Inspection on 07/06/06 for The Haven

This inspection was carried out on 7th June 2006.

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

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

Other inspections for this house

The Haven 23/02/09

The Haven 09/05/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Haven 17 Church Road Tovil Maidstone Kent ME15 6QX Lead Inspector Debbie Sullivan Key Unannounced Inspection 7th June 2006 09:35 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 The Haven DS0000066703.V292926.R01.S.doc Version 5.1 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. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Haven Address 17 Church Road Tovil Maidstone Kent ME15 6QX 02089478603 02089440340 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) Mr Karim Bhanji Rozita Heshmati-Bhanji Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th September 2005 Brief Description of the Service: The Haven is a large detached property that has been converted to a residential home from a vicarage. The home has 29 single rooms and one double room. Accomodation is on two floors and there is a stair and a shaft lift. Each room has a call bell; only one room does not have ensuite facilities. There are four lounges and a dining room and a well kept garden surrounds the property. The home is located approximately two miles from Maidstone town centre, there is a bus stop nearby and local shops and other facilities are within easy walking distance. The current weekly fee is £405.00; extras are hairdressing, chiropody, papers and toiletries. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over six and a half hours; time was spent with the manager, the new providers, residents, staff and relatives. Information was gained verbally and from reading samples of the homes’ policies and procedures and other documentation. A tour of the property took place and residents were joined at lunchtime. Information was also gained from the home’s pre inspection questionnaire, and a number of comment cards returned by residents, relatives and visitors, and professionals. Since the last inspection the home has undergone a change of ownership. Throughout the day staff were helpful in providing information and the atmosphere was welcoming and friendly. Comments from residents during the inspection and on comment cards included, “ My room has all I want” “There is company if you want it” “I was ill at the time, but my family made a wise choice” “The Haven has maintained a happy and friendly atmosphere” “The food here is very good” Comments from relatives and visitors included, “All very caring staff” “We have always found the manager and staff to be most caring, thoughtful and extremely kind” “Staff have looked after (relative) with great care and kindness. It is a warm welcoming place with friendly staff. As a family we are very happy with The Haven” “My sense is that the residents feel well cared for and have a good sense of family belonging” Comments from Health and Social Care Professionals included, The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 6 “We have a good relationship with The Haven, staff know residents well and call us when appropriate. Standards of care and hygiene are good” “Receptive to support and changes in practice that have been suggested” Comments from staff spoken with during the inspection included, “The best job so far” “The manager is supportive” What the service does well: What has improved since the last inspection? The garden has been improved and work is taking place to reduce any health and safety hazards in the outside environment and further enhance the garden. A list of staff present for fire practices is being kept. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 7 MAR sheets are correctly completed. Plans are in place for further improvements to the environment. A part time maintenance worker is employed. 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. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 8 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 The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 9 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): 1,2,3,4 and 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are able to access information about the home and can feel confidant that on moving in their needs will be met. EVIDENCE: The new owners have updated information about the home, and some information and documentation is still undergoing revision. Prospective residents have access to a brochure about the home; one resident spoken with had one visible in their room. Relatives and residents confirmed that they had been able to visit to view the facilities prior to admission; one comment card stated that the home had been chosen in preference to others in the area. Each resident has a contract with the home, and the manager undertakes an assessment of need prior to a place being offered. Comments made by residents and relatives during the inspection and on comment cards were positive regarding the care received and the level to The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 10 which needs are met. The last inspection evidenced that residents or their representatives are sent a letter confirming the offer of a place. The home does not offer intermediate care. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 11 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): 7,8,9,10 and 11 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their health, personal care and social needs are well met and recorded; their privacy and dignity are respected at all times. EVIDENCE: Some care plans were inspected, these included those of three service users who were case tracked. Care plans are stored on the carer’s office and information held on computer is downloaded and added to the care plan, those seen included information on health, personal care and social needs, risk assessments, reviews and daily log records. Care plans had been signed by relatives or residents. District nurses were present during the inspection and residents and relatives felt that needs were well met, a comment from a visitor was that if their relative was unwell the home always let them know and kept them up to date with progress. Evidence was in place on care plans of liaison with and input from health and other professionals, and given verbally regarding a resident who requires The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 12 mental health reassessment. The change in needs was evident during the inspection, and staff had good understanding of the background of the resident and how to manage the behaviour sensitively. A care manager arrived during the inspection unexpectedly to discuss a resident, and the manager found time to meet them during a very busy day. Wishes in the event of death can be recorded on care plan. Medication storage and MAR sheets were inspected. One resident was selfmedicating. Medication is stored in a tethered trolley and another area of the home, it is recommended that the location of the trolley be reviewed as it encroaches on communal space, and the purchase of a larger trolley be considered. MAR sheets were correctly completed and it is recommended that any hand written entries be recorded on care plans, so that the reason for handwriting is clear. Throughout the day residents requiring personal care were attended to discreetly. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 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): 12,13,14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices regarding their daily lives and contact with family and friends is supported. Meals are varied and there is plenty of choice, however, a review of the dining room arrangements would allow residents to better enjoy mealtimes. EVIDENCE: The home offers a range of activities including exercise sessions, quizzes, bingo and visits from a PAT dog, the manager was hoping to arrange some outings for the summer and the new owners have expressed intent to involve families in the home more. There are four lounges in the home offering different environments so residents can choose to listen to music, watch TV or spend time in a quiet area or their own rooms. One resident went out for the afternoon and there were several visitors present during the inspection. Visitors said that they are always welcome at any time and they have always found the home welcoming. Regular religious services take place and there is a hairdressing room. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 14 The home does not have a private visitors room, although due to the number of communal spaces the manager advised that there is usually private space to be found when necessary. Residents are able to make personal choices about their daily lives such as when to get up and go to bed, meal choices and area to access in the home. Residents were joined for he second lunch sitting, the dining room currently cannot accommodate all the residents. The meal was enjoyed by those present although the general atmosphere was somewhat busy and rushed with staff clearing away plates before all on a table had finished a course. The new provider has expressed intent to review the dining room environment. Daily meal choices are offered and special diets can be catered for. Comments from residents regarding the meals were positive and residents are consulted about the menu. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 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): 16 and 18 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to protect residents from abuse, the procedures for ensuring that CRB checks are always undertaken and available for inspection needs to be enhanced. Residents and their relatives can be sure that any complaints will be listened to and taken seriously. EVIDENCE: The home has a complaints procedure that is accessible to residents, staff and others. The complaints recording book was inspected, there had been two complaints since the last inspection that had been appropriately responded to, one had come to the knowledge of CSCI at the time it was made. Relatives and staff spoken with were aware of the procedure; relatives had been able to refer any queries regarding care issues to the manager and received an immediate response. Residents spoken with had not had cause to complain. No new care staff had been employed since the home changed hands, it was recorded at the last inspection that CRB’s were evidenced, although on this inspection they were not available in the staff files and were located off the premises. The maintenance worker recently employed had not had a CRB check; the manager and new provider undertook to action this. The home has an Adult Protection policy that was reviewed in July 2005. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 16 The Haven DS0000066703.V292926.R01.S.doc Version 5.1 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): 19.20,21,22,23,24,25 and 26. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a well-maintained, safe, clean and homely environment for residents to live in. EVIDENCE: The home is well decorated, cleaned to a high standard, well maintained and offers a pleasant spacious environment. Improvements are being made to the grounds and gardens so that they are safer and more accessible for residents. A maintenance worker is now employed part time and the new providers are reviewing parts of the property that may need refurbishment, such as the dining area. Four lounges are available each offering a different environment, one is in a conservatory. There are grab rails throughout the building and equipment to aid independence is available for communal or personal use. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 18 Individual bedrooms are all well decorated and residents have personalised them to differing degrees with their own furniture, ornaments and pictures and photographs. A small number of ensuite toilets required new floor tiles and one bedroom was without window restrictors. Residents spoken with were all satisfied with their rooms and one resident who had moved in fairly recently was hoping to move in more furniture of their own. The home has one shared room occupied by a married couple; screening is in place for privacy. One room had a very slight odour the resident had recently. been assessed for continence aids which should alleviate this. The laundry is situated in the basement away from any food preparation areas and it has a washing machine with a sluice facility. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 19 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): 27,28,29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriate mix of staff and a staff group who are well trained and competent supports residents. Recruitment procedures are through. EVIDENCE: The home employs care staff and senior carers, domestic and kitchen staff, a bedmaker and a maintenance worker. Three carers and a senior carer are on duty during daytime shifts and two carers are on at night. Throughout the inspection care staff on duty spoken with and observed were competent and confident in their roles and had a good understanding of individual needs, a key worker system is in place. Staff receive regular update training in topics such as first aid and manual handling and had recently undertaken dementia training due to the changing needs of the resident group. Seventy five percent of care staff have obtained an NVQ. Staff spoken with said that they were well supported by the manager and regular appraisal meetings take place with a senior carer. It is recommended that staff meetings be introduced. A fairly new member of staff said that their induction was more thorough than they had experienced in other similar services, and they had not been expected to work alone until they felt confident, they enjoyed working at the home. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 20 The new providers are in the process of issuing all staff with new contracts of employment. Some staff files were inspected, necessary documents were all in place except CRB documents which were not kept in the home. This is referred to in the Complaints and Protection section of this report. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 21 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): 31,32,33,36,37 and 38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed in the best interests of residents and staff. Procedures for ensuring the health and safety of residents could be enhanced in terms of safe working practices involving hazardous substances. EVIDENCE: The home changed ownership in April 2006,the existing deputy manager remained in post and has applied to become the registered manager, the views of staff, residents and relatives spoken with were that there had been no reduction in the quality of the service since the handover and there were some positive changes. The atmosphere in the home is open and inclusive and staff feel that the manager is approachable and supportive. The views of residents and relatives are being sought, a meeting for residents and relatives was held the week The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 22 before the inspection and a quality assurance survey had recently been circulated. The new providers are planning improvements to the premises. Records are kept securely in the care or managers’ office, although CRB documents were not on the premises for inspection. Some records in respect of safe working practices were inspected; fridge and freezer temperatures are recorded daily and were in range, maintenance checks seen were up to date and records were up to date of fire equipment testing and fire practices. Safe working practices were observed, with the exception that a cleaning trolley containing hazardous substances was left unattended on the upstairs corridor for some time. Accidents were correctly reported in the accident book. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 2 2 The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home” Timescale for action 07/08/06 2 OP18 12(1)(a) In that where a handwritten entry is made on a MAR sheet the reason for this is recorded on the care plan. “The registered person shall 07/08/06 ensure that the care home is conducted so as to make proper provision for the care and welfare of service users” In that all care and ancillary staff employed must have a CRB check undertaken. “The registered person shall ensure that records are at all times available for inspection” In that CRB documents must be available for inspection in the home. “ The registered person shall DS0000066703.V292926.R01.S.doc 3 OP37 17(2)(3)( b) Schedule 4(f) 07/08/06 4 OP38 13(4)(a) 07/08/06 Page 25 The Haven Version 5.1 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” In that a restrictor must be fitted to the window in room 14. Items that could fall and cause injury must be removed from the tops of wardrobes. The cleaning trolley must not be left unattended when in use. 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 OP9 OP13 OP15 Good Practice Recommendations It is recommended that the location of the medication trolley be reviewed and a larger trolley be purchased. . It is recommended that any plans for relocating accommodation in the home include the provision of a dedicated visitors’ room. It is strongly recommended that the planned review and refurbishment of the dining room area take place and arrangements for the serving and clearing of meals be reviewed to ensure that residents take meals in a pleasant and unhurried atmosphere. It is recommended that if residents bring their own furniture a check be made that they have access to a lockable storage space and any decision not to have one is recorded. It is strongly recommended that ensuite toilets with damaged floor tiles or worn floor tiling have these replaced. It is recommended that staff meetings be held and staffing records be put into more secure files or folders that are sectioned. It is recommended that advice be gained from a fire officer regarding the fitting of a clear vision panel in the door at DS0000066703.V292926.R01.S.doc Version 5.1 Page 26 4 OP24 5 6 7 OP26 OP36 OP38 The Haven the top of the basement stairs. The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Haven DS0000066703.V292926.R01.S.doc Version 5.1 Page 28 - 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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