Archived: Haverholme House

Updated 8 December 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was undertaken on 1 and 7 November 2017, by one adult social care inspector.

Before the inspection, the provider was asked to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We considered this information during our inspection. We also looked at the notifications received and reviewed all the intelligence the Care Quality Commission held to help inform us about the level of risk for this service. We spoke with the local authority to obtain their views about the service prior to our visit. We reviewed all of this information to help us to make a judgement about the service.

We looked at how the service used the Mental Capacity Act 2005 to ensure that when people were assessed as lacking capacity to make their own decisions, best interest meetings were held in order to make important decisions on their behalf.

During the inspection we spoke with five people who used the service, three relatives, four visiting professionals, the operations director, senior support manager, four staff and the chef. We also spent time observing the interactions between people, visitors, relatives and staff whilst in the communal areas of the service.

We looked at a selection of documentation relating to the management and running of the service. This included three staff recruitment files, three staff supervision records and appraisals, staff training records and rotas. It also included three people's care records and medicine administration charts, minutes of meetings held with people who lived at the service, relatives and staff, quality assurance audits, policies and procedures, maintenance records and complaints and compliments. We also undertook a tour of the building.

During the inspection we observed how staff interacted with people who used the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people using the service.

Updated 8 December 2017

Haverholme House is registered to provide residential care for up to 47 older people, some of whom may be living with dementia. There are two units, Grove Court and Pine Tree Court with a range of communal rooms available for people to use. The service is situated in attractive grounds on the outskirts of Appleby village, near Scunthorpe.

At the last inspection in October 2016 the service was rated requires improvement in four domains; safe, effective, responsive and well-led. This gave the service the rating of requires improvement overall. We found no breaches of regulation. This rating was awarded in the four domains because we had to make sure positive improvements that had been made were maintained over time since the inspection in February 2016. At that time we had found the provider was in breach of ten regulations. These were in relation to person centred care, need for consent, safe care and treatment (including management of risk, medicines and infection prevention and control), safeguarding people from abuse, premises, complaints, staffing (numbers, support and training), good governance, fit and proper person's employed and non-notification of incidents. In February 2016 the service had been rated 'inadequate' and it was placed in special measures. During this inspection we found improvements in all of these areas had been maintained.

The inspection was completed on 1 and 7 November 2017, by one adult social care inspector. No breaches of regulation were found.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 manager had been appointed and they were going to make a registered managers application to the CQC. Therefore the domain 'well-led' cannot be rated higher than requires improvement.

We found staff understood how to identify signs of possible abuse and knew how to report this to help to protect people from harm and abuse. Staff recruitment procedures were robust. Infection prevention and control measures were in place. Staff had good knowledge and understanding about risks present to people’s wellbeing. People who used the service told us they felt safe living there. There were sufficient numbers of competent staff provided to meet people’s needs.

Accidents and incidents were monitored and there were plans in place to inform staff of the action they must take in the event of an emergency. This helped to protect people’s health and safety. General maintenance of the premises was undertaken.

People received their medicine as prescribed and staff were appropriately trained with the skills required to carry out their role effectively. Minor issues regarding people’s prescribed creams were dealt with immediately by the manager to protect people’s wellbeing.

Staff received supervision and an annual appraisal was being planned for staff who still required this.

People’s independence was promoted even if there were risks attached to this. The service gained permission to share relevant information with health care professionals so that people’s wellbeing could be promoted.

The environment had been enhanced with reminiscence areas for example, an old fashioned post office and a 1950’s lounge. Gardens had level access and were inviting. There was a wide variety of activities provided in house and links with the community were being enhanced.

People’s capacity was assessed and care and support was provided in line with the Mental Capacity Act 2005, which helped to protect people’s rights.

People were treated with respect. Staff were kind and patient in their approach to people and respected their diversity. People’s confidentiality was maintained and care records were stored securely, in line with data protection legislation. Advocates were provided to people if this was required, to help them raise their views.

People were offered choices of food and drinks and individual dietary needs were catered for and monitored in line with their care plan. People had access to health services when required and the service responded quickly when they needed advice or guidance from other professionals.

The service had a complaints policy and welcomed feedback from people living at the service, relatives and staff. Issues raised were investigated and this information was used to enhance the service provided to people.

People who used the service had personalised care plans in place and their individual’s preferences were documented. Risk assessments were in place along with life history, medical conditions and professional contact records. People’s communication needs were recorded and staff were aware of this, which ensured people were able to let staff know their needs.

Family and friends were welcome to visit the service and people living at the service were encouraged to maintain their family contact.

There was an effective management team at the service who were open and transparent. They were supporting a new manager who had recently been appointed. The service's visions and values were known by the manager and all parties were working to maintain or improve the service provided for people.