Inspection on 07/04/06 for Haven Lodge

This inspection was carried out on 7th April 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 but made no statutory requirements on the home.

Other inspections for this house

Haven Lodge 18/11/05

Haven Lodge 27/07/05

Haven Lodge 29/12/04

Haven Lodge 07/06/04

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

CARE HOMES FOR OLDER PEOPLE Haven Lodge Haven Lodge 54 Terrace Road Plaistow London E13 0PB Lead Inspector Seka Graovac Unannounced Inspection 7th April 2006 1:20 X10015.doc Version 1.40 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 DS0000028357.V288256.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 Older People. 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 DS0000028357.V288256.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Haven Lodge Address Haven Lodge 54 Terrace Road Plaistow London E13 0PB 020 8472 3032 020 8470 8959 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) Pridegold Ltd Dhunraz Ramjeawon Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: Haven Lodge is a registered care home for older people, including those who suffer from dementia. The home provides both respite and permanent care. The home has thirteen single and one double room. The building is located in a quiet residential area in Plaistow, close to public transport and other amenities. Car parking is unrestricted on the road. The proprietors are Pridegold Ltd. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted approximately five hours. The home was assessed against the key National Minimum Standards for Care Homes for Older People. The previous inspection had been conducted in November 2005 and fifteen breeches of Care Homes Regulations had been identified at that time. The inspector paid particular attention to the actions that the home put in place to remedy the identified issues. The inspector was introduced to the residents of the home, some of whom remembered her from her previous visits. She spent some time talking individually with two residents and they also showed their bedrooms to the inspector. The inspector also saw another bedroom (shared) and all the communal areas of the home. She also saw several staff members who were on duty and spent some time discussing the care service with the Registered Manager and the Registered Individual for the organisation and looking through the home’s records, such as: service users’ files, staff files, food and other health and safety records. What the service does well: Service users’ support and care needs were assessed by the home prior to the admission being arranged. The home encouraged service users’ contact with their relatives and friends. The visitors-log was appropriately kept. The environment was clean and fit for its purpose. Service users were looked after by the appropriate number of well supervised and trained staff. The home was a member of the National Care Homes Association. The Responsible Individual took keen interest in the running of the home and visited it on a regular basis. All examined health and safety records were in date. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? The service has improved in a number of ways since the previous inspection: • • • • • • • The information boards were kept up-to-date. The risk assessments were more detailed and the appropriate control measures were put in place. The procedure for reporting any allegations of abuse has been amended and the complaints log was appropriately kept. The screen was made available in the shared bedroom. Duty roster, staff training strategy and the service satisfaction survey have all been made available. The waste was appropriately managed Gas-safety certificate was available. In addition to the above improvements that have been made in response to the requirements made at the previous inspection, some areas of the home have had new carpets and an industrial carpet shampooer was bought. What they could do better: Four requirements that had been made at the previous inspection, had to be restated. The inspector was particularly concerned that some service users still did not have the appropriate care plans in place. The care planning and the medication records did not adequately support the care provision to the service users. The care plans are the major care giving document and form a part of the contract. The service users’ care can not be appropriately delivered without them. The fact that the care plans have been signed as reviewed on a monthly basis, also puts in question the professionalism and integrity of the staff and the management involved. The requirement regarding more activities being organised for the residents also had to be restated. Keeping of food related records has worsened since the previous inspection despite the issues being identified then and the management agreeing to remedy them. The hood-extractor above the cooker in the kitchen was still dirty. In addition to the repeated requirements, six new breaches of legislation were identified at this inspection, totalling ten requirements. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 7 The prospective and current service users have not been given the appropriate information about the home. The home must update their Statement of Purpose and the Guide and ensure that they are written in an appropriate style for the intended readers. The Registered Persons must ensure that the appropriate medication procedures are carried out at all times. The Registered Person must ensure that the opened packages of perishable food are stored labelled and dated. The Registered Person must have an up-to-date training and knowledge on Adult Protection and fully implement the appropriate procedures at all times. The Manager must hold the appropriate management qualification. 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 DS0000028357.V288256.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Service users’ support and care needs were assessed by the home. However, the prospective and current service users have not been given the appropriate information about the home. EVIDENCE: The home’s Statement of Purpose and the Service User’s Guide were out of date and did not have the appropriate information included. The Statement of Purpose was dated January 2003 and the Guide, October 2003. The Guide was also not written in an appropriate style for the intended readers. The Registered Person must ensure that an up-to-date Statement of Purpose that is complaint with the Care Homes Regulations, Schedule 1 is made available in the care home. The Registered Person must ensure that an up-to-date Service User’s Guide written in plain English or other appropriate language is made available to the prospective and current service users and their relatives. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 10 The examined service users’ files contained the appropriate care needs assessments done by the home as well as the external health and social care agencies before the placement was made. They also contained the contracts with the placing authorities. The inspector case-tracked care of the service user who has been admitted since the previous inspection. She was informed that his relatives visited the home prior to his move, but he himself did not as it was difficult to arrange for that with the hospital. The inspector recommended that the prospective service users visit the home, as well as their relatives before moving in. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The care planning and the medication records did not adequately support the care provision to the service users. Otherwise, their health needs and privacy were met. EVIDENCE: The inspector case-tracked care of two service users. Despite the requirement being made at the previous inspection and the related discussions held with the management of the home, for one of them (admitted more then two years prior) a care plan was not available. For the other service user, who was admitted almost a half a year prior to this inspection, the care plan was incomplete. For example, nothing was written under cognitive and mental health care needs although the person was diagnosed with schizophrenia and suffered from confusion. Those conditions were the main reason for him having to receive the residential care. The inspector was also concerned that the records were showing that the care plans were reviewed on a monthly basis and no change was needed! Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 12 The Registered Persons must ensure that each service user has an individual care plan agreed that identifies all the care and support needs of that individual and how they are going to be met by the home. The medication was securely stored in a wall-cabinet in the dinning room. The inspector scrutinised medication administration records for two service users for the period of two weeks prior to the inspection and found that during this period four signatures to confirm that the medicine was given as prescribed were missing. The Registered Persons must ensure that the appropriate medication procedures are carried out at all times. The examined service users’ files contained records of correspondence and good liaison with other health and social care professionals. The service users were well and comfortable at the time of the inspection. One person, who was recently discharged from the hospital was agitated at times and received the appropriate attention from the management and the staff on duty. The service users had the keys for their bedrooms if assessed as safe and their privacy was respected. A curtain used to divide the beds in the shared accommodation had been put up since the previous inspection. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 and 15. Food related record-keeping remained unsatisfactory. The lack of organised external activities remained evident. The home encouraged service users’ contact with their families and friends. EVIDENCE: The service users who spoke to the inspector were generally satisfied with the care in the home. However, they expressed their wishes to go out and have more organised entertainment. This was congruent with the findings of the home’s own satisfaction survey. The home had an activities coordinator who worked fifteen hours a week. Weekly activities plans were available, but it was not clear if the activities actually took place, who participated and what was actually done. Despite the requirement being made at the previous inspection, regarding service users being given opportunities to engage in activities outside of the home, none have been arranged since the previous inspection. The requirement was repeated. This inspection happened a week before Easter. On the inspector’s question what was organised to celebrate the Easter, the Registered Manager replied: “Nothing special”. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 14 The Registered Manager stated that the activities coordinator took the service users to the places of worship if they wanted to go. The home also encouraged service users’ contact with their relatives and friends. The visitors-log was appropriately kept. One service user showed her collection of flowers that she got for the mother’s day from her family. She particularly liked natural flowers decorated with glitz. She was also very fond of red roses that were made specially for her by her friend. The inspector was told that the family of a Hindu resident took her to the temple when she wanted to go. The examined service users’ files were somewhat confusing regarding the individual risk assessments. Different, although concurrent related records were found in different sections of the files. The inspector recommended that the individual risk assessments are reviewed and put together in one place. The inspector visited the kitchen. The hood-extractor above the cooker was dirty despite the related requirement being made at the previous inspection. The cleaning schedule was available and showed that it was last time cleaned almost two months before this inspection. The related requirement was repeated. Although the menu records have improved since the previous inspection, the overall food related record-keeping has worsened. The fridge and freezer temperatures and the cooked meat temperatures were not recorded as regularly as required. The Registered Persons must ensure that all food related records, such as temperatures of fridge/ freezers and cooked meat are kept as required. The inspector also noted that some perishable food including meat products was stored in the fridge without being labelled and dated when the pack was opened. The Registered Person must ensure that the opened packages of perishable food are stored labelled and dated. Some service users commented that they did not enjoy the food in the home, while the others told the inspector that they did enjoy it. The home provided gluten-free food for one service user. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home had the appropriate policies and procedures for dealing with complaints and potential protection issues. EVIDENCE: The home had an appropriate procedure for dealing with complaints and the complaints-log was available for inspection. According to records, there have been no complaints raised with the home since the previous inspection. An old complaint that had adult protection implications have been discussed with the management of the home. The Registered Manager provided staff training on Protection of Vulnerable Adults. As he stated that he himself attended the related training three years ago, the requirement was made for him to update his training on this subject. The policy and procedure on Protection of Vulnerable Adults, how to recognise potential abuse and what to do in case of an allegation being made has been amended since the previous inspection and encompassed multi-agency working. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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, 20, 23, 24 and 26. The environment was clean and fit for its purpose. EVIDENCE: The environment was very clean, tidy and well maintained at the time of the inspection. The management has dealt with all the requirements related to the environment identified at the previous inspection. The service users were comfortable in the communal areas and satisfied with their individual space. Their bedrooms were personalised in accordance with their wishes and interests. The inspector was informed that some areas of the home have had new carpets fitted since the previous inspection and an industrial carpet shampooer was bought. The waste was appropriately managed. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 17 Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Service users were protected by the home’s staff related procedures. EVIDENCE: There were two staff on duty and a cook at the time of the inspection. The Registered Manager and the Responsible Individual were supranumery. The duty roster was displayed in the office and indicated two care staff on duty at all times. A cook, an activities co-ordinator and a cleaner were deployed in addition to the care staff. The inspector viewed the staff files for three staff members including the most recently employed one. The documents seen indicated that the home’s recruitment procedure was thorough. The files contained the application forms, references, identity checks and Criminal Record Bureau Disclosures. The Registered Manager stated that out of twenty staff, eight have completed National Vocational Qualification in Care and eleven care staff were in process of doing so. The home kept individual staff training records, but the training strategy and the plan were not available at the time of the inspection. However, this document was forwarded to the inspector, a day after. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The home was not always run in the best interest of the service users. Ten breaches of legislation were identified at this inspection, including four restated ones with the targets expired. EVIDENCE: The Manager was registered with the Commission. He had many years of experience in the care field. He is a Registered Nurse (Mental Health) and also has a qualification in teaching and assessing (ENB 998). However, he was still working on the Registered Managers Award (including NVQ level four in Management) and the requirement was made that the qualification in achieved by the end of July 2006. The inspector was disappointed and concerned that four requirements had to be restated from the previous inspection. The care planning and food safety records were particularly poor. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 20 Standard 35 relating to service users’ money was assessed as partly met due to lack of the related information available through the home’s care planning system. There were some other issues in relation to records keeping, such as the records being unavailable because they were outside of the home at the time of the inspection. This included minutes of the staff and the service users’ meetings. The last staff meeting’ minutes available were dated 02nd of December 2006. The satisfaction survey results were also not available at the time of the inspection, although they were brought to the Commission’s office a day after. The Registered Persons must ensure that the home’s procedures regarding record-keeping are fully implement and that the required records are securely kept on the premises at all times. The home is a member of the National Care Homes Association. The Responsible Individual took keen interest in the running of the home and visited it on a regular basis. Regulation 26 reports were available at the home and were also sent to the Commission on a monthly basis. Staff supervision records indicated regular supervision. All examined health and safety records were in date, including a gas-certificate that was outstanding at the previous inspection. Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 2 3 Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 22 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 OP1 Regulation 4 Requirement The Registered Person must ensure that an up-to-date Statement of Purpose that is complaint with the Care Homes Regulations, Schedule 1 is made available in the care home. The Registered Person must ensure that an up-to-date Service User’s Guide written in plain English or other appropriate language is made available to the prospective and current service users and their relatives. The Registered Persons must ensure that each service user has an individual care plan agreed that identifies all the care and support needs of that individual and how they are going to be met by the home. The previous target expired. The Registered Persons must ensure that the appropriate medication procedures are carried out at all times. DS0000028357.V288256.R01.S.doc Timescale for action 31/07/06 2. OP1 5 31/07/06 3. OP7 15 31/07/06 4. OP9 13 14/04/06 Haven Lodge Version 5.1 Page 23 5. OP12 16 The Registered Persons must ensure that service users are given opportunities and supported to engage in the activities outside of the home. The previously agreed target expired on 31/12/05. 31/05/06 6. OP15 16 The Registered Persons must 30/04/06 ensure that all food related records, such as temperatures of fridge/ freezers and cooked meat are kept as required. The previously agreed target expired on 31/12/05. The Registered Person must 14/04/06 ensure that the opened packages of perishable food are stored labelled and dated. The Registered Persons must ensure that all parts of the kitchen (including the hoodextractor above the cooker) are kept clean and that the records are available to confirm that. The previously agreed target expired on 31/12/05. The Registered Person must have an up-to-date training and knowledge on Adult Protection and fully implement the appropriate procedures at all times. The Registered Person must hold an appropriate qualification in management. 30/05/06 7. OP15 16 8. OP15 16 9. OP18 13 31/07/06 10 OP31 9 31/07/06 Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 24 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 OP5 Good Practice Recommendations The inspector recommended that the prospective service users visit the home, as well as their relatives, before moving in. The inspector recommended that the individual risk assessments are reviewed and put together in one place. 2. OP14 Haven Lodge DS0000028357.V288256.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 DS0000028357.V288256.R01.S.doc Version 5.1 Page 26 - 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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