Inspection on 10/10/06 for Haven Lodge

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven Lodge 03/10/07

Haven Lodge 21/02/06

Haven Lodge 27/06/05

Haven Lodge 24/11/04

Haven Lodge 09/08/04

Similar services:

Kings Lane (32)

Pemdale

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Haven Lodge 14 Wellesley Road Clacton On Sea Essex CO15 3PP Lead Inspector Pauline Dean Final Key Unannounced Inspection 10th October 2006 10:30 Haven Lodge DS0000017844.V315156.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 Haven Lodge DS0000017844.V315156.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. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven Lodge Address 14 Wellesley Road Clacton On Sea Essex CO15 3PP 01255 421089 01255 223641 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) Wilkinson03@aol.com Mr Paul Wilkinson Mrs Catherine Covey Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2) of places Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 9 persons) Two persons, over the age of 65 years, who require care by reason of a learning disability, whose names were made known to the Commission in September 2006 The total number of service users accommodated in the home must not exceed nine persons 21st February 2006 Date of last inspection Brief Description of the Service: Haven Lodge is an established residential care home, registered under the Care Standards Act 2000 for nine service users with learning disabilities and/or mental health disorders. Fees for service users range from £414.20 - £550.00 per week. Toiletries, chiropody and hairdressing are charged at cost. There is single bedroom accommodation for all nine service users located on the ground, first and second floors. One service user has their own en-suite facilities. There is a bathroom and shower room on the first floor and a further bathroom on the second floor. There is a separate toilet on the first floor and toilets in the first floor shower room and second floor bathroom. Communal facilities consist of a front lounge and a rear dining room/day room. At the rear of the property there are outbuildings, which house the homes laundry/ utility room, storage and smokers room. The homes office is located on the first floor. There are front and rear gardens with off the road parking on the driveway. The rear garden is paved with shrub and flowerbeds. The home is a semi-detached property within walking distance of Clacton town centre where there are shops, churches, markets, cinema, theatre, sea front, amenities and the esplanade. GP surgeries are also close by. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection covered all key National Minimum Standards and standards detailed in the last inspection’s Requirements and Recommendations. In addition consideration was given to all recent records relating to the service, including information sent to the Commission by the provider. A record of inspection was collated prior and during the inspection process. Regulation Inspector Pauline Dean completed a site visit to the home on 10/10/06, which lasted 7½ hours. At this visit, the inspector was able to speak with service users, Mrs Cathy Covey, the registered manager and staff. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of three service users, a process known as case tracking. Of the twenty-six National Minimum Standards inspected on this occasion, fifteen were met, ten nearly met and one not met. Of the requirements six were repeat requirements of which one was issued for the second time an immediate requirement. Within the inspection report it can be seen that there have been some improvements in care practice and record keeping in the home. All three outcomes for these sections – Choice of Home, Individual Needs and Choices and Lifestyle were found to be good. Policies and procedures, environment issues and management and staffing still require attention, for whilst they were noted to have adequate outcomes, issues such as the Regulation 26 visit and report by the registered provider still require attention. Issues around the premises and outstanding repairs and decoration also require attention. What the service does well: Haven Lodge continues to offer a homely environment. The majority of the service users have lived at Haven Lodge for many years and are therefore settled and established in Clacton on sea. Management and staff support and enable service users to access leisure, training and educational facilities in the community. Within the home there is a relaxed feeling. Service users come and go as they wish, with support given as agreed. On the day of the site visit, service users were seen to go out shopping alone and escorted. Several of these trips were impromptu events requested by the service users. Surveys were left with the home at the site visit and seven service users completed, some with assistance these forms. Whilst none had made additional comments, all had spoken positively regarding their care, the Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 6 cleanliness and they said that they were able to do what they wanted and could make decisions about what they did each day. What has improved since the last inspection? What they could do better: As was acknowledged in the last report, an extensive decoration and maintenance programme has taken place in recent years. However, shortfalls were now evident e.g. the new bedroom accommodation, the former night sleep-in room still requires attention. Initially a new Schedule of Accommodation is required, detailing this accommodation and alongside this the outstanding shortfalls detailed in this report and the previous report require attention. These items are a new central light and repairs to the sink unit cupboard. In addition immediate attention is required to the shower cubicle, tiling and shower curtain in the home. Not only was this highlighted in the last inspection report, but it had been noted in the May 2006 Regulation 26 visit and report by the registered provider. Whilst it is acknowledged that five out of the six care staff have a National Vocational Qualification (NVQ) level 2 training in care, basic training needs require attention and the need to develop a training and development programme was identified as a requirement. As at the last inspection, the introduction of the Regulation 26 visits and reports by the Registered Provider was pursued at this inspection. An Immediate Requirement was left at the home and An Immediate Requirement Notice was left at the home for completion by 17th October 2006 and subsequently the Commission has received an email confirmation that there will be an immediate compliance with this Regulation. Further detail of the action to be taken is awaited at the time of writing this report. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 7 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. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 8 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 Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that service users move into the home knowing that their needs will be met. EVIDENCE: There have been no new admissions since the last inspection. The most recent admission was in September 2003 when a Care Management Assessment was completed by the placing authority. Prior to moving to Haven Lodge the service user had lived at the sister home of the group, but following an assessment and review it had been decided that Haven Lodge was a more appropriate placement. Currently Haven Lodge has seven service users and therefore has two vacancies. The Care Management Assessment process was considered with Mrs Cathy Covey, the registered manager and the importance of visits and assessment meetings was highlighted. Haven Lodge DS0000017844.V315156.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 at least once during a 12 month period. 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. Care planning documents detailed health, personal and social care needs and records evidenced all aspects of care required. Service users are enabled to make decisions through risk assessments and risk management. EVIDENCE: A plan of care had been developed for all three of the service users involved in this case tracking exercise. Between seven and nine care plan objectives were set. These covered all aspects of personal and social support and healthcare needs as identified from their initial assessment on admission to Haven Lodge. Key workers undertake monthly reviews; records were seen of these reviews. The plan of care is reviewed six monthly, with reviews set to take place this October. Mrs Covey spoke of involving service users, key workers and family (if they wish) in these reviews. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 11 Records sampled evidenced that service users are enabled to make decisions about their lives. Within the records there were examples of service users making choices as to the activities they wish to take part in, the work they wish to do and the friends they wish to make. During the site visit, service users were seen coming and going from the home as they wished. Care staff and support workers supported them as they needed or they were enabled to make shopping trips to local shops. All three service users involved in this case tracking exercise have decided not to hold their own money, preferring instead for the home to hold their money. Records and the cash was sampled and checked for three service users were found to be in good order. During the day, the inspector observed examples of service users being supported and assisted with their money in preparation for a shopping trip. Within service users’ files and the plan of care there was evidence of the home supporting and enabling service users to take responsible risks. Individual risk assessments were seen which related to the individual’s care. Examples seen were a risk of falls, harming from scalding and leaving the home for long periods e.g. overnight. From speaking to a service user it was evident that the home had spoken to them about a particular risk and they were fully aware of the concerns and risks involved. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff support and assist service users to participate in educational, training and community activities, as they are able. Staff support service users to maintain family links & friendships. Service users rights are respected and responsibilities are recognised. Mealtimes were a positive experience for service users. EVIDENCE: During the site visit, the inspector spoke to a service user who had an allotment. They spoke of buying seed for planting this autumn and Mrs Covey confirmed that the home had benefited from some of produce grown at the allotment. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 13 The same service user also attends a training centre where they enjoyed gardening with a second service user from the home. In addition this service user works as a voluntary worker for the Salvation Army working in the kitchen and café they run locally. A third service user had enrolled at an adult education class in needlework – crossstitch. They had previously attended other craft and art classes. Mrs Covey said that each year they review the college prospectus for new craft activities. Mrs Covey said that all of the service users are encouraged to use local community facilities such as shops in Clacton town, pubs, places of worship and the library. Service users at Haven Lodge to a varying degree use all of these facilities. Evidence of this was seen on the day of the site visit and from records held in the home. Three service users attend local churches and the majority attend a weekly evening social club – The Gateway Club. The majority of the service users were planning to spend a day or a few days at the home’s caravan. Four were planning to stay overnight and two service users purchased disposal cameras to take away with them. This was further confirmed in the survey work conducted by the Commission for seven service users spoke of being able to choose what they did each day. Mrs Covey spoke of the ways in which the home supports and assists service users to maintain contact with family and friends. Two service users regularly meet up with their relative each week, whilst another service user maintains contact by telephone calls, the occasional visit and cards. On touring the premises, the inspector noted that all bedroom doors could be locked. Mrs Covey said that the majority of service users do not wish to lock their doors and this was noted as we went around the home, although those who did choose to lock their rooms had done so. Mrs Covey said that all of the service users chose to open their mail, although they may wish staff to read the contents to them. During this visit, there were many examples of care staff and service users talking and laughing together. There was a relaxed and happy atmosphere in the home. Haven Lodge offers a four-week rotation planned menu. Preferences and choices are offered, with the main meal of the day at lunchtime. Those service users who are out at training centres during the day, take sandwiches and have their cooked meal in the evening. Some seasonal changes to the menu planning had been introduced this autumn. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 14 Records of meals taken were kept alongside the planned menu. Overall, these records were well presented, although little detail was found of desserts and vegetables served. Mrs Covey said that two service users have a low fat diet and a third has a low cholesterol diet. Haven Lodge shops weekly for food supplies using a local supermarket, butchers and freezer shop. Milk and bread are purchased daily by a service user for the care home. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Quality in this outcome area is adequate. This judgement has been made using available evidence and including a visit to the service. Overall, the home’s arrangements for supporting the healthcare of service users was satisfactory, with the exception managing blood glucose monitoring. EVIDENCE: The ethos of Haven Lodge is such that service users are enabled to have control over their lives. Personal support is offered in private as needed, with guidance and support given as required. Service users are encouraged to choose their own clothes, hairstyles and make up, with assistance given in shopping for these items as necessary. Care planning and record keeping evidenced that service users are able to choose the time they get up and the time they go to bed. Meal times are flexible, with service users who are out during the day having their cooked meal at night or whilst they are out working. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 16 Service users are supported and enabled to access healthcare professionals, as they are needed. Within the record keeping of the case tracking sample, evidence was seen of visits to the GP, psychiatrist, chiropodist, opticians, Community Psychiatric Nurse and appointments at the hospital with a consultant. Appointments were planned and diarised in the individual’s care plan and in the home’s diary. Medication administration and record keeping was sampled and inspected. They were found to be in good order for the three service users who were part of the case tracking. Records were also seen of medication returned to the pharmacist. These were well managed. A senior care worker who went through medication in the home with the inspector and they informed the inspector that none of the current resident group are self-medicating. The management of a service user with diabetes was considered with the home. A referral had been made to the diabetic nurse and ongoing blood glucose monitoring had commenced. Whilst it is recognised that care staff had undertaken this duty with the best of intentions, the need for care staff undertaking blood glucose monitoring to have appropriate competent based training was highlighted with Mrs Covey. Mrs Covey was advised to review the present arrangements, discussing with the diabetic nurse and the Tendring Care Home Nurse the action to be taken and the training required. Clearer guidance, policies and procedures need to be implemented to ensure that care staff are trained and accredited to manage this procedure if needed. Two of the current service user group are aged over 65 years of age. Consideration has been given as to their accommodation and their needs and this was said to be detailed in their care plans. These care plans were not sampled and inspected at this inspection. Mrs Covey said that at present there are no issues with regard to the age and ability and if and when these occur they will be considered with the service user through assessment and care planning. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, service users were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Haven Lodge had two complaints procedures. One was found on the notice board and the second was found in the home’s policies and procedures file. There were differences in the information contained in these documents. Furthermore, the home needs to review their complaints procedure for they need to ensure that reference to the Commission is with regard to inspection and regulation and not as a investigator of complaints. Mrs Covey agreed to review these documents and develop one procedure, which can be given and/or explained to each service user in an appropriate language/format. Haven Lodge has a collection of policies on adult protection. These detailed the signs of abuse, preventing abuse of a person in care and suspicion of abuse and the action to be taken should abuse be suspected. Two care staff who were spoken to were aware of these policies and understood the procedure for referral should they have any concerns. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: Haven Lodge is a semi-detached house with service users accommodation on all three floors. The property is in keeping with the surrounding accommodation, which houses both residential and commercial properties. Overall the premises are well maintained and decorated; this was particularly noticeable in the home’s communal areas. Mrs Covey said that with the current vacancies she and the registered provider are given some thought to changes to the registered accommodation to add en-suite facilities to some bedroom accommodation. As at the last inspection one of the service users had moved into the former sleep-in accommodation. The Commission for Social Care Inspection (CSCI) had not been notified of this change to the service users’ accommodation and the registered provider is asked to submit a new Schedule of Accommodation, Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 19 detailing the bedroom changes and the measurements of the new service user’s bedroom. Some changes have been made to this room. A new wardrobe and chest of drawers had been added and the service user had had the room decorated to their liking. However, shortfalls noted in the last inspection report included a damaged sink unit cupboard and office-type florescent ceiling lighting still require attention. Confirmation of compliance, as detailed in the National Minimum Standards – Standard 26, is required immediately. In additions, changes to the accommodation will also need to be changed and corrected in the home’s Service Users’ Guide and the Statement of Purpose. As at the last inspection attention is required to the 1st floor shower room. Replacement shower curtains have been used to replace a sliding door. These were found to be torn and hanging from the unit. Tiling within the shower was also found to be discoloured with black mould. In a Regulation 26 visit report of May 2006, the registered provider spoke of costing a replacement walk in shower in the next four weeks. No further reports were found and nothing has been done to improve this facility. This work is long overdue; particularly when it is considered that the majority of service users use this shower, for it is the only shower other than one en-suite facility in the home. Laundry facilities are to be found at the rear of the garden in separate accommodation. Haven Lodge has one washer and one dryer, both domestic in character. Service users who are able are encouraged to do their own washing and this was seen on the day of the site visit. A sink for hand washing is also to be found in this room. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to keep service users safe and address their basic needs. The home has an experienced and dedicated staff team and service users are protected by the home’s recruitment practices. EVIDENCE: Staff rotas detailed staff on duty. As at the last inspection staffing levels had been reduced at night to one asleep carer only. Whilst it is acknowledged that there has been a reduction in the resident group, it was not clear if consideration had been given to the ratio of care staff to service users according to the assessed needs of the service users and whether staffing levels had been reviewed taking into consideration the Department of Health’s Residential Forum Guidance. Mrs Covey agreed to send in a staff rota with staffing hours calculated and copies of the Residential Forum Guidance calculations to the Commission for Social Care Inspection (CSCI) within one month. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 21 At Haven Lodge there are currently six permanent care staff and the registered manager. In addition there are six hours allocated to a cleaner for the home. Mrs Covey said that now she is the registered manager of two care homes she allocates her time between the two homes spending either three or two days a week in each home. At this inspection it was only possible to sample and inspected the file of one staff member for Mrs Covey said that the other files had been moved to the main office of the two homes to complete new contracts for all staff. The one staff file inspected was found to be in good order. Overall, the staff recruitment practice and record keeping had improved. Records were seen of written references, Criminal Record Bureau (CRB) disclosures and confirmation of employment. Mrs Covey said that five out of the six care staff have a National Vocational Qualification Level 2 in Care. Whilst it was acknowledged that overall Haven Lodge has a skilled experienced staff team, the practice with regard to both induction and foundation training which meets the Sector Skills specification was incomplete. The need to review and develop a training and development programme for all care staff referencing both Skills for Care and the Learning Disabilities Framework Award (LDAF) accredited training was acknowledged by Mrs Covey. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a qualified, competent and experienced manager to run the home. The home has to develop a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Safe working practices are promoted through ongoing training. safety certification promotes a safe working environment. EVIDENCE: Mrs Covey, the Registered Manager, has completed the National Vocational Qualification (NVQ) level 4 in care in September 2005 and the Registered Managers Award in January 2006. Mrs Covey said that she has a job description, which sets out her roles and responsibilities. This was not inspected at this inspection. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 23 Health and Mrs Covey said that a quality assurance questionnaire had been given to all service users at Haven Lodge and on their return she was planning to undertake a review and analysis of the results, which will be published in the service users’ guide. It is hoped that this will be completed in the new year when it will be inspected in full. Alongside the quality assurance questionnaires, Mrs Covey said that she is using a quality assurance audit tool. This manual has been used to review the National Minimum Standards and their compliance in the home. The majority of records sampled and inspected under Schedule 3 and 4 of the Care Homes Regulations 2001 were found to be well maintained, up to date and in good order. One exception was the Regulation 26 report and visit. As at the last three inspections, the need to comply with the requirement to complete Regulation 26 visits by the Registered Provider was highlighted as a shortfall. An Immediate Requirement Notice was left at the home for completion by 17th October 2006 and subsequently the Commission has received an email confirmation that there will be an immediate compliance with this Regulation. Further detail of the action to be taken is awaited at the time of writing this report. From sampling a staff file, discussion with care staff and Mrs Covey, some shortfalls were noted in basic training requirements. Whilst it is acknowledged that six care staff have completed First Aid training in July 2006 and two care staff have completed Infection Control training in January 2005 and July 2006, some shortfalls were noted. On the one staff file sampled and inspected both the Fire Safety and the Moving and handling training had expired. As stated earlier in this report, there is a need to review and develop a training and development programme for all care staff to ensure that safe working practices are maintained. Safety certifications and record keeping was sampled and inspected. Safety certification for the gas safety and gas maintenance was seen. The latter was out of date – dated April 2005. Fire Alarm and Emergency Lighting, NICEIC Electrical Installation and Periodic Inspection Report for an Electrical Installation were sampled and inspected and were found to be in good order, as was the portable appliance testing - PAIPASS. This was dated September 2006. Weekly checks and records are kept of hot water temperatures and fire alarm testing, with monthly testing and records kept of the emergency lighting, fire evacuations and smoke detector testing. In addition the home has completed a Fire Risk Assessment. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 2 36 X 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 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 2 X 1 2 X Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 25 Yes 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 YA20 Regulation 18 (1) (c) Requirement The registered manager must ensure that all staff required to conduct blood glucose monitoring have accredited competence-based training. The registered manager must ensure that there is a clear and effective complaints procedure, which includes the stages of, and time scales, for the process, and that services users know how to complain. The registered person must ensure that each service user has a bedroom, with furniture and fittings, sufficient and suitable to meet individual needs and lifestyles. This is with regard to the new bedroom accommodation. A Schedule of Accommodation, measurements and detail of the new bedroom must be sent to the Commission with the Action Plan. (This is a repeat requirement. Previous timescale of 20/04/06 was not met.) Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 26 Timescale for action 24/11/06 2. YA22 22 24/11/06 3. YA26 23 24/11/06 4. YA27 23 The registered person must ensure that there are sufficient toilet, bath and shower facilities to meet service users’ accessed needs. (This is a repeat requirement. Previous timescale of 20/04/06 was not met.) The registered manager must ensure that staffing levels are appropriate to the assessed needs of the service users and the size, layout and purpose of the home, as calculated using the Department of Health Residential Forum Guidance. Copies of calculations and staff rota to be sent to the Commission. (This is a repeat requirement. Previous timescale of 20/04/06 was not met.) The registered person must ensure that there is a staff training and development programme, which meets Sector Skills Council workforce training targets and ensures that staff fulfil the aims of the home and meet the changing needs of service users. (This is a repeat requirement. Previous timescale of 20/04/06 was not met.) The registered person must ensure that effective quality assurance and quality monitoring systems are in place to measure success in achieving the aims, objectives DS0000017844.V315156.R01.S.doc 24/11/06 5. YA33 18, 19 24/11/06 6. YA35 18 24/11/06 7. YA39 24 24/11/06 Haven Lodge Version 5.2 Page 27 and the statement of purpose of the home. (This is a repeat requirement. Previous timescales of 09/01/05, 15/08/05 & 20/04/06 not met.) 8. YA41 26 The registered provider must ensure that visits are made in accordance with Care Home Regulations 2001 - Regulation 26. (This is a repeat requirement. Previous timescale of 09/01/05, 15/08/05 & 08/03/06 were not met.) An Immediate Requirement notice was left at the home at the time of the inspection. 9. YA42 13, 16, 23 Schedule 4 The registered manager must 24/11/06 ensure that safe working practices are promoted through basic training opportunities and the development of a training and development programme. The registered manager must 24/11/06 ensure that the health and safety of service users and staff is maintained through the maintenance of regular checks and inspections. Namely the gas maintenance check. 17/10/06 10. YA42 13, 23 Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations The registered manager should ensure that nutrition records fully detail all foods served and eaten. Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haven Lodge DS0000017844.V315156.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!