Care Home: Havana House Care Home

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What the care home does well Potential new residents benefit from having the appropriate information made available to them prior to accepting admission into the home. Appropriate trial visits are also arranged, in order to assist potential new residents in the decision making process. Pre- admission assessments allow for only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident`s privacy and dignity. Medication administration and storage procedures are effective and allow for the safe handling of medicines. Residents end of life choices are clearly recorded. Residents dying or critical illness wishes are observed and respected. Residents benefit from an activities calendar that is arranged according to their choice. Contact within the local community and with family/friends is actively encouraged. Residents experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Residents can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Resident`s bedrooms are appropriately equipped and personalisation of bedrooms is encouraged. Specialist aids and equipment are provided, where required. Bathrooms, toilets and communal spaces are provided in ample quantities. Infection control and cleaning procedures are in place, with the environment being well maintained and odour free. Residents experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current residents. Staff are appropriately supervised and supported to conduct their jobs effectively. The management and administration of the home is good, with evidence of consideration being given to residents and/or relative`s opinion at all times. Appropriate Quality Assurance measures and procedures have been implanted to ensure that the service is operated in the best interests of residents. Clear records are maintained of any personal allowance accounts maintained by the service for residents. Maintenance and environmental checks are appropriately conducted, ensuring that the health, safety and welfare of residents, staff and visitors are protected. What has improved since the last inspection? This is the services first inspection since registering in November 2008. What the care home could do better: There is a need for Terms and Conditions of Contracts to be further developed. Current contracts in place do not provide all parties with the specific details of how fees are paid and who shall pay them.Havana House Care HomeDS0000072779.V375562.R01.S.doc Version 5.2 It is required that when Regulation 26 Visits are conducted on a monthly basis, that a report is produced and made available for inspection. The homes Statement of Purpose is in need of updating to include the number and size of each bedroom. It is recommended good practice that all pages of care plans and daily record sheets are named for the each individual resident. Staff files need further developing, by means of having a recent photograph of each staff member maintained on their individual staff file. Key inspection report CARE HOMES FOR OLDER PEOPLE Havana House Care Home 4 Broomhill Road Hucknall Nottingham NG15 7QH Lead Inspector Rebecca Shewan Key Unannounced Inspection 26th May 2009 09:30 DS0000072779.V375562.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havana House Care Home Address 4 Broomhill Road Hucknall Nottingham NG15 7QH 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) 0115 9632 858 Havana House (Nottingham) Ltd Mrs Rita Slack Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 28 New Registration 2. Date of last inspection Brief Description of the Service: Havana House is an adapted and extended property situated on the outskirts of the town of Hucknall. Hucknall has a range of shops, banks, public houses and cafes and is a car or bus ride away. There are good public transport links near the home. The home is registered to accept up to 28 people within the category of old age and Dementia. The accommodation is on two floors and there is a vertical lift to provide access for people with mobility difficulties. There are grab rails throughout the home to assist residents’ mobility. There is an enclosed patio and garden area to the rear of the home and a small car park at the side. The current range of fees for the service are £375 - £400 per week depending on dependency needs. There are additional charges for chiropody (£25), Hairdressing (£4- £18.50), newspapers/magazines (varied), dry cleaning (varied) and toiletries (varied). Potential new service users find out about the service by word of mouth, from placing authorities, Healthcare Professionals, Care Managers and by contacting the home directly. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star – good service. This means that people who use the service experience good quality outcomes. This unannounced inspection took place during the morning and afternoon of the 26th May 2009. The homes Annual Quality Assurance Assessment (AQAA), incident reports and previous inspection reports, held by the Care Quality Commission, were read before the inspection. The inspection of the home took seven and a quarter hours. Records such as care plans, staff files and medication records were also viewed. Nineteen service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Appointed Manager, two Senior Carers, a Carer Assistant, a Cook, a visitor and two residents were spoken with. What the service does well: Potential new residents benefit from having the appropriate information made available to them prior to accepting admission into the home. Appropriate trial visits are also arranged, in order to assist potential new residents in the decision making process. Pre- admission assessments allow for only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Medication administration and storage procedures are effective and allow for the safe handling of medicines. Residents end of life choices are clearly recorded. Residents dying or critical illness wishes are observed and respected. Residents benefit from an activities calendar that is arranged according to their choice. Contact within the local community and with family/friends is actively encouraged. Residents experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 6 Residents can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Resident’s bedrooms are appropriately equipped and personalisation of bedrooms is encouraged. Specialist aids and equipment are provided, where required. Bathrooms, toilets and communal spaces are provided in ample quantities. Infection control and cleaning procedures are in place, with the environment being well maintained and odour free. Residents experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current residents. Staff are appropriately supervised and supported to conduct their jobs effectively. The management and administration of the home is good, with evidence of consideration being given to residents and/or relative’s opinion at all times. Appropriate Quality Assurance measures and procedures have been implanted to ensure that the service is operated in the best interests of residents. Clear records are maintained of any personal allowance accounts maintained by the service for residents. Maintenance and environmental checks are appropriately conducted, ensuring that the health, safety and welfare of residents, staff and visitors are protected. What has improved since the last inspection? What they could do better: There is a need for Terms and Conditions of Contracts to be further developed. Current contracts in place do not provide all parties with the specific details of how fees are paid and who shall pay them. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 7 It is required that when Regulation 26 Visits are conducted on a monthly basis, that a report is produced and made available for inspection. The homes Statement of Purpose is in need of updating to include the number and size of each bedroom. It is recommended good practice that all pages of care plans and daily record sheets are named for the each individual resident. Staff files need further developing, by means of having a recent photograph of each staff member maintained on their individual staff file. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 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 Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is appropriate information available to potential new residents and their representatives to make an informed choice, prior to admission, about whether the home will be able to meet their needs. Trail visits are arranged as matter of course and further allow residents with the opportunity to ensure the home meets with their expectations. The home has good processes in place for assessing potential new residents. Services are offered to only those resident’s whose needs can be met. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 10 EVIDENCE: The homes Residents Guide and Statement of Purpose were viewed. Both documents are available in large print and pictorial format. The documents contain most of the required information, in order to ensure that an informed choice can be made about admission to the home, services provided and the facilities available. The Statement of Purpose does not currently include details of the number or size of bedrooms provided. Therefore a Recommendation has been made. The Appointed Manager carries out pre- admission assessments. Copies of care management assessments from the placing authority are obtained, where these exist. The Appointed Manager addresses any issues, which are highlighted within this assessment. Records inspected showed that preadmission assessments are carried out on all new and potential residents. Documentation relating to the most recent admissions to home were viewed and were found to have been completed fully and conducted with the involvement of the resident and/or their representatives (where applicable). Intermediate care is not provided by this home. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a good provision of health care and personal support by the home. All care is administered in way that protects residents privacy and dignity. Medication procedures ensure that all necessary precautions are taken to ensure errors do not occur and that medications are stored and administered safely. EVIDENCE: Discussions with the Appointed Manager highlighted that the previous system for recording care plans did not meet the requirements of the National Minimum Standards. The Appointed Manager confirmed that six of the current Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 12 residents care plans had been updated and formatted in a more structured way and that all care plans would be updated by the end of June 2009. The new care plans system is designed by use of picture bank and large print. Four care plans were sampled, two of each format and it was evidenced that those devised under the new format were comprehensive, detailed in content and covered all aspects of resident’s needs. They are written to allow the assessor to gain a good overview of individuals medical, mental health, social and personal care needs and provide the assessor with a clear overview of the Residents current needs, limitations and required assistance. Resident’s and relative/representative involvement in the care plan generation and review process was also evident. Care plans are reviewed on a monthly basis and are updated to accurately reflect any change in needs. Suitable risk assessments were also observed to be in place. It was evidenced from the care plans, daily records and risk assessments sampled that the front page was the only one named for the individual resident, therefore a recommendation has been made. Care plans also include records of the individual residents Mental Capacity, visits conducted by Healthcare professionals and family/friends. Residents are registered with one GP from a local Health Practice. District Nurses attend the home as needed and are accessed via the GP. Domiciliary opticians and dentists attend the home twice times a year and on an as required basis. Access to Audiology is arranged via the Rope Walk (hearing Centre) based in Nottingham. Physiotherapy, Occupational Therapy and the Dietician are sourced via GP. The home has a Chiropodist who attends the home every six to eight weeks and as required. The home has good procedures in place for the monitoring and recording of all drugs administered, disposed of and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Medication administration records were viewed and these were found to be maintained appropriately. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. End of life care plans have been introduced as part of the new care plan system. These care plans detail individual residents wishes in the event of being critically ill and during their end of life. It was also observed that it has been clearly recorded where resident’s have not wished to discuss this subject. The Appointed Manager reported that any resident would be supported to stay at the home during critical illness or death, as long as their needs could be met. External healthcare professionals would be used in order to assist Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 13 residents to remain at the home. Resident’s relatives/friends would be supported to remain with the resident for as long as they need in order to pay their last respects. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to enjoy a stimulating programme of activities to choose from. The home provides a good range of social, cultural and recreational facilities. Resident’s benefit from a nutritious diet and resident’s choice and wishes are respected when planning menus and meals. EVIDENCE: A newly appointed Activities Coordinator is in post. The Appointed Manager and Activity Coordinator have met with all residents’ to discuss their likes and dislikes and a list of their preferences has been generated. There is a published list of activities for residents to view. Activities include: Birdie Man, Organist, singer and keyboard, staff pantomimes, birthdays Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 15 (celebrated with a cake and party if wanted), bingo, keep fit – chair based exercises, reminiscence, domino, card games, arts and crafts, visiting musician (most evenings). 1:1 sessions are not currently in place, the Activity Coordinator reported that there are plans to implement such sessions. Trips into the local community are arranged. There are currently no day centre attendees at present. There is currently no church service provided, though the Appointed Manager reported that this can be arranged but residents have declined to date. A visiting priest visits monthly and meets with two residents who wish to practice their belief. Discussions with the Registered Provider/Registered Manager highlighted that although the current residents had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents are encouraged to go on holidays and days out with their family. Menus are planned with residents input. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and residents guests are also welcome to have meals at the home. Meals can be taken in the residents bedroom or in the communal dining room. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Photographs of f meals were noted in dining area, these are designed to assist residents with menu choice. Residents and friends spoken with stated that ‘the food is lovely here, I have no complaints’ and ‘I have never, in all the time I’ve visited here, heard anyone complain about the food’. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure. The legal rights of residents are safeguarded and protected. The homes procedures, processes and staff training should protect residents in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received one complaint within the past five months. The complaint has been resolved and appropriate action was taken by the Appointed Manager to address the concerns raised. Residents voting preferences are clearly recorded in the new system care plans. All service users currently vote via proxy or by post. The Appointed Manager states that those who would be able to attend the polling station would be assisted to do so. Advocacy services are available if needed. All residents currently have family to act on their behalf. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 17 Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last five months. This was evident from the staff files were viewed. A copy of the both the Nottingham City and County Councils Safeguarding Adults procedures are readily accessible to staff. There have been two Safeguarding Alerts raised by the home in last five months. One of which was not reported in a timely manner. Discussions with the Appointed Manager confirmed that the resident had requested that this information was shared with anyone. The Appointed Manager stated that she felt torn being acting within the procedures and the residents wishes. The incident has now been investigated accordingly and the Appointed Manager stated that both she and staff have learnt a valuable lesson from this incident. The Appointed Manager confirmed that all future allegations made, would be discussed with the appropriate authorities and the actions taken would be under their guidance. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides accommodation for residents that is safe, hygienic and odour free. There are sufficient toilet and washing facilities for residents. Private and shared spaces are available and are subject to an ongoing plan of refurbishment. Infection control procedures are adhered to at all times. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 19 EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. Since taking over the home in November 2008, there have been new carpets, bathroom flooring and equipment installed. Plans are in place to have all windows modernised with double glazing. Residents, friends and staff spoken with said ‘All area’s of the home look cleaner and a lot tidier’. CCTV has been installed to the external areas f the home, following a burglary in February 2009. Communal spaces provide residents with ample areas to partake in group activities or meet with guests/visitors in private. The dining area is a large area and suitable to meet the needs of residents. The garden is secure, well maintained and freely accessible to residents. There are plans in place to build a summer lounge/conservatory in the garden in the future. There are three bedrooms with en suite facilities (toilet and hand wash basin). Additionally there are toilets, assisted bathrooms and a walk in shower available. Specialist aids and adaptations were noted throughout the premises. There is a shaft lift to enable access to both floors. Ramps and grab rails were also observed throughout the home. There is clear pictorial and written signage of all rooms within the home. There is a call bell system in place, which encompasses all areas of the home. All bedrooms are single occupancy. Bedrooms viewed were observed to be comfortable and residents own possessions were noted. Personalisation of bedrooms is promoted in order to encourage residents to feel ‘at home’. Some residents have keys to their bedroom, whilst others have been risk assessed as being unable to have their own key. Lockable facilities are available to each resident and in accordance with a suitable risk assessment. Furniture and fittings are appropriate to the needs of residents. Residents are encouraged to bring personal possessions into the home, as long as they meet with Fire Safety requirements. Heating, water, ventilation and lighting is provided in accordance with environmental health and safety requirements. There is emergency lighting throughout the home. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. Staff were observed adhering to infection control procedures. The home was clean and odour free throughout. There is a daily cleaning schedule in place. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills, training and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which details staff designations and hours of working. The Appointed Manager reported that staffing levels are reviewed to ensure that resident’s needs are met and that should a residents needs change then staffing levels would be increased accordingly. The home has a permanent staff team of the Appointed Manager, six Senior Care Assistants, nine Care Assistants (and one on the homes bank), two Cooks, three Domestics and a handyman. The management of the home are committed to training staff in National Vocational Qualification (NVQ). Three care staff are NVQ, level 2 or above, trained in care and twelve care staff are currently completing the NVQ level 2 or 3, in care training. Both Cooks are trained to NVQ level 2 in Food and Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 21 Catering. Additionally there is a Domestic who has achieved the NVQ level 2 in domestic skills. A Senior Care Assistant spoken with confirmed that they are due to commence the NVQ level 4 in the near future. Staff recruitment files were viewed and it was evidenced that these files contain the majority of items required under the Care Homes Regulations 2001. Current photographs of staff are based on their passport photo. This was discussed with the Appointed Manager and it was deemed appropriate to have individual photographs on file. Therefore a recommendation has been made. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Training records were observed and it was evidenced that the staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of First Aid, induction, Moving and Handling, Fire Safety, Infection Control, Health and Safety, Safeguarding Vulnerable Adults. A new training provider has been used for all mandatory training for the year of 2009 and the Appointed Manager reported that all mandatory subjects would be completed by July 2009. Additional training is also provided in Dying, Death and Bereavement, Dementia Awareness, Mental Capacity, COSHH Awareness, Continence, Nutrition and Diet and other subjects that arise from changes in residents needs. Staff spoken with confirmed that the training is better and enables them to feel confident to conduct their jobs effectively. Residents and visitors spoken with stated that ‘the staff team seem to be more motivated’. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents experience the benefits of a home that is well managed and administrated. Consideration is given to resident’s choice and opinion in all aspects of provisions provided. The health, safety and welfare of residents and staff are protected at all times. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Appointed Manager has been seconded from Silverdale (a sister home) since January 2009. She is the Registered Manager of Silverdale and has been in the care home environment for nine and a half years. The Appointed Manager stated that she does all mandatory training with the rest of the staff. Her qualifications include: Registered General Nurse, Registered Managers Award, D32 and D33 (NVQ Assessor) and D34 (NVQ internal verifier) qualified. She also has obtained the 703/7 teaching certificate. Residents spoken with said that the Appointed Manager was friendly, approachable and always takes residents concerns or comments about the home seriously. Staff said that she was ‘firm but fair and always encouraging in her manner’. The Appointed Manager operates an open door policy and it was observed that she interacts well with both staff and residents. A formal quality monitoring system is in place. Between April and May 2009 service user, staff and family questionnaires were distributed. Regulation 26 visits are conducted by the Registered Providers. It was evidenced that the reports are not consistently provided to the Appointed Manager. Therefore a Requirement has been made. Service user/relatives meetings are held three monthly. The recent Quality Assurance audit responses highlighted that monthly meetings were deemed ‘a bit too much’. Staff meetings are held monthly, whilst senior staff meetings are held fortnightly. All meetings are minuted; these were viewed during the inspection. A Residents Committee exists, which has three members at the present time. A newsletter is generated, once correlated the Quality Assurance audit results will be published in the newsletter. The financial procedures of the home were assessed during the registration process and found to be satisfactory; therefore these were not assessed during the inspection. Personal allowance accounts are maintained for some residents. The accounts were audited and a clear audit trail was observed. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. Staff are appropriately supervised. The Appointed Manager supervises all staff and detailed records are maintained. All staff have had an appraisal for the year 2009. Staff spoken with said that they could discuss issues with the Appointed Manager outside of their usual supervision time. Records are maintained in a secure manner. Residents can have access to their records upon request. Family members can only have access to records Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 24 with the residents consent. The Appointed Manager stated that the residents next of kin can request access if the resident lacks capacity. The Appointed Manager is currently in the process of updating all policies and procedures. All existing policies and procedures were in need of being written to fall in line with current guidance and Regulations. The home’s AQAA and observations made on the tour of the premises provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. On the tour of the premises it was noted that unnamed bath and COSHH products were in many of the homes bathroom and toilet areas. Therefore an immediate requirement was made. A second tour was conducted and it was observed that all products had been removed. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 25 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP2 Regulation 5A (2) (b) Requirement That individual contracts for Terms and Conditions of stay are reviewed and amended to include details of who pays the fees and when they are paid. That Regulation 26 visits are reported on a consistent monthly basis and the reports are made available for inspection. Timescale for action 26/06/09 2. OP33 26 26/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP29 Good Practice Recommendations That care plans and daily records have each page named for the individual that they relate to. That staff files are updated to include a recent photograph. Havana House Care Home DS0000072779.V375562.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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