of wardrobes can prevent accidental toppling over. Recent inspection reports have detailed progress in the fitting of radiator covers. Further progress was noted during this visit whereby it is believed one radiator is now uncovered. The covering of this radiator needs to be completed prior to the forthcoming colder weather to safeguard residents from the risk of scalding. Since the previous inspection the registered person has purchased a portable hoist. This piece of equipment is stowed downstairs due to having no passenger lift it would not be possible to use this equipment both downstairs and upstairs. Training on the hoist for all staff was reported to of taken place. Lighting with the lounge and the conservatory is domestic in style. It was pleasing to note considering the extremely hot weather during the early part of the summer that a air conditioning unit was located within the conservatory. Infection control measures such, as the provision of liquid soap is good. Personal protective equipment such as gloves and aprons were available for staff usage. The lack of wash hand basins within toilets is however a cause for some concern, due to the relative smallness of these rooms it is difficult to envisage how they could be improved. The laundry contains two washing machines neither, of which have a sluice facility; the provision of such equipment needs to be reviewed due to the Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 19 number of residents who are incontinent. The laundry does not contain a wash hand basin although one is available nearby in the staff toilet. A number of bedrooms had a malodour about them; the registered person stated that this was due to the earliness of the visit and the high number of residents with incontinence issues. All responses on the residents questionnaire stated that the home is always clean and tidy. One response stated: ‘To enter the home is a pleasure, its always clean . .’ While another relative / visitor stated: ‘I find the home is always clean & tidy. . ‘ Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some recruitment shortfalls and shortfalls regarding elements of training are of concern and need improvement. EVIDENCE: On the morning of the first visit of this inspection the deputy manager and one carer were on duty in addition to a domestic and a cook. As part of a later visit the staff rota was viewed and demonstrated that two persons one of whom would be a senior are on duty throughout the waking day. The night shift is covered by one wakeful member of staff and one person who is able to sleep part of the night and therefore on call. The Haven does not operate a key worker (named worker) system. One relative / visitor commented on a questionnaire returned to the CSCI that: ‘Staff are very friendly and make you welcome.’ While another commented: ‘The staff are excellent.’ Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 21 Currently a total of 2 carers hold a National Vocational Qualification (NVQ) level 2. As the staff team consisted of a total of 13 carers this represents just over 15 of the workforce. The relevant National Minimum Standard states: ‘A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved by 2005’ A number of staff have enrolled upon NVQ training level 2 or 3. In addition some staff may have some transferable evidence following other training undertaken, which may assist with their future NVQ training. Despite the staff now undertaking this training the home will continue to fall short of the required number of trained carers even after these persons have completed their training. The registered person therefore needs to draw up an action plan as to how this standard will be met. All members of staff consulted reported that they had attended mandatory training as well as some good practice training. Training records were held within the personal records seen by the inspector. Those seen did not fully evidence that staff receive sufficient training for example a lack of infection control training. Training development assessments are not in place. The personal records seen gave some cause for concern and need improvement. Sufficient evidence that two written references are obtained prior to an individual commencing employment was not in place. In addition the personal files did not show the date when employment commenced. The registered person must ensure that a full work history is obtained at the point of interview. A suitable CRB (Criminal Records Bureau) discloser was held on the majority of staff files. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Evidence that action has taken place following a questionnaire to relatives indicates a willingness to improve the service provided. The continual propping open of fire doors and some other health and safety matters are of concern. EVIDENCE: The registered person has extensive experience of working with older people. However despite the previous report indicating that the registered person was to commence upon the Registered Managers Award (RMA) level 4 NVQ this has not taken place. An action plan as to how the required qualifications are going to be achieved must be submitted to the commission. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 23 One senior member of staff issued a questionnaire to residents families. At the start of the inspection a number had been returned to the home although they were not at that time fully audited. A number of the questionnaires returned were viewed, the majority of the responses were positive. The main concern appeared to be in relation to the lack of activities. As indicated above the registered manager has recently appointed a part time activities coordinator in an attempt to address this shortfall. Following this inspection the results were collated and shared with the inspector. These results and action taken need to be available to all current and potential residents as well as other parties such as the commission. Since the previous inspection a small number of residents have died; the registered person did not inform the CSCI of these deaths as required under Regulation 37. The registered manager has recently informed the CSCI of notifiable events; verbal notifications must always be followed up in writing. As highlighted elsewhere within this report policies and procedures seen during this inspection were in need of reviewing. Fire doors continue to be propped open despite previous inspection reports. It is accepted that residents need to be able to gain ease of passage around the home and therefore arrangements need to be made whereby fire doors can be held open without compromising safety. A glass panel in a fire door was broken and in need of replacement. A fire risk assessment was in place dated October 2005; arrangements were in place for this to be reviewed. Staff training regarding fire safety was also planned. Records regarding water temperature were available. Some bedroom temperatures appeared too cool while a bath temperature was too high. These temperatures need to be addressed to ensure that hot water is delivered at a safe but comfortable temperature. A two-litre bottle of bleach was found within an unlocked cupboard in the upstairs bathroom. All cleaning materials and any other hazardous items must be held securely at all times. A ‘sticker’ was noted on both of the over bath hoists stating ‘tested 20/06/06 next test due June 07’. This was brought to the attention of the registered person as all hoisting equipment needs to be serviced every six months under the Lifting Operations and Lifting Equipment Regulations 1998. It was noted that the seal on a freezer located within the laundry was split. Although records held demonstrated that it was holding its temperature the seal is in need of replacement. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 24 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X 2 2 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 5 Requirement The registered person must review documentation such as the statement of purpose and service users guide. Copies of these revised documents must be supplied to the commission. A full assessment of care needs must be undertaken prior to admission, which is sufficient in detail to provide an initial care plan and risk assessment. The registered person must ensure that care plans and daily routines are agreed and signed by either the individual resident or their representative. (Previous timescale of 07/10/05 following an inspection on that date not met. A new and revised timescale for compliance is given) Timescale for action 31/12/06 2. OP3 14 31/10/06 3. OP7 OP12 15 (1) 12 (2) (3) 31/10/06 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 26 4. OP7 15 The registered person must ensure that each residents care plan sets out in detail the action, and any identified strategies, which need to be taken by care staff to ensure that all aspects of need are met. A risk assessment must be carried out in respect of every resident, in respect of all aspects of their lives, and with particular attention to prevention of falls, moving and handling, pressure prevention and nutrition. Any equipment used must also be risk assessed. 31/10/06 5. OP7 OP22 OP38 13 31/10/06 6. OP8 14 (2) The registered provider must ensure that suitable equipment is available to ensure that all residents are able to be weighed safety. (Previous timescale of 30/09/05 and 30/11/05 not met - new timescale set) 30/11/06 7. OP9 13 (2) The registered person must ensure that accurate records are maintained regarding all aspects of medication management. 20/10/06 8. OP18 1213 The procedure for dealing with suspicions or allegations of abuse must be reviewed. (Requirement not re assessed – revised timescale given) 30/11/06 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 27 9. OP19 OP24 23 (2) All areas of the home must be well maintained and suitable to meet identified care needs. 31/10/06 10. OP25 13 Exposed pipe-work and radiators must be guarded or have guaranteed low temperature surfaces. (This requirement has appeared within the previous four inspections. This requirement continues to be part met, as one radiator remains uncovered. The timescale for action has been further extended by which time all radiators must be suitably covered). 30/11/06 11. OP26 13 (3) The registered person must carry 30/11/06 out risk assessments and review the current washing machine facilities taking into account current care needs. The registered person must prepare an action plan as to how the required level of staff qualified to NVQ level 2 is to be obtained. 31/12/06 12. OP28 18 (1) 13. OP29 19 Staff employment files must 31/10/06 contain all the required information as specified in Regulation 7, 9, 19 and Schedule 2. Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 28 14. OP30 18 All staff must have individual training and development assessments and profiles. (Previous timescale of 31/05/05 and 30/11/05 not met – new timescale given) 31/12/06 15. OP30 18 All staff must receive the training 31/12/06 to meet the care needs of residents and the requirements of the standards. The registered person must 31/12/06 supply an action plan regarding plans to met the required level of training. All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4. Records must be available for the purpose of inspection. (Previous timescale of immediate and on going set on 07/10/06 not met) 30/11/06 16. OP31 9 (2) 17. OP37 17 (2) Schedule 4 (7) 18. OP38 37 The registered person must 20/10/06 ensure that the commission is notified in writing of all events as required under regulation 37. The registered provider must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage. (Previous timescale of 30/04/05 28/07/05 and 30/10/05 not met 31/10/06 19. OP38 23 (4) Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 29 this requirement must be addressed in full). 20. OP38 13 The registered provider must ensure that a health and safety policy specific to The Haven is known to all members of staff and be available for inspection (This standard was not assessed as part of this inspection. A revised timescale is given) 21. OP38 13 The registered person must ensure that hot water is delivered at a safe but comfortable temperature. A general risk assessment of the premises and Risk Assessments must be carried out and recorded for all the safe working practice topics referred to in Standards 38.2 and 38.3. (This standard was not assessed as part of the inspection carried out on 10th October 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection) 20/10/06 30/11/06 22. OP38 13 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The home’s copy of the British National Formulary should DS0000018686.V294500.R01.S.doc Version 5.2 Page 30 Haven, The not be less than 12 months old. No copy of this document was available within the home during this inspection 2. 3. OP10 OP26 The practice of using the commode wheelchair as described within the report should be reviewed. A fly screen should be provided for the window in the kitchen. This recommendation remains in place 4. OP29 The home’s equal opportunities policy should be referred to in the service users’ guide. (Not reassessed on this occasion) Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 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 Haven, The DS0000018686.V294500.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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