Inspection on 09/07/07 for The Haven

This inspection was carried out on 9th July 2007.

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 11/07/06

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 08:10 9 and 11th July 2007 th 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.V336517.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.V336517.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 simon@havenresthome.demon.co.uk 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.V336517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th July 2006 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 does not provide nursing care. People living in the home who require nursing attention receive this from the community nursing service, as they would in their own home. 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. Communal areas consist of a large lounge with a smaller one leading from it. The dining room is in a conservatory leading from the large lounge. Access to the rear garden can be reached via the dining area. Limited car parking is available at the front of the home. The home is located on a bus route between Worcester and Birmingham. The registered provider stated on 9th July 2007 that fees at The Haven are between £400.00 and £430.00 per week. Fees include services such as hairdressing, chiropody and toiletries such as soap and razors. Fees do not include clothing, international telephone charges and items of a luxury nature. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One regulation inspector based at the Worcester office of the Commission for Social Care Inspection (CSCI) undertook this unannounced key inspection over two days. This inspection takes into account information received by the CSCI in relation to the home since the previous inspection as well as the visits to the home. Since the last key inspection, which took place during July and August 2006, the commission received some concerns regarding the use of the stair lift. Elements regarding this matter are included within this report. Prior to this inspection the registered provider was requested to complete a Annual Quality Assurance Assessment (AQAA) document. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service. It is a legal requirement that this form is completed and returned to the commission within a given timescale. The registered provider completed this document accordingly and returned it the commission. Comments from within the AQAA are included in this inspection report. A number of questionnaires were sent to a sample number of people residing at the home, their relatives as well as health and social care professionals. A number of completed questionnaires were returned to the commission. The contents of the completed questionnaires are taken into account as part of this inspection. The registered provider was present throughout this inspection. Discussions took place with the registered provider, two visitors, and some members of staff. In addition discussions took place with a number of people who use the service. A partial look around the home took place which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, handover and significant event records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. What the service does well: Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 6 Comments from relatives seen within the home during this inspection were positive. Other positive comments were included within the questionnaires returned to the commission prior to the inspection. Pre admission assessments are carried out and individuals can access information regarding The Haven prior to their admission. The initial fourweek placement is on a trial basis. One relative stated on a questionnaire returned to the commission ‘I visited the home and liked The Haven because it is small and the atmosphere is very friendly.’ Care plans are reviewed monthly. Time is allocated on a weekly basis to carry out this essential task. A private chiropodist visits the home regularly; the cost of this service is included within the fee charged for residing within the home. The recording on the medication records was generally good. Open visiting is in place, relatives and friends are able to see people using the service in either the communal areas or within the individuals bedroom. An activities organiser works within the home four hours per week. Favourable comments included ones regarding food provision within the home. The standard of the accommodation is good especially in communal lounges. The back garden is in good order and accessible. The registered provider has recently secured funding to improve this facility. The majority of staff have recently attended or are due to attend a range of different training courses. Funding has been secured to provide NVQ (National Vocational Qualification ) training to staff over 25 years of age. Recruitment procedures within the home were sufficiently robust to safeguard people using the service. The registered provider undertakes an annual quality assurance survey. The results of a survey conducted in May 2007 were available and generally very positive. Documents evidenced that equipment such as hoists and portable electrical appliances are tested and serviced as required. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Some amendments are needed to documents such as the statement of purpose and service users guide. The monitoring of weight loss/ gain needs to improve. Some improvements are needed on the MAR (Medication Administration Record) sheets although these are primarily matters for the supplying chemist to address. Systems need to be in place following any errors made with medication administration. A number of comments within the questionnaires completed by relatives and returned to the commission highlighted that people believe improvements could be made regarding the provision of activities. The complaints procedure is not on prominent display within the home to remind individuals of their right to raise issues of concern with the most appropriate person. If any concerns or complaints are made these need to be recorded along with the action taken. Risk assessments regarding environmental issues are lacking and are needed in order to identify potential hazards within the home. A number of areas where risk assessments are necessary where identified during this inspection including windows restrictors, wardrobes and a radiator. The number of staff holding a NVQ (National Vocational Qualification ) level 2 or above falls below the National Minimum Standard. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 8 Although the registered provider has extensive experience in running a care home and caring for older people a formal qualification as highlighted within the National Minimum Standard is not held. Under Regulation 37 of The Care Homes Regulations the registered provider needs to inform the commission of certain event or incidents within the home. The reporting of these incidents needs to improve. 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 summary of this inspection report can be made available in other formats on request. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 9 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.V336517.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5. Standard 6 is not applicable to The Haven. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals who may potentially use the service are provided with sufficient information to help them make a decision regarding admission into the home. Care needs are assessed prior to admission to ensure that the home can provide the level of care needed. EVIDENCE: The registered provider supplied the inspector with a copy of the home’s statement of purpose during this inspection. This document has been briefly viewed and seen to include information which would be useful to potential people using the service. The document was dated November 2006 and has a review date of November 2007. Some references to the former National Care Standards Commission need to be amended to the Commission for Social Care Inspection. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 11 A signed contract / statement of terms and conditions following a recent admission into the home was seen. On a questionnaire returned to the commission before this inspection one relative commented: ‘I visited the home and liked The Haven because it is small and the atmosphere is very friendly.’ The registered provider has in the past confirmed that the initial four-week placement at The Haven is on a trial basis. This was also stated upon the AQAA returned to the commission. The file of a recently admitted person using the service contained a pre admission assessment carried out by the registered provider. The information available was sufficient to prepare an initial care plan. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care of people using the service is based on individual need. Care plans are improving. The management of medication has continually improved given people who use the service a positive level of care. EVIDENCE: Individual care plans are in place for each person using the service. As part of this inspection a sample number of care plans were viewed and the contents discussed with the registered provider. The previous inspection report noted some good practices in particular the fact that the deputy manager was taking time out on a daily basis to up date care plans. A number of shortfalls were however previously noted and these needed attention in order to meet the associated National Minimum Standards. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 13 On the AQAA returned to the commission the registered provider recorded that ‘ a new care plan is being phased in over the next few months to give a more detailed plan of care.’ The lack of detail / strategies and direction within care plans formed part of the previous inspection report. The registered provider informed the commission before this inspection of his intention to replace care plans with new documents in order to provide the details required. Some of the care plans seen during this inspection were upon the new template while others were not. The standard of the care plans therefore varied. The care plans on the new documentation were generally of a good standard. The registered provider gave an undertaking that the remaining care plans would be brought up to this standard. Taking into account the improvement seen the commission has confidence that the improvement will be sustained. Risk assessments were in place covering matters such as moving and handling, fall prevention, pressure sore prevention and nutrition. Suitable equipment is not available in order that everybody using the service can be weighed. The registered provider was aware of alternative methods of monitoring weight such as using body mass indicators. The commission received three questionnaires completed by relatives prior to this inspection. All three respondents stated that they feel the home meets the needs of their relative and that the home keeps in touch with them. A number of questionnaires sent to people using the service were also returned. It was evident that these were completed on behalf of individuals residing within the home however these also stated that people receive the care and support they need. A chiropodist visits the home on a regular basis. The cost of private chiropody is included within the fees therefore people using the service do not have to pay any extra for this service. The previous inspection report noted that one person using the service was seen sat at the dining room table in a wheeled commode chair. It was also noted that the same chair was used to transport another individual from the dining room into the lounge. It was of concern to witness the same practice as part of this inspection. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 14 The management of medication was assessed as part of this inspection. Over recent inspections improvements in the management of medication have been noticed. Some matters were noted regarding information or the lack of it on the MAR (Medication Administration Record) sheets however these were primarily issues to do with the supplying pharmacist. The registered provider had already discussed some of these matters with the chemist. The controlled drugs register balanced with the medication held within the controlled drugs cabinet. The inspector noted that a drug error had occurred the night before this inspection took place. Although drug errors are a serious matter it was however noted that the person on duty took immediate action upon realising the mistake. Systems need to be evaluated following such incidents to ensure that there are no lesions to be learnt. People using the service looked suitably dressed taking into account gender issues and weather conditions. Standard 11, which covers the wishes and the care of people who are terminally ill was assessed as part of this inspection following a comment received by the commission prior to this visit. ‘Could not praise the home enough for the care and attention they gave to my *** in her last days. The staff were so caring.’ During the inspection the registered provider supplied the inspector with a copy of a letter recently sent to The Haven from the family of another person who used to reside at the home. The letter was very complimentary in a number of areas including the following: ‘thank you ( the registered provider) and your team for the expert, gentle and understanding care that my ** received.’ ‘we were delighted with the way each resident was treated as an individual and their dignity maintained.’ ‘During the last week of her life your staff continued to care for ** in an expert and professional manner.’ Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 15 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. 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. People who use the service have access to limited social stimulation within the home. The food provided was good with a reasonable choice available. EVIDENCE: Visitors are able to call to see their relative / friend at any reasonable time. Visitors are able to use communal areas such as the lounge or dining room as well as the bedroom belonging to the person living in the home as they wish. A signing in and out book is maintained and completed by visitors. During this inspection two visitors were consulted, both made positive comments regarding the home. The inspection started early each morning. On both occasions it was noted that the majority of people using the service were up and dressed by the time the inspector arrived. At 7.30 am it was noted that eight out of the thirteen people within the lounge were asleep. The registered provider was confident that people get up each morning when they wish to get up. A number of the Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 16 care plans viewed showed that individual choose to get up before the day staff come on duty. Before the completion of the inspection carried out during the summer of 2006 an activities organiser commenced work at The Haven working two hours twice per week (Tuesday and Thursday). It was pleasing to note that the above organiser who holds a GNVQ (General National Vocational Qualification) still works at the home. The activities organiser maintains a record of events undertaken as well as a planned schedule of events. The file contained some paintings done by people using the service. Activities undertaken included taking individuals out on a one to one basis, nail painting and making cards. One relative made a comment regarding good nail care within the home. It was noted that the activities organiser had recorded on one occasion that she had needed to work as a carer due to staff training taking place. No activities were seen to take place during the course of this inspection as the organiser was on days off. It was however noted that the service users guide states ‘ A wide range of activities are organised by staff on a daily basis, service users are also encouraged to pursue their own hobbies and interests.’ In answering a question on the survey forms sent to people using the service ‘ Are there activities arranged by the home that that you can take part in?’ the following responses were received. Always Usually Sometimes Never 0 2 2 0 It was apparent that a representative rather than the individual himself or herself had completed the above survey forms. One relative stated on a questionnaire: ‘ Perhaps a little more could be done with a few more activities to stimulate the residents.’ Another relative commented: ‘ there are a few limited activities’ These findings were different to a survey undertaken by the registered provider in May 2007. The survey undertaken by the home found that the Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 17 majority of responses were either ‘excellent’ or ‘good’ in relation to activities provided or arranged. A hairdresser visits the home. The cost of hairdressing is included within the fees therefore people using the service do not have to pay any extra for this service. It was stated that currently one person who is a practicing Roman Catholic receives Holy Communion. Nobody using the service receives a visit from anybody from Church of England denominations and nobody attends church. The registered provider stated on the AQAA document returned to the commission that ‘ food is cooked fresh from raw ingredients daily, no meals are frozen all cakes and pastries are prepared and freshly baked on a daily basis.’ One relative stated on a questionnaire returned to the commission: ‘Meals are freshly cooked and look very appetising’ Breakfast was seen on one occasion, the majority of people using the service were eating either cereals or porridge and toast. The inspector joined people using the service for lunch. The meal was a mixed grill, which was well presented and appetizing. One person required assistance with eating; this was carried out in line with the instructions within the care plan and in a sensitive and unhurried manner. The registered provider confirmed that hot and cold drinks are available at any time upon request. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People using the service have a suitable complaints procedure available to them in order to raise any concerns. Any concerns raised need to be suitably recorded to evidence that they are taken seriously. Staff are currently receiving training in matters regarding safeguarding. EVIDENCE: The registered provider stated upon the AQAA document that the home had not received any complaints for 3 years. A number of cards complimenting the service were on display. Since the last inspection the commission were contacted regarding some concerns held by a relative regarding the stair lift and health and safety matters. These concerns were forwarded to the registered provider to address. As the registered provider stated nobody had made any complaints for 3 years it was evident that the above concern was not regarded as such within the home. The commission received three questionnaires completed by relatives prior to this inspection. All three respondents stated that they are aware of how to make a complaint if needed. The complaints procedure is included within the Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 19 service users guide and statement of purpose, which are available, but is not displayed within the home. Staff were in the process of receiving training regarding safeguarding adults (protection of vulnerable adults). One member of staff consulted was able to give a good understanding of the conditions associated with safeguarding and who should be informed in the event of actual or suspected abuse. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, 25 and 26 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 maintained provides a comfortable place for people using the service to reside. EVIDENCE: A communal lounge and smaller lounge off are well maintained, well furnished and homely in appearance. The dining area is located within a conservatory. Since the last inspection a partition in the entrance hall has been removed. The walls have been re plastered and redecorated. The appearance of the hallway is greatly improved and more open. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 21 A stair lift is provided giving access to the first floor of the building. A bathroom and small toilet can not be reached via the stair lift therefore a small number of steps have to be negotiated to reach this area. Since the last inspection a concern regarding health and safety matters in relation to the stair lift was raised with the commission. These concerns were sent to the registered provider to respond to. Additional information regarding the stair lift is reported elsewhere within this report. Many of the bedrooms were viewed. One double room and one single bedroom have some matching furniture, which looks pleasant. Double bedrooms had matching covers on the beds. Since the last inspection 10 new beds and mattresses have been purchased. Some other bedroom furniture is in need of replacing due to signs of fatigue. Wardrobes remain unsecured to the wall. The securing of wardrobes can prevent wardrobes accidental toppling over. Lockable furniture was not available in every bedroom. Nobody living within the home holds a key to his or her bedroom. The upstairs bathroom was refurbished during 2005 which improved the previous provision. The toilet next to the bathroom is not ideal as it is small and has a concertina door. The wallpaper in this toilet is in need of replacing. The registered provider reported that this is scheduled for later this year. Previous inspection reports have given details of the ongoing programme to fit covers to radiators to prevent accidental scalding. A radiator in a bathroom is now covered. The registered provider stated within the AQAA document that ‘ all radiators now have covers’. This is not the case, as one radiator, which is partly obstructed by a wardrobe, remains uncovered. One portable hoist is available within the home. This piece of equipment is stowed downstairs. As The Haven has 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 within the lounge and the conservatory is domestic in style; all the bulbs were in working order. The furniture and décor within the lounge is of a good standard. The AQAA document states that an air conditioning unit is provided within the conservatory. This unit was not in place during this inspection, it was stated that it was removed due to the relative cool weather experienced at the time of this inspection. The last two inspection reports indicated that the registered person was aware of the need to have environmental risk assessments. Earlier reports have stated that once available they would need to be readily accessible to staff. A Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 22 risk assessment regarding the stair lift was available but no others regarding the environment have been done. The registered provider undertook to carry out these risk assessments. Windows above ground level are fitted with a restrictor to prevent accidental or deliberate falling to the ground. It was apparent that the restrictors can however be over ridden therefore allowing the window to fully open. The fact that the window restrictors can be over ridden needs to be risk assessed to ensure that safe systems are in place to prevent potential injury. Infection control measures such, as the provision of liquid soap continues to be good. Personal protective equipment such as gloves and aprons are available for staff usage. Wash hand basins are not provided within toilets however due to the relative smallness of these rooms it is difficult to envisage how such facilities could be provided. The laundry does not contain a wash hand basin although one is available nearby in the staff toilet. Some malodour was detected during the early part of the inspection. The home accommodates a high number of residents with continence difficulties. The odours detected were dealt with efficiently. No odours were detected within communal areas such as the lounge or within toilets. The home was seen to be clean and tidy throughout. One comment received prior to this inspection stated ‘The Haven is always very clean and always smells fresh ’ The back garden is well maintained. The garden can be reached via the conservatory. The registered provider has secured some funding to improve the garden further. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 23 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. 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. Staff in the home are trained in many areas however the number of qualified staff needs to be increased in order to complement the level of skill within the home. Recruitment procedures in place assist in the safeguarding of people using the service. EVIDENCE: A staff rota was on display. Staffing levels within the home remain the same as previous inspections. Throughout the working day two carers are on duty, this number includes the deputy manager except days when she is allotted time to up date care plans. One wakeful carer and one person sleeping in cover the night shift. The suitability of staffing levels needs to be kept under review especially night staff in line with changing care needs. The registered provider is the only male working within the home. The age range of staff is currently from 18 to 64 years of age. No agency staff are used at The Haven as the registered provider wishes to ensure consistency as far as possible. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 24 Additional staff are employed to carry out domestic and catering duties. Currently a total of two carers hold a NVQ (National Vocational Qualification) level 2. As the staff team consists of a total of twelve carers this represents 17 of the workforce. The relevant National Minimum Standard states that a minimum ratio of 50 needed to be achieved by 2005. At the time of this inspection one carer who already holds a level 2 has commenced upon a level 3 NVQ. A total of three carers are currently undertaking level 2 training and the deputy manager plans to undertake level 3 training. Taking these figures into account the 50 level will not be met assuming these persons are successful and no other changes occur. The registered provider has recently secured funding to enable staff over 25 years of age to enrol on NVQ training. The files of two recently appointed members of staff were viewed and found to be in satisfactory order. Evidence was seen that PoVA (Protection of Vulnerable Adults) first checks and CRB (Criminal Records Bureau) disclosers are undertaken A list of staff training events was on display. It was noted that moving and handling training and food hygiene training had already taken place. Forthcoming training includes risk assessment and health and safety, infection control, protection of vulnerable adults, dementia care and challenging behaviour. It was reported that first aid training is to be arranged. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered provider is suitably experienced to manage the home but currently does not hold the required qualifications. Systems needs to be developed to improve the risk assessment and notification process throughout the home. EVIDENCE: The registered provider (who works as the manager) has extensive experience of working with older people. Previous reports have indicated that the provider will commence upon the Registered Managers Award (RMA). The National Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 26 Minimum Standard states that the registered manager has by 2005 a level 4 NVQ in both management and care. Despite the previous assurances the need to obtain the RMA remains outstanding. The registered provider stated that he has made contact with a company who are able to provide the necessary training. The registered provider will be making arrangements as to how to address the above shortfall within the next six months. Prior to this inspection, along with the AQAA document, the provider supplied the commission with the collated results from the homes most recent survey. The results from the survey were positive in all areas including catering and food, daily living, personal care, premises and management. Other means of quality assurance need to be developed in order to monitor practices within the home. No money is held on behalf of people living within the home. The fee charged includes services such as hairdressing and private chiropody. The previous report highlighted the need under Regulation 37 for the commission to be informed without delay of certain events in the home. This was not previously happening. Over recent months the commission have received a couple of notifications as necessary. During this inspection it became apparent that an incident had taken place very recently, which although discussed at the time needed to be recorded as an event. No notification has as yet arrived at the office of the commission. Hoisting equipment including the stair lift was last serviced during May 2007 therefore in line with the Lifting Operations and Lifting Equipment Regulations 1998. Portable electrical appliances were tested during June 2007. The required health and safety poster was on display. Food safety records including ‘Safer Food Better Business’ were in good order. Fly screens are not fitted within the kitchen, it was reported that the window was locked to prevent opening. The fire safety records were in good order although the most recent test was not recorded. Since the previous inspection devises have been fitted to fire doors leading into the dining room to ensure that they close in the event of the fire alarm sounding. Shortfalls regarding risk assessments throughout the environment are included elsewhere within this report. Risk assessments are required in order to identify potential hazards within the home and to put into place suitable strategies to reduce the risk. Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 27 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X X 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 13 Requirement Improvements within the care planning documents must continue. Care plans must be up to date and detail how carers are able to meet identified care needs. Timescale for action 30/09/07 2 OP8 14 (2) Systems need to be in place in order to determine whether people using the service are gaining or losing weight. 31/08/07 3 OP16 22 Any concerns or complaints made must be recorded along with the action taken to resolve the matter. All parts of the home must be assessed for the risk they present to the people that use the service and action taken to minimise any identified risk 31/08/07 4 OP19 13 (4) (a) 30/09/07 Haven, The DS0000018686.V336517.R01.S.doc Version 5.2 Page 29 5 OP28 18 (1) An action plan must be in place to ensure staff are suitably qualified to carry out their work. The above requirement replaces a similar requirement within the previous report which was not met. 30/09/07 6 OP38 37 The registered person must 31/08/07 ensure that the commission is notified in writing of all events as required under regulation 37. Previous timescale of 20/10/06 not fully met. A revised timescale is given for full compliance. 7 OP38 13 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. Previous timescale of 10/10/05 not met. A revised timescale is given for full compliance. 31/10/07 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.V336517.R01.S.doc Version 5.2 Page 30 Haven, The not be less than 12 months old. This recommendation was not assessed as part of this inspection. 2 OP10 The practice of using the commode wheelchair as described within the report should be reviewed. This recommendation remains in place It is recommended that the home’s complaints procedure is displayed within the home. It is strongly recommended that wardrobes are secured within bedrooms to prevent accidental toppling. A fly screen should be provided for the window in the kitchen. This recommendation remains in place 3 4 5 OP16 OP19 OP26 6 OP31 Proposals to pursue suitable management training should be maintained. Haven, The DS0000018686.V336517.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!