Inspection on 24/05/07 for 51 Havacre Lane

This inspection was carried out on 24th May 2007.

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

51 Havacre Lane 21/04/06

51 Havacre Lane 06/12/05

51 Havacre Lane 29/03/05

51 Havacre Lane 12/10/04

51 Havacre Lane 18/03/04

51 Havacre Lane 17/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 51 Havacre Lane Coseley Dudley West Midlands WV14 9NP Lead Inspector Deirdre Nash Key Unannounced Inspection 30th May 2007 10:00 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 1 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 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 51 Havacre Lane Address Coseley Dudley West Midlands WV14 9NP 01902 409704 01902 493080 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) Black Country Housing and Community Services Group vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2006 Brief Description of the Service: Havacre Lane is a purpose built four bedded single bedroom house situated within walking distance of local shops and facilities, close to the railway station and public transport services. Other facilities include a lounge/dining room, kitchen, laundry, bathrooms and toilet facilities. The registered provider is a not for profit social landlord who offers long stay accommodation at the home for younger adults with a learning disability. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all of the information that we have received about this home since it was last inspected. We sent out comment cards to the home for residents and relatives to complete. Six were sent back to us and the views expressed in them are shown in this report. We sent the manager of the home a questionnaire to fill out in order to bring us up to date with facts and figures about the home. This was returned to us in good time. The Inspector called at the home without notice mid morning, spoke with the manager, a member of staff and met three of the residents. We looked around the home and looked at records. The care of a sample of one resident was followed in this way to see if the home is providing a service that meets the national minimum standards. Residents appear generally well. They look healthy and well looked after and can communicate comfortably with staff. One relative said to us, ‘ The staff are always very supportive, they spend lots of time explaining things to my sister. I always think how well dressed my sister is when I see her and how happy she is.’ What the service does well: The manager is qualified and experienced and the home is run in the best interests of its residents. The home provides good personal care and makes sure that residents get routine as well as specialist health care including mental health care. Staff have got to know the residents well, encourage contact with their families and friends and are clearly committed to their welfare. The manager is producing new and good quality systems to update individual care plans for staff to follow. These plans weigh up the benefits and risks involved in ordinary daily events and leisure activities so that residents can live an active life in relative safety. Residents have some choice about their meals and staff do encourage healthy eating. Staff are properly recruited, supervised and trained and residents are helped to keep busy, pursue hobbies and interests, develop skills and get out and about regularly. Residents each have their own bedroom and residents throughout the day use these as they please. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although the home is clear about the needs that it can and cannot meet and has put in place new documentation for admission, terms and conditions are not transparent. Residents and prospective residents do not know exactly what they are paying for. EVIDENCE: The home has made no new admissions since the last inspection. The new manager sowed us a new set of admission assessment including risk assessment documents and service user plan. There is also a new contract format. This new paper work has been recently completed for one resident at the home who’s needs have changed and it is very comprehensive. This will provide a very thorough framework for assess needs of prospective new resident. We saw an updated new Statement Of Purpose and Service User Guide with photos and a easy format complaint procedure in the file of the resident that we chose to ‘case track’. We looked at the training file of this residents keyworker and saw records although, no certificates for Positive Approaches training, Challenging Behaviour training and some training in Epistatus and Epilepsy. These topics 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 9 reflect some of the specific assessed needs of this resident. Certificates should be obtained and kept on file in the home so that we can see them We looked at the residents contract for accommodation. The home is owned and run by a housing association. It is a resident friendly version of a housing contract but is not transparent about the terms of occupation. It does not say that it is a not say that it is a tenancy agreement but it is called a tenants contract. It says, ‘you can be asked to leave and a meeting will be held about it- but the landlord must apply to a court of law to get you moved.’ This is unlikely to be accurate in a care home where occupation of a room is a ‘permission’ that may be withdrawn at any time. We have asked the manager to look into the accuracy and transparency of these terms and conditions of accommodation. Also our sample resident told us that he had just come back from holiday in Blackpool. We asked who paid for it and the manager says that the Provider used to pay for residents holidays but now the residents save to pay for them themselves. We saw nothing in the residents file to show that he was notified about paying for the holiday himself or that he agreed to do so. The statement of purpose says that the home provides a holiday every year. This should be cleared up. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents care is planned with their involvement, the home supports them to make their own decisions and take risks involved in everyday living. Residents live as ordinary life as they are able. EVIDENCE: The care file of our sample resident contains a comprehensive written service user plan dated in April this year. A review date is planned in. The care plan is cross-referenced to risk assessments. There is also a daily routine plan. We saw daily and nightly records of his care and well being and these include daily decisions made by the resident. It is the intention of the home to use this system of care planning for all residents now and this is very positive progress. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Although higher staffing levels could increase individual community contact, the home has a strong commitment to enabling residents to develop their skills and experience. Residents have a life style suited to their age and interests. EVIDENCE: We saw an activities plan in the file of our sample resident for week commencing 20/05/07. We compared the planned activities including those outside of the home in the community, with the activity record and the daily notes for the resident. This confirmed that the plan had largely been carried out and also showed where alternatives were offered and the choice that the resident made at the time. We had a short chat with the resident during which he confirmed generally the activities on record for the previous day. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 12 We spoke to another resident at some length and she told us that her family come to visit her at the home and that she receives ‘phone calls from them that she can take in private. We saw fresh food in the kitchen and good quality grocery provisions in the larder. We saw food intake records that include the percentage of the dish that he actually ate in the file of our sample resident. We saw residents making themselves a cup of tea in the kitchen. Two residents confirmed that they go to the supermarket with staff each week to shop for the home. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides health and personal care and support based on individuals needs including meeting their particular needs. Residents are well looked after and get the help that they need to look after themselves. EVIDENCE: We met three residents and each looked well and well cared for. One relative wrote to us that the care home ‘.. Gives the care and attention to my brother that he needs.’ Another said, ‘I always think how well dressed my sister is when I see her and how happy she is’. This resident told us that she enjoys the help that staff give her to wash her hair and that she chooses her own products. The care records of our sample resident show regular and up to date appointments for opticians, dentist, chiropody and a medical review last year. There are also records of two monthly psychiatric reviews, G.P visits and a hospital admission. There are guidelines for seizures and an individual protocol 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 14 for epistatus, a nutritional risk assessment and a list of medication, guidelines and signed consent for staff to administer medication. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home promotes an open culture where residents feel safe and supported to share any concerns in relation to their protection and safety. Good policies and procedures and an ethos of valuing people protects residents. EVIDENCE: We have received no complaints about the home since the last inspection and the manager says that she has received none. We saw a copy of the complaint procedure in pictorial form in each bedroom that we visited. Notification has been made to us since the last inspection of a number of incidents involving one resident. The manager has taken appropriate action under the adult protection procedures to protect the other residents and inform their social services departments of each incident. The key worker filed that we looked at showed a certificate for protection from abuse training. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although communal rooms appear bare and bathrooms are shared, the home provides a physical environment that is appropriate to the needs of the residents. Residents live in a comfortable home. EVIDENCE: We looked around the house with one resident and she showed us her bedroom. All residents have their own room and there are sufficient communal bathrooms and toilets for four people. Bedrooms contain personal belongings where residents want them. One resident told us that she is having her room re decorated this year. Some parts of the home have been redecorated since our last visit including the laundry and the dining room table and chairs have been replaced. The bathroom floor covering still needs to be replaced, as it is shabby and stained 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 17 and the three piece suite is badly worn and shabby. The manager says that this is on plan to replace as is the carpet, cooker and dishwasher. She has contacted us since our visit to say that the home has been allocated funds for this work now. Communal rooms including the kitchen are sparsely furnished and filled. The manager says that this is on risk assessment. We found an odour coming from the stair and landing carpet and many surfaces around the home feel tacky. One resident’s bedroom that we visited did not feel or look fresh. All doors including toilet and bathrooms have a dark grimy patch around the handle from people’s hands over months or years and the electric light pull chords are similarly dirty. This could spread infection. The care staff including night staff do the cleaning. The house needs a deep clean regularly as residents do spend time at home and wear it hard. The garden is neat and we saw summer bedding in tubs bearing individual residents’ names. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home recruits, trains and supervises its staff well. Residents are looked after by a professional team have confidence in the staff that care for them. EVIDENCE: The new manager reports that the home has a reliable staff team that know the residents well. When we arrived we saw two staff on duty plus the manager for three residents that were at home. This is adequate for planned outings and activities and one resident was able to go out with two members of staff to buy groceries. It may not be sufficient for spontaneous coming and going however. There are two members of staff on duty over night and this is very positive. We saw the personnel file for the key worker of our sample resident. It contains all of the information and proofs necessary to protect vulnerable 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 19 residents. Records show that this worker has had two formal supervision sessions with a manager since December last year. The staff training matrix shows all staff have updated their health and safety training. The file that we looked at showed no vocational qualification. The manager reports that three care staff have NVQ at Level 2, one at Level 3 and 3 staff are working towards Level 2. The deputy manager is working towards the Registered Managers Award. The deputy and senior have training in supervisor of staff. The manager also tells us that the new Skills for Care Induction programme will be implemented for new care staff later this year. This is all positive progress in supporting and guiding staff in their work with challenging residents. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42, 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect and the manager is qualified, competent and experienced. Residents live in a home that is safe and run in their best interests. EVIDENCE: The home has a new manager; she is not registered with us but tells us that she is in the process of putting together her application. She is experienced and qualified. Requirements made at the last inspection have been complied with and the we have been notified of adverse events as we should be. Findings throughout this inspection show that the home has made many improvements since our last visit. New systems and frameworks have been 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 21 put in place to ensure that the home is run in the best interests of the residents and meet its regulatory requirements. All records that we saw are well kept, and we saw a monthly inspection checklist undertaken by the manager. One staff member told us that the new manager ‘is getting on top of things.’ We saw reports of monthly visits from the responsible individual. The home should send us copies so that we can be confident that the new manager is getting the support that she needs to continue the improvements. We saw a valid certificate of insurance cover. There was however no sign of the homes registration certificate. It was not on the wall and the manager could not find it. It is an offence under the Care Standards Act 2000 not to display this certificate, we have written to the Provider to tell them to take immediate action to find and display the certificate. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 2 28 3 29 x 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x 3 3 2 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 23 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 RQN Regulation CSA 2000 S.28 Requirement The home must have a certificate of registration and it must be put on display in a conspicuous place so that residents and their representatives can be sure that the home is operating lawfully and safely. COMPLIED Timescale for action 18/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard YA5 YA7 YA41 Good Practice Recommendations Review the contents of the written terms and condition for accommodation and make sure that they accurately reflect the rights of people who use the service. Make clear in writing the homes rules on smoking so that residents know what their rights and responsibilities are. Keep copies of staff training certificates on file at the home so we can be confident that competent people look after residents. 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Office West Point Mucklow Office Park Mucklow Hill Halesowen B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 51 Havacre Lane DS0000025011.V337027.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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