The Care Quality Commission
  • Care Home
  • Care home

Archived: Haversham House

Overall: Requires improvement read more about inspection ratings

327 Bromsgrove Road, Redditch, Worcestershire, B97 4NH (01527) 542061

Provided and run by:
Springlea Limited

All Inspections

29 September 2015

During a routine inspection

This inspection took place on 29 September 2015 and was unannounced.

The provider for Haversham House is registered to provide accommodation and personal care for up to 16 older people who may have needs due to old age, physical disability or dementia. The accommodation is provided over two floors. On the day of our inspection there were 11 people living at the home.

The provider had not had a registered manager at this home since January 2013. However, they had appointed a new manager who had submitted their application to the Care Quality Commission which was being progressed. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection on 30 and 31 December 2014 at which breaches of legal requirements were found that had an impact on people who lived at the home. The provider did not work within the guidelines of the Mental Capacity Act 2005 (MCA) as this had not been applied consistently when people were unable to make their own specific decisions about their care. We also found the provider had not sent in statutory notifications of events and incidents which happened at the home as they are required to do by law. After our comprehensive inspection the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches and sent us some action plans.

At this inspection we found that these actions had been completed and improvement had been made in areas we had concerns about. The provider had sent in a statutory notification to us about an event which had happened at the home as they were required to do by law. People were asked for their permission before staff provided care and support so that people were able to consent to their care. Where people were unable to consent to their care because they did not have the mental capacity to do this decisions were made in their best interests and staff provided care in the least restrictive way in order to effectively meet people’s needs.

The provider had systems in place for recording information about medicines and specific aspects of people’s care. Although these systems were in place we found they were not always effective to make sure people’s safety and well-being was continually promoted. For example, the checking of staff competencies were not regularly completed and the required improvements made were not always monitored for their effectiveness.

People’s medicines were kept safely and made available to them. However, we saw the administration of people’s medicines was not consistently managed in a safe way so that avoidable risks to people receiving their medicines as prescribed were sufficiently reduced.

We saw staff were busy in the morning meeting people’s personal care and medicine needs. Staffing levels had improved in the mornings during the week so that people’s individual needs were met to reduce risks to people’s safety but this had not happened at weekends. However, the manager could not show us how staffing levels had been monitored at weekends for their effectiveness in promoting people’s needs and safety.

Staff were trained and understood their responsibilities in the prevention and reporting of potential harm and abuse. Improvements had been made to ensure checks had been completed on new staff to make sure they were suitable to work at the home before they started working there. Risks to people had been assessed and staff knew how to reduce risks to people’s safety when supporting people with their care. Staff understood their responsibility in dealing with any accidents or incidents that may occur. These were monitored to reduce any issues of concerns and the likelihood of these happening.

People enjoyed the food they received and were supported to eat and drink enough to keep them healthy. When staff supported people at meal times they did so with respect and ensured people’s dignity was maintained. When they needed it people had access to other healthcare professionals to make sure their health needs were met in a timely way.

People felt staff treated them with kindness. Staff respected people’s dignity and privacy and supported them to keep their independence. Staff spoke with people in a way they could understand and this helped them to be involved in making choices about their care.

People received care that was personal to them because staff knew what their individual preferences and needs were. Staff responded to changes in people’s wellbeing and supported them as necessary. However, people were not consistently supported with having fun and interesting things to do. The manager had already identified this as an area that needed to be improved.

People were comfortable to complain and felt able to discuss any concerns with the staff. There had been improvements made in recording complaint investigations and actions taken in response to complaints. We also saw people and their relatives now had regular opportunities of providing their views and suggestions about the quality of services people received at regular meetings.

30 and 31 December 2014

During an inspection looking at part of the service

This inspection took place on 30 and 31 December 2014 and was unannounced.

The provider is registered to provide personal care and accommodation for up to 16 older people who may have who may have needs due to old age, physical disability or dementia. Nursing care is not provided. The accommodation is provided over two floors. On the day of our inspection there were 12 people living at the home.

At the time of this inspection, the provider did not have a registered manager in post. The provider is required to have a registered manager in post at Haversham House. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had been in post since January 2014 and they told us they would complete the registration application process to the CQC.

The provider is required to send the Care Quality Commission statutory notifications of incidents and deaths of people. The manager confirmed to us that they had not sent us statutory notifications as required. A statutory notification is information about important events which the provider is required to send to us by law.

The provider was not meeting the requirements set out in the Mental Capacity Act (2005). We found that the manager was not following the requirements of the MCA and as a result were not acting in accordance with the law. This meant people could not be confident that decisions are always made in people’s best interests when they are unable to do this for themselves.

The manager was aware of their responsibilities under the Deprivation of Liberty Safeguards (DoLS) and we saw staff provided care to people in the least restrictive way.

People told us they felt safe at the home. The staff we spoke with understood how to recognise and report any abuse.

Risk was assessed but management plans were not always accurate and complete with any changes made due to professionals advice or a person’s increase in needs. This meant that people were not always properly protected from harm.

Improvements were needed to the staffing arrangements to make sure there were enough staff who were organised in the right way to meet people’s needs effectively. The provider and manager told us that they had agreed that additional staff were required at certain times but this needed to be fully implemented.

We saw that not all the appropriate pre-employment checks had been carried out for new members of staff who had been recently recruited. These checks are important and ensure as far as possible that only people with the appropriate skills, experience and character are employed.

People were cared for by staff who knew them well and who they described as kind and caring. People’s privacy and dignity had been promoted by staff practices.

People’s nutritional needs were met and health care support was arranged to keep people well.

People had their prescribed medicines available to them and appropriate records were kept when medicines were administered by trained staff.

The provider ensured staff training was up to date to enable them to provide effective care to people.

Care provided was mainly centred on providing for people’s personal care needs. There was a lack of consistent planning of fun and interesting things tailored to meet the individual needs of people.

People knew how to raise complaints and the provider had arrangements in place so that people were listened to. The investigation and action taken in response to complaints was not always recorded.

Meetings for people who lived at the home and their representatives had not been held to monitor and improve the quality of the service people received. This meant that opportunities had been missed to gather people’s views to see what action was needed to improve the quality of the service.

The provider had a quality assurance process for monitoring and checking the quality of the service. While improvements were in progress there was not always evidence of effective arrangements in place so that the provider had opportunities to check that action had been taken to improve standards.

You can see what action we told the provider to take at the back of the full version of this report.

19 July 2013

During a routine inspection

When we carried out this inspection 13 people were using the service. We spoke with the manager, three care workers and the cook. We spoke with everybody who was using the service during our inspection. We also spoke with one relative. Comments made by people who used the service included: “Things are really good here, I’m like part of the furniture” and: “This is a very happy place it’s always so friendly”.

We observed how staff interacted with people. We saw that staff spoke with people in a respectful manner. From our observations we saw that people were provided with care that met their individual needs. Staff knew about the needs of the people they were caring for. We looked at care records and found that these contained guidance for staff on how to meet their needs.

People told us that they enjoyed the meals provided and that they were offered regular drinks. This meant that the risk of people becoming dehydrated was reduced.

We found that checks were in place to ensure that staff were suitable to work with vulnerable people.

There was a procedure in place for people to make complaints if they were not happy with any aspect of the service provided.

19 October 2012

During an inspection looking at part of the service

On 02 and 04 May 2012 we inspected Haversham House. During that inspection we had concerns about the care and welfare of people, safeguarding people from abuse and how staff were supported with their training and supervision.

Following that inspection, we issued compliance actions to ensure that the provider took action to comply with the regulations in order to protect the health, safety and welfare of people who used the service.

We received an action plan from the provider detailing the actions they were going to take and when they planned to achieve compliance.

On 19 October 2012 we carried out an inspection at Haversham House to see if the provider had met the compliance actions.

There were 13 people who used the service at the time of our inspection.

While at Haversham House we saw that care workers were being courteous and respectful towards people who used the service.

Care plans, risk assessments and other records were in place to give staff guidance and direction about the level of care required to meet individual needs.

Information on safeguarding was available for members of staff.

We found that improvements had taken place in the amount of training and support provided for members of staff.

2 May 2012

During a routine inspection

When we visited Haversham House we met people who lived there and staff members on duty at the time which included the registered manager. One of the providers and the nominated individual were present for a period of time.

While at Haversham House we observed people's care and support to help us understand the experiences of people who used the service. Many of the people who lived at Haversham House were not able to tell us much about their experience at the home due to their condition. Comments did however include:

'happy'

'fine mustn't worry'

staff 'look after us'.

Care workers were seen talking to people who lived at Haversham House in a friendly, courteous and respectful manner. We saw examples where people's dignity was respected such as closing bedroom doors when personal care was taking place.

The registered manager informed us that she was aware of some gaps in the information contained in people's care plans. The care plans we saw had been reviewed during March 2012. These care plans were easy to read and under separate headings which made it easy to find information. We found that although care plans had been recently reviewed the information in them was not always up to date with the care described by care workers. This meant that there was a risk of inappropriate or unsafe care being given.

The care plan for one person could not be found at the time of our visit.

We looked at training records which showed that the most recent training in safeguarding occurred during June 2010. We established that one out of the seven night care workers had attended this safeguarding training. We spoke with staff and asked what information was available to them regarding the local safeguarding procedures implemented by Worcestershire County Council. These procedures could not be found and no other information such as posters or handbooks were available.

We found the home to be clean and tidy. Equipment such as commodes and frames around toilets were also clean.

Medication Administration Record (MAR) charts were found to be completed and showed who had administered medicines and when. These demonstrated that people were given medicines as prescribed by a medical professional. Information was recorded about known medication allergies.

We tested the temperature of the hot water in the first floor bathroom and found it was in line with the recommended temperature set by the Health and Safety Executive (HSE). Records of hot water temperatures were maintained throughout the service. These weekly records showed that water had been delivered in line with the recommended temperature.

We looked in detail at moving and handling training and fire awareness training and concentrated upon members of staff employed to work during the night. We found significant gaps.

The registered manager informed us that the service had received no complaints other than one sent to the service via the Care Quality Commission. This had been investigated and found to be unsubstantiated. We did not see any readily available information on complaints within the service for people to read. Information on complaints was included within the Service Users Guide which we saw on the manager's computer.

31 August 2011

During an inspection looking at part of the service

We undertook a visit to Haversham House. The registered manager was on duty when we visited.

Nobody at the service knew that we were going to be visiting. Although we did not have lengthy discussions with people living at the home, they did not tell us of any concerns or worries they had regarding the care they receive. We noted that staff treated people with kindness and that people appeared to be clean and appropriately dressed. During our visit we had no concerns regarding people having their privacy and dignity respected

Records held were not consistent regarding people's medication regimes. In addition care plans and risk assessments were either not an accurate reflection of some care needs or not in place at all. This meant that risks were not always managed appropriately and people may not always receive care in a consistent manner.

Records regarding the water delivered to the only communal bath indicated that it was too hot which put people at risk of scalding.

11 March 2011

During an inspection in response to concerns

We undertook two visits to Haversham House. Nobody at the service knew we were going to be visiting. People living at the home did not tell us of any concerns or worries they had regarding the care they receive. One person stated that staff are good and expressed satisfaction with the care provided. We noted that staff treated people with kindness and that people appeared to be clean and appropriately dressed.