Inspection on 21/02/06 for Haven Lodge

This inspection was carried out on 21st February 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 11 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 10/10/06

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 Unannounced Inspection 21st February 2006 10:30 Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 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.V284393.R01.S.doc Version 5.1 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.V284393.R01.S.doc Version 5.1 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 (3), Mental disorder, excluding of places learning disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (3) Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate nine people with learning disabilities who may also have a mental disorder Three persons, aged 65 years and over, who require care by reason of a learning disability who may also have a mental disorder, whose names were made known to the National Care Standards Commission in March 2003 The total number of service users accommodated must not exceed nine persons 27th June 2005 3. 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. 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.V284393.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in February 2006. This was the second inspection of the inspection year 2005 – 2006. Mrs Cathy Covey, the Registered Manager, was not present during this inspection. A senior carer assisted with this inspection. During this inspection a total of four care staff were spoken with and the majority of the service users were met. Five of the nine service users were spoken with during the day, as they went about their daily tasks. No visitors or relatives were present during this inspection. Records relating to both service users and staff were sampled and inspected, as were some of the policies and procedures. Twelve of the forty-three standards were inspected; of these only two were met, with nine nearly met and one standard was not met. It is disappointing to find that little progress has been made to the shortfalls identified in the last report and therefore seven are repeat requirements remaining from the last inspection. All key standards were inspected over the two inspections of the inspection year 2005 – 2006, with some key standards inspected on both occasions. What the service does well: What has improved since the last inspection? Service users spoken with during this inspection were generally happy with the care they receive and were relaxed and responsive to staff on duty. There was one exception, however, and this related to the service user who had moved bedroom accommodation. They did not appear happy with the new arrangements. This is dealt with in detail in this report. Care staff on duty spoke of working well as a team. There is close liaison with the other care home owned by the Registered Proprietor and in the absence of the registered manager care staff are supported by each other. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 6 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. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 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 Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Choice of Home’ were not considered in full at this inspection. They were inspected at the last inspection. During this inspection, the Inspector spoke with five service users, all of which had resided at the home for sometime. Three service users said that they were happy with their rooms and all spoke of wishing to live in the Clacton area because of relatives and friends. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 9 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. Service users’ assessed needs and personal goals are detailed in their individual care plans. These plans, however, had not been reviewed and revised to help ensure that personal care needs are met. EVIDENCE: Care plan records were sampled and inspected for two service users. Both care plans had been reviewed under a six monthly review in September 2005. They were due for a further six monthly review in March 2006. For one of the care plans sampled, the monthly key worker review was last conducted and recorded in December 2004; for the other entries were found for December 2005 and January 2006. Clearly this requirement needs to be reviewed and actioned. Care plan goals were seen to be set and these normally covered 8 – 9 primary care goals. Each goal was numbered and the numbering was referred to in the daily record keeping. Unfortunately, there was referencing to the wrong care plan goals in the records kept and no action had been taken to review, update and revise care plan goals. This was particularly notably with regard to a care plan goal to ensure personal safety of a service user at night. From discussion Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 10 with care staff it would appear that different measures are taken than those detailed in the care plan goal. Alongside this there is a risk assessment and management strategy that will require revision and health care records, which were incomplete. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Lifestyle’ were not considered in full at this inspection. They were inspected at the last inspection. Service users spoken with during this inspection said that they are able to undertaken hobbies, activities and work experiences as they wish. One service user regularly assists at the Salvation Army café and a further two service users work at a training centre, gardening and painting. In addition, one service user regularly meets with their relative and a second service user visits family and friends in St Oysth. These service users were engaged in these activities on the day of the inspection. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 12 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): 19 & 21. Record keeping and planning for meeting health care needs was found to have some shortfalls and did not detail fully if service users’ physical and emotional health care needs are met. The management of ageing, illness and death of a service user needs to be further considered to help ensure that staff and management deal with these matters with sensitivity and respect. EVIDENCE: As at the last inspection, Haven Lodge had failed to detail healthcare professionals visits. Care staff and service users spoke of visits by a Community Nurse, however, record keeping did not evidence this. Furthermore, in a second care plan sampled it was noted that the service user had regular injections. Health care records did not detail these events, even through they had been noted in daily records. As at the last inspection, Haven Lodge is reminded of the need to consider the individual care needs of the resident group. Within care plans there is a need to consider ageing, illness and mobility in service users’ continued care at Haven Lodge. Some consideration has been given to these matters, but further deliberation and detail in individual care plans is needed. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 13 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): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Concerns, Complaints and Protection’ were not considered in full at this inspection. They were inspected at the last inspection. A copy of the home’s complaints procedure was found on display in the home’s office and in a Quality Assurance manual. The home’s adult protection policy was also found in this manual. One care staff member on duty was spoken with and they said that should they have any concerns they would raise these concerns with senior care staff, the Registered Manager or the Registered Proprietor. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 14 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): 26, 27 & 28. Haven Lodge provides a safe, homely and pleasant environment, which was clean and comfortable. EVIDENCE: A tour of the premises was undertaken at this inspection and the accommodation was found to be clean, tidy, bright and free from offensive odours. One of the service users had moved from a 1st floor room to a 2nd floor room. This bedroom accommodation was the former sleep-in accommodation. The Commission for Social Care Inspection (CSCI) had not been made aware of this change to the service users’ accommodation. The Registered Provider is therefore required to notify the Commission immediately, submitting a new Schedule of Accommodation, detailing the bedroom changes and the measurements of the new service users’ bedroom. Facilities and fixtures in this room also require attention. Omissions noted on this inspection included a damaged wardrobe and sink unit cupboards and office-type florescent ceiling lighting. Confirmation of compliance, as detailed in the National Minimum Standards – Standard 26, is required. Changes to the Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 15 accommodation will also need to be changed and corrected in the home’s Service Users’ Guide and the Statement of Purpose. Attention is required to the 1st floor shower room. Replacement shower curtaining for a sliding door was found torn and hanging from the unit. It is understood that this room is to undergo renovations, with the removal of the toilet to the bathroom next door to the shower room. This planned work is in need of urgent attention to ensure that service users have the required bathing and shower facilities. Overall the communal areas of the home were well maintained. The front lounge was well decorated and furnished. The rear dining room/lounge was also well decorated, however, attention is required to the dining room chairs as several were found to be wobbly, with loose joints. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 16 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. No consideration has been given to the Department of Health Residential Forum Guidance when calculating staffing levels and therefore it was not possible to confirm if service users’ needs are met. Staff recruitment practices and procedures had shortfalls and do not ensure that services users are supported and protected. There was no evidence of a staff training and development programme to ensure that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: Staff rotas detailed staff on duty. From discussion with the care staff it was understood that staffing levels had been reduced at night to one asleep carer only. 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. Confirmation and copies of these calculations are required to be sent to Commission for Social Care Inspection (CSCI) with the Action Plan for this inspection. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 17 The files of two care staff were sampled and inspected. Overall, references and checks were in good order, with the exception of a Criminal Record Bureau (CRB) disclosure for one care staff member, terms and conditions for both care staff members and confirmation that they had received copies of the Code of Conduct and Practice as set by the General Social Care Council (GSCC). Staff spoken with were unable to confirm that they had received the latter two items. Staff training records were sampled and inspected for two care workers. One had evidence of a TOPSS Induction training course, whilst the other care worker had only completed an in-house Induction Checklist. Neither of these staff records evidenced an individual training and development assessment and profile and these care workers were not aware of such a document. Both care workers spoke of their wishes to enter into NVQ training and had made a request to be considered for this training. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 18 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): 27, 39 & 41. Staff and service users are well supported by the home’s Manager, who is hands-on and part of the care team in the home. An effective quality assurance and quality monitoring system is still required as analysis of completed questionnaires needs to be undertaken. Shortfalls identified in staff recruitment checks failed to ensure that service users’ rights and interests are safeguarded. EVIDENCE: Mrs Covey, the Registered Manager, has completed the National Vocational Qualification (NVQ) level 4 in care and management in September 2005. Care staff on duty were not aware of a quality assurance and quality monitoring system in place. As at the last inspection, there is a need to develop an annual development plan based on a systematic cycle of planningaction-review. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 19 Staff recruitment records had shortfalls as detailed earlier in this report (see National Minimum Standard 34). The home is reminded of the need to ensure that all record keeping is up-to-date and accurate as highlighted. As at the last two 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 8th March 2006 and subsequently the Commission has received a Regulation 26 report for March 2006. Confirmation has also been received that there will be immediate compliance with this Regulation. Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 20 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 2 27 2 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 X 2 3 X 2 X 2 X X Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 14, 15 Timescale for action The registered manager must 20/04/06 develop and agree with each service user an individual care plan, which is reviewed with the service user at least every six months. (This is a repeat requirement. Previous timescale of 15/08/05 not met.) The registered manager must 20/04/06 ensure that healthcare needs of service users are addressed and record keeping clearly details these needs. (This is a repeat requirement. Previous timescale of 15/08/05 not met.) The registered manager must 20/04/06 ensure that individual service user needs are considered with regard to ageing, illness and death. Individual care plans need to be agreed and reviewed regularly. (This is a repeat requirement. Previous timescale of 15/08/05 not met.) Requirement 2. YA19 16 3. YA21 14, 15 Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 22 4. YA26 23 5. YA27 23 6. YA33 18, 19 7. YA34 17, 18 8. YA35 18, 19 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. The registered person must ensure that there are sufficient toilet, bath and shower facilities to meet service users’ assessed needs. 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. This is with particular regard to night staffing levels. Copies of calculations to be sent to the Commission. The registered manager must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. (This is a repeat requirement. Previous timescale of 09/01/05 & 15/08/05 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. 20/04/06 20/04/06 20/04/06 20/04/06 20/04/06 Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 23 9. YA39 24 10. YA41 11. YA41 The registered person must 20/04/06 ensure that effective quality assurance and quality monitoring systems are in place to measure success in achieving the aims, objectives and the statement of purpose of the home. (This is a repeat requirement. Previous timescale of 09/01/05 & 15/08/05 not met.) 17,18,24,25, The registered manager must 20/04/06 review record keeping ensuring that records for the effective and efficient running of the business are maintained, up to date and accurate. This is with regard to staff recruitment records. (This is a repeat requirement. Previous timescale of 09/01/05 & 15/08/05 not met.) 26 The registered provider must 08/03/06 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 not met.) An Immediate Requirement notice was left at the home at the time of the inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Haven Lodge DS0000017844.V284393.R01.S.doc Version 5.1 Page 24 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.V284393.R01.S.doc Version 5.1 Page 25 - 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. 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