Inspection on 03/10/07 for Haven Lodge

This inspection was carried out on 3rd October 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven Lodge 10/10/06

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 Key Unannounced Inspection 3rd October 2007 09:45 Haven Lodge DS0000017844.V352538.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.V352538.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.V352538.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.V352538.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 10th October 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. 20p - £551. 38p per week. Hairdressing, toiletries, magazines, newspapers, leisure and chiropody are charged at cost. At the time of this inspection en-suite facilities were being added to the bedroom accommodation. All bedrooms are single rooms and either shower/bath and wash hand basin and toilet facilities are being installed. The bedroom accommodation will decrease from accommodation for nine service users located on the ground, first and second floors, to accommodate for seven service users. 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.V352538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Haven Lodge took place on 3rd October 2007 over a 7¾-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in October 2006, looking at records and documents at Haven Lodge and talking to the registered manager, Mrs Cathy Covey, the registered provider Mr Paul Wilkinson, care staff and a support worker and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in September 2007 was considered as part of the inspection process and a tour of the premises was completed at the visit to the care home. Surveys were left with the home for distribution to all of the people living at Haven Lodge and six surveys were completed and returned to us by the people using the service, two by relatives, carers and advocates and six staff surveys were completed and returned to the Commission for Social Care Inspection (CSCI). Twenty-seven National Minimum Standards were inspected. This included all key standards. One requirement and one recommendation was made as a result of this inspection, with all outcomes either good or adequate. What the service does well: Haven Lodge continues to offer good quality care to the people living at the home. Individuality is respected and promoted in the home, with management and staff enabling and promoting choice in activities, leisure and daily life. Catering arrangements were managed well with choice and a healthy diet promoted. The people who live at Haven Lodge continue to access a range of educational, leisure and work activities, with staff and management support as needed. Haven Lodge DS0000017844.V352538.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. Haven Lodge DS0000017844.V352538.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 Haven Lodge DS0000017844.V352538.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Detailed information is found in the Service users’ Guide and the Statement of Purpose. A comprehensive admissions process ensures that people who come to live at Haven Lodge are assured that their needs are met. EVIDENCE: Both the Service Users’ Guide and the Statement of Purpose have been reviewed and revised as part of a policy and procedure review conducted by the home in October 2007. Some changes had been made to these documents to reflect the current arrangements and the planned changes to the environment. On completion of these alterations the home will need to update and revise the schedule of the new accommodation to fully reflect the new bathing and shower facilities and the installation of en-suite facilities in all bedrooms. In view of these necessary changes, these documents were not considered in full at this inspection, but will be reviewed when the premise changes are complete and a revised Service Users’ Guide and Statement of Purpose are required. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 9 Within the Annual Quality Assurance Assessment completed in September 2007 it was said that the home would like to produce a brochure for prospective service users as they consider living at Haven Lodge. It is hoped that this will be completed alongside the revision of the Service Users’ Guide and the Statement of Purpose. The most recent admission to Haven Lodge was in September 2003 when a Care Management Assessment was completed by the placing authority. Prior to moving to Haven Lodge this person 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. There are currently six people living at Haven Lodge. Haven Lodge DS0000017844.V352538.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. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documents were comprehensive detailing health, personal and social care needs. Regular reviews were in place to ensure that the people who use the service receive the care they wish and require. Risk assessments enable the people living at Haven Lodge to take manageable risks. EVIDENCE: The care plans of two people living at the home were sampled and inspected and they were used to case track care in the home. One of these was the most recent admission in 2003. The registered manager said that care plans are being revised and formatted. This was found to be the case in this care plan, with some information was found in the old format/file, which is to be moved over to a new format. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 11 Within a second care plan sampled the new format was evident. A new check list and a section entitled – Service Users’ File, detailed an inventory of belongings and personal possessions, furniture inventory, valuables, medication and incident report formats as required. A section entitled – Assessment and Care had the details and particulars of the individual listed under the following headings - biographical information, emotional wellbeing, lifestyle, mental agility & faculties needs, physical health & wellbeing, risk assessment, summary & overview & service users’ plan of care. These sections had been completed in detail and covered all aspects of personal and social support and healthcare needs. Further changes are planned within the plan of care with new headings to be introduced. Of particular interest was the heading, which asked for service users comments and wishes, for the registered manager spoke of wishing to involve the person living at the home more in their care. Both care plans were current and in good order, with evidence of input from keyworkers and regular reviews. Within the care plans sampled and the daily records there was evidence of decision-making by the people living at Haven Lodge. Some choices were seen around visiting friends, going shopping or going to a local café for a cup of tea. During the inspection, the people living at the home were seen coming and going from their rooms and the home as they wished. One person went out to work on their allotment, another went into Clacton for a cup of tea, a third visited a relative and a fourth person went shopping. Escorts were provided as were needed. Risk assessments were seen in place on the two care plans sampled. Risk assessments were in place for the management of aggressive behaviour and when a person decides to stay out over night. In both cases, risk assessments had been completed with risk management strategies in place to manage the behaviour. Records are kept as and when necessary. Haven Lodge DS0000017844.V352538.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routine and activites in the home were flexible and optional, with people who live at Haven Lodge being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Links with the local community are encouraged and promoted. Haven Lodge provides a varied and nutritious menu for individuals to select from. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 13 EVIDENCE: As at previous inspections, the people living at Haven Lodge are supported and encouraged to be part of the community. Each year, the home considers the classes, which are on offer in the local Adult Community College. Of the two people part of this case tracking, one has enrolled on a Pottery Course, but had decided not to attend the first session. As in previous years other people have enrolled in both educational and leisure classes, which had just began for the autumn term. One person living at the home continues to work at a training centre, where they enjoy gardening. This same person has an allotment, which they were busy working on the day of the visit to the care home. Another person has work in the kitchens of a garden centre one day a week. As stated earlier in this report, the people in the home are supported to go out and about in the community. The home is within walking distance of the town centre and all access the town as they wish, either with support or alone. Public transport, either buses or trains are used to go into Colchester, Walton on the Naze and Jaywick on shopping trips and visiting friends and family. Haven Lodge along with it’s sister home has the use of a caravan at a holiday centre in St Oysth. The registered manager said that the people living at the home had all visited the caravan during the summer, some staying overnight and some for day trips only. The home has the use of a people carrier for these trips. One person living at Haven Lodge continues to have contact with a local church attending church services and meetings regularly and has a regular visit from a friend from church. Another person attends church with their family as they wished. Links with families continue to be maintained. Of the two people sampled, as part of the case tracking it was evident that they meet and visit regularly their family and friends. This was noted in their daily records and confirmed in conversation with them during the visit to the care home. When asked the question in the service users’ survey – ‘Do you make decisions about what you do each day?’ four of the people said that they were always able to do this, one said that they could usually do this and one said that sometimes they could do this. Within the survey work conducted by the Commission for staff, one commented that the home ‘Listens and guides service users to do what they wish and desire,’ whilst another said that the home would look ‘if any courses Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 14 come through for service users’ they are informed about them to keep them independent’ and they continued that ‘most of them (service users) do something during the week to keep occupied.’ A relative commented in a completed survey that the home ‘try to encourage residents to go out to day centres or get some work’. They went on to say that the home ‘arranges a holiday and some days out, plus they go to see a show at the theatre’. In addition they confirmed that they were aware that some of the people living at Haven Lodge continue to attend a Thursday evening club – Gateway Club. This was confirmed by a person living at the home and noted in the daily records seen. A Team Leader has responsibility for ordering food supplies and catering arrangements at the home. At the inspection, we were able to speak with them and they detailed the planning and shopping arrangements they followed. Both local shops and a large supermarket are used weekly or as needed. A four-week rotation menu is used with two choices offered at lunch and teatime. Hot and cold dishes are offered, with healthy options seen within the supplies. Nutrition records are kept of choices made and the food eaten and special diets such as diabetes and high cholesterol are considered. At breakfast the people who live at Haven Lodge are offered a choice of cereal and fruit juice and the carer said that porridge is served and enjoyed every other day. A roast lunch is served each Sunday and a rotation of different joints is offered each week. All staff (with the exception of the most recent employee) have completed a basic food hygiene course using a video and workbook package. Food temperature checks are recorded and kept and temperature checks are recorded for the two fridges and a freezer. These were in good order. Haven Lodge DS0000017844.V352538.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for supporting the healthcare of the people living at the home was detailed to enable staff to know what action is required and what action is to be taken. EVIDENCE: Within the care plans and daily records sampled and seen at the inspection, there was evidence of the people living at Haven Lodge receiving their personal support in the way they prefer and require. One person part of the case tracking exercise was able to buy and select their own clothes. They had additional 1:1 hours of a support worker and this enabled them to plan for shopping trips into Clacton or Colchester. None of the current service user group have the need of technical aids and equipment. All of the people living at Haven Lodge use three local doctors surgeries. Individuals are supported and aided as required to attend GP and consultant appointments. The registered manager said that all of the people living at Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 16 Haven Lodge are offered annual health checks and input from other healthcare professionals is accessed as needed. One person manages their own healthcare needs alone, as is their wish. Medication administration and record keeping was sampled and inspected for the two people living at the home who are part of the case tracking. The storage and record keeping was found to be in good order. Medicines were in good supply and the home was not holding excessive medication supplies. Records were seen of medicines entering the home. These were detailed on the Medication Administration Record (MAR) sheet and a return book is used for returning and disposing of medication. We were told that no Controlled Drugs were being held in the home on the day of the inspection and staff are no longer required to complete blood glucose monitoring. Signatures and initials of staff giving medication were seen and all staff giving medication had in-house medication training, which was competence based. Haven Lodge DS0000017844.V352538.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Haven Lodge were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: A new policy on the management of complaints was found in the home’s Policy and Procedure manual. This detailed the action to be taken by the care service giving the timescale for acknowledging a complaint and responding to a complaint. Reference to Commission for Social Care Inspection (CSCI) was appropriate with details given as to how to contact us. The registered manager said that the home had not had any complaints since the last inspection. Within the survey work conducted by the Commission six service users said that they knew who to speak to if they were not happy and four said that they would speak to staff. With regard to the question about knowing who to complain to, four said that they knew who to complain to, whilst two said they did not know. One person added ‘I don’t like to complain in case I upset somebody.’ One relative who had completed a survey said that they could not remember who to complain to and the other said that they did know who to complain too. With this in mind, the care home should look to promoting their new complaints procedure to ensure that all service users, relatives and representatives are fully aware of the ways they can raise their complaints. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 18 A Policy on Abuse was found in the home’s Policy and Procedure manual. This detailed different types of abuse, the action to be taken in the event of abuse occurring or suspected & the handling of the incident. Information relating to local authority contacts and referral processes was held in both the complaints and whistle blowing policy. Two staff spoken to at the inspection had some understanding as to the need to raise any concerns should they have any concerns. All six surveys completed by staff said that they knew what to do if a service user, relative, advocate or a friend of a service user raised a concern. One person said that they would raise any concerns with the ‘manager straight away.’ Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 19 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 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, haven Lodge provides a safe environment that is accessible to the people who live at the home. It is homely and meets individual’s needs. EVIDENCE: A tour of the premises was conducted at the inspection. There was ongoing building work; six bedrooms were having en-suite facilities of a shower or bath, wash hand basin and toilet fitted. The seventh bedroom on the ground floor already has these facilities. The communal areas, the lounge and dining room are to be found on the ground floor. They were in good decorative order with furnishings and furniture of good quality. On the first floor building work was ongoing and when completed there will three single bedrooms with en-suite facilities, a staff shower room with a toilet and a separate toilet. In addition the home’s office Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 20 is located on this floor. Bathroom fittings and fixtures were being installed on the day of the inspection and new carpets and decoration are to follow. On the second floor some changes to the existing accommodation will provide three single bedrooms with en-suite facilities and a staff sleep-in room. The existing bathroom is to be incorporated into one of the single rooms. On completion of these building works the home will need to make an application to register this new accommodation and the registration will reduce from nine to seven residents. Furthermore changes will be needed to the Schedule of Accommodation in the Service Users’ Guide. The kitchen and laundry rooms remain as at previous inspections. The laundry room in an external building at the rear of the property. Entrance to the laundry room is through a storage room and a room used by service users who are smokers. In the laundry there is one washer and one dryer and hand washing facilities. The registered manager said that the walls of this building require painting and these are to be completed as part of the ongoing building work. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 21 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): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the care home should expect that there are sufficient staff and staff recruitment practices and training ensure that they are safe and their individual needs are addressed. EVIDENCE: The registered manager said that all staff, apart from the most recent employee has a National Vocational Qualification (NVQ) level 2 in care. Whilst there have been some staff changes, the registered manager said that the home had good staff team who worked well together. Senior staff had been given additional responsibilities such as catering and medication, which has assisted the registered manager, as she is responsible for two care homes. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 22 Staff rotas in the home detailed staff on duty. Rotas were seen for weeks from 18th August to 28th September 2007 and generally there were two care staff on duty from 07:30 hours to 22:00 hours, with one person on sleep-in duty over night. The registered manager said that the ratio of care staff to service users is sufficient to meet their needs. Should any changes be required, and then these staffing levels will be reviewed. The registered manager’s hours were not detailed on this rota. Mrs Covey said that she does have a separate rota with her hours on which is held at the other care home. She was advised of the need to have a copy of this rota in each home. Staff files were sampled and inspected. Files of two staff employed since the last inspection were inspected. We had an opportunity to speak with them at the inspection. The record keeping and the order of these files were in good order. Detailed application forms with clear employment histories were seen and references had been taken up and received from previous employers and personal referees. Photographs and evidence of identity checks completed were seen. A new improved application format had been used for the most recent employee and a pre-employment Fitness Assessment Questionnaire had been completed. Both employees had been interviewed and an Interview Questionnaire had been used at the interview with a detailed assessment of the applicant completed by the registered manager. Evidence was seen of a completed enhanced Criminal Record Bureau (CRB) and a Protection of Vulnerable Adults (POVA) 1st check for one member of staff. However, for the most recent member of staff the Criminal Record Bureau (CRB) was still awaited. A Protection of Vulnerable Adults (POVA) 1st check had been completed however, but it was clear that this member of staff was not being supervised at all times until the Criminal Record Bureau (CRB) check has been cleared. The registered manager was made aware of this shortfall and acknowledged the need to ensure this carer is supervised at all times. The second staff file sampled had evidence of completion of a thirteen-week probation period, with a contract of employment in place and they had started on the Skills for Care Induction training. The member of staff confirmed this, although they were unable to show their work, as it was not in the care home. A third staff file was also sampled and inspected had an induction record sheet on the file and the records stated that this person had completed the Common Induction Standards. In addition the records detailed in-house training in Food & Hygiene and Medication. The registered manager said that this care worker had moved on to an E-Learning qualification (NVQ) which included Induction training (Adult Literacy) and Induction (Adult Numeracy). Record sheets seen Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 23 detailed completed courses and course planned for each individual care worker. Comments relating to training in the staff surveys completed for the Commission were positive. Comments such as ‘Training is being covered by ongoing courses’ and ‘As soon as new training has come up, we are asked do we want to do it (unless it is something we have to do). An example – dementia course has come up and a lot of us said it would be interesting to do it.’ Both care staff spoken to at the inspection said that they had found both the manager and staff very supportive and helpful. They had attended staff meetings, which whilst they had seemed daunting, had proved useful and interesting. Staff surveys completed by all six care staff were overall positive as to the support they receive from the manager. Three stated that they regularly receive support; one said that this happened often and two said that it sometimes happened. When asked ‘What does the service do well? five staff members made comments such as (the service) ‘provides safe and healthy environment’, ‘looking after service user needs’, ‘they (service) work well as part of a team’ and they (service) care very much about the people who live here.’ The only negative comment found in the staff surveys was when asked what the service could do better, a response had been ‘employ more staff.’ Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 24 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Haven Lodge benefits from clear management structure and the people who use this service benefit from a quality assurance and quality monitoring system. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. EVIDENCE: Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 25 Since the last inspection, the registered manager has developed a programme and plan of her work, sharing her working hours between the two care homes she manages. Supervision sessions and staff meetings are arranged and planned in each home and are detailed in the home’s diary. To keep abreast with changes in legislation and care practices, the registered manager says she accesses courses in the locality. Training courses put on by the local mental health team are found and the registered manager said that she is hoping to attend both mental health training and managing challenging behaviour training in the near future. At the inspection the registered provider brought into the home a file entitled – ‘Quality of Service Programme’. Within this document there were surveys for service users, relatives and staff, which were entitled ‘About care in the home’ covering admission to the home and ‘About living in the home.’ Following the site visit, the Commission has been informed that survey work has been completed and an analysis of the findings completed. As stated earlier in this report, policies and procedures have been reviewed and revised. Sampled and seen at this inspection were the new recruitment procedures, complaints and adult protection policies and a Health & Safety Policy Statement, which was completed & dated 03/10/07 referencing current Health & Safety legislation. Regulation 26 visits and reports had recommenced following the last inspection. Copies of these were seen at the home. Samples were seen from January 2007 to September 2007. Safety certifications were sampled and inspected at this inspection. The Gas Landlord & Service Maintenance checks was completed 23/10/06 is to be checked again this month. Fire Extinguishers were serviced 16/11/06 and the registered manager said that these are due to be serviced in November 2007. Fire Alarm & Emergency lighting checks were completed on 11/07/07 and they are current for a year. The maintenance of electrical systems and electrical equipment under NICEIC was completed in January 2005 and is due to be checked in 2010. Portable Appliance Testing (PAT) was completed 06/09/07 and is certificated until September 2008. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 26 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA34 Regulation 19 Schedule 2 (7) Requirement People who use the service must be safeguarded by thorough recruitment practices and procedures, namely the supervision of care staff with a Pova 1st check. Timescale for action 04/12/07 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. Refer to Standard YA33 Good Practice Recommendations The registered manager’s duty hours must be planned and recorded within the home. Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Haven Lodge DS0000017844.V352538.R01.S.doc Version 5.2 Page 29 - 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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