Inspection on 05/07/05 for Whitehaven Care Home

This inspection was carried out on 5th July 2005.

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

The inspector 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

Whitehaven Care Home 09/05/07

Whitehaven Care Home 25/09/06

Whitehaven Care Home 20/12/05

Whitehaven Care Home 17/11/04

Whitehaven Care Home 10/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Whitehaven Care Home 22 Whitehaven Horndean Portsmouth Hampshire PO8 0DN Lead Inspector Feargal Gallen Unannounced 5 July 2005, 10:30 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 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. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Whitehaven Care Home Address 22 Whitehaven, Horndean, Portsmouth, Hampshire PO8 0DN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 9259 2300 Mr Roland Fiford Ms Beverley Walton Care Home 15 Category(ies) of Dementia (3) registration, with number Old age, not falling within any other category of places (15) Dementia - over 65 years of age (15) Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/11/04 Brief Description of the Service: Whitehaven is situated in a quiet residential area of Hordean. The home is registered with the Commission for Social Care Inspection (CSCI) and provides accommodation for 15 older people many of who have dementia. The home does not offer any nursing. All service users have their own room and there is a pleasant rear garden where service users can sit out in the warmer weather. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 5th July 2005. The timing of the inspection was due to the Commission receiving five regulation notices regarding one resident falling in the space of one week. The manager of the home was not present at the beginning of the inspection but joined after an hour and remained for the rest of the process. The inspector looked at three residents care files, two staff files and other documents kept in the home. He spoke with residents and two members of staff. What the service does well: What has improved since the last inspection? There were two requirements from the last inspection. One that a rail was erected in the raised patio area to prevent residents falling this has now been completed. The other area was that staff files contained all the documentation Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 6 as required by legislation from files examined this would appear to be achieved. 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. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5 Prospective residents can be confident that their needs will be assessed prior to admission within the limitations of information made available to the manager. Opportunities exist so that residents/families can visit prior to admission. EVIDENCE: Each of the resident’s files looked at contained detailed pre-admission assessments. The manager usually carries out the assessments. If the person is in hospital the manager does try to gain access to the nursing and medical notes as well as talking to staff. Access to the notes does differ from hospital to hospital and among different staff. In this case the manager must relay on staff to give the correct assessment of the person. This did not happen with one assessment that took place consequently leading to an inappropriate admission to the home. Had the home received the correct information they would have not accepted the person for admission. The inspector saw evidence in the manager’s assessment book of assessments carried out and declining admission because they could not meet the needs of that person. The manager informed the inspector that prospective residents/families are given the chance to visit the home prior to admission and experience life in the Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 9 home. Meet the residents and staff and look at the bedroom they will occupy. If more than one room is empty they will be given choice of room. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 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 standard(s) 7 and 8 Residents can be confident that the home will compile a written plan of care for their assessed health, personal and social needs. Resident’s assessed needs are being met with the exception of one resident whose needs could not be identified before admission well enough. EVIDENCE: The inspector looked at three residents files including the file of the resident who was experiencing high amounts of falls. Each file contained an assessment and from this the needs were identified and care plans are then devised on how to manage those needs. Risk of falls are assessed and a plan on how to reduce the risk is in place. There are plans in place on how to deal with each resident’s dementia and how it is presented. One resident who was suffering from a mild depression had a care plan in place on how to manage this need. Plans are evaluated at least monthly or when the assessed need changes. Night care plans are in place and signed nightly by staff to indicate they have followed the plan. Daily notes are kept by staff and these contained information that was cross referenced to the care plans and when needs changed. Some entries did not have dates next to them but this seemed to be contained to the multi-disciplinary visits/contacts. Families are kept informed of changes to the care plans and are invited to help draw up care plans in Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 11 consultation with the staff. Staff members were able to confirm when spoken to how they used the care plans to obtain information required to meet resident’s needs. The home is able to meet the needs of all their residents with the exception of one individual. From the entries in the daily notes, incident/accidents forms it was evident that the needs of the person were greater than what the home could provide for. The inspector asked how this was not picked up in the preadmission assessment. The manager informed the inspector that when conducting the assessment they did not have access to nursing or medical notes and relied on a staff nurse to help complete the assessment. Had the residents behavioural problems been identified admission would not have taken place. The manager was able to provide a written summary on what action they had taken to find a suitable placement for the resident. This had been hindered some what by slow access to a psychiatrist which was not the fault of the home. On the day of the inspection the resident was admitted to hospital for further assessment. This was the only resident the home could not meet the needs of. Due to the nature of the category provided for it was not possible to gauge accurately if the residents were aware of their care plans. No family members were seen by the inspector. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Residents can be confident that the home will provide activities to satisfy their social, cultural, religious and recreational interests and needs. EVIDENCE: There was a list of activities displayed in the lounge for the month of July. These included a day centre, which is mainly craft orientated, music and movement, incare services provide a variety of activities that help stimulate residents, two different music sessions, reflexology and church services. The hairdresser also attends the home. There were pictures on the wall of recent VE day celebrations that was held in the home. Residents who normally stay in their rooms through choice were involved in these celebrations. Staff who work at the home were seen in the afternoon to be involved with residents playing a game in the lounge. Two members of staff commented that activities in the home were outstanding compared to other homes they worked in. One resident was out at a club for the afternoon while the inspection was taking place. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Residents can be confident that their complaints will be taken seriously and acted upon. EVIDENCE: The home has a complaint procedure that is displayed in the home. This details how the home would receive, record, investigate and feed back the outcome to the complainant. Each resident/family is supplied with their own copy in the resident’s guide. The name of the Commission needs changing from NCSC to CSCI. There is a complaint log kept in the home. There have been no complaints recorded in the home since 3rd January 2004. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 21 and 24 Resident’s safety is at risk from easy access to the road. Residents live in a well maintained home. There are sufficient bathing and toilet facilities. Bedrooms are safe and personal to the individual. EVIDENCE: The Commission has received recently two regulation 37 notices concerning two residents who left the building by themselves. One resident made it to the top of the road and was assisted by a neighbour who phoned the home and a staff member went to bring the resident back to the home. The other resident only went to the back yard before staff were alerted. The home has erected a gate on one exit to prevent this happening again, however further risk assessments are needed. The home has a raised patio area that residents use frequently. A new safety rail has been erected to safeguard the residents from falling. The patio area contains table, chairs and parasols for residents use. The home is in good condition and maintainence work is continually carried out. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 15 There are ample communal toilets close to the lounge and dinning rooms and seven or the fifteen bedrooms have en-suite facilities. The two communal bathrooms have new chair lifts installed. Bedrooms reflected the resident’s own choice by having individual items in their rooms. Lots had photos of family members both present and present. Some residents had small pieces of their own furniture. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 29 and 30 Residents can be confident that staffing levels and skill mix will meet their needs. Residents are supported and protected by the homes recruitment policy. Not all staff are aware of the homes induction programme. EVIDENCE: The duty rota was examined and staffing reflected what the rota stated for the day of the inspection. Staff felt that there were sufficient numbers on to meet the needs of those living in the home. On each day shift there is a senior carer who is supported by a carer. At night there is one staff member who is supported by a sleeping staff member who is on call if required. Two staff members files were inspected as part of the process. They contained all the information required by schedule 2, application form, two written references, form of identification, photograph and CRB disclosure. Two new members of staff were spoken to and neither of them could confirm they had begun a formal induction programme. However the inspector did not ask the manager to supply information about the induction programme and this will be followed up at the next inspection. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 33 35 and 36 The home is managed by a person who is suitably qualified to do so. The home is run in the best interest of residents. Residents are free from financial abuse by the home. Resident’s benefit from a supervised staff team however new staff members lack induction. EVIDENCE: The registered manager and the head of care have both obtained there NVQ 4 in care and the manager has also obtained her NVQ 4 Registered manager award. Their certificates are on display on a wall in the home. There is a quality assurance questionnaire in place that the providers use to gather information about how people feel the home is run and what changes they would like to see. The manager stated they are in the process of changing the form and a new format will be used to gauge opinions that should more accurately reflect how people think the home is performing. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 18 The home does not manage any of the resident’s personal monies or an appointee for their benefits. Staff records contain copies of supervision records that are occurring on a frequent basis. One new member of staff was able to confirm a session with the manager that had taken place recently. Supervision dates are planned in a diary for each staff member, that the inspector seen. Two new members of staff felt they were supported by the management team. They had read policies and procedures but had not begun any formal induction process. Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 3 x x 3 x x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x 3 2 x x Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 13 (4)(a)(c) Requirement The home must risk assess accessability to the road and take appropriate action to safeguard residents. Timescale for action 31/07/05 2. 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 Good Practice Recommendations Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 21 Commission for Social Care Inspection Hampshire Area Office 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Whitehaven Care Home H54 S11581 Whitehaven V237128 050705 FINAL 240805 .doc Version 1.40 Page 22 - 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!