Inspection on 31/01/06 for Haven Lodge Care Home

This inspection was carried out on 31st January 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven Lodge Care Home 11/02/09

Haven Lodge Care Home 18/12/06

Haven Lodge Care Home 05/07/05

Haven Lodge Care Home 08/03/05

Haven Lodge Care Home 07/12/04

Haven Lodge Care Home 04/03/04

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

CARE HOME ADULTS 18-65 Haven Lodge Care Home 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY Lead Inspector Sharon Rosenfeld Unannounced Inspection 31st January 2006 09:00 Haven Lodge Care Home DS0000002232.V283415.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 Care Home DS0000002232.V283415.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 Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Haven Lodge Care Home Address 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY 0115 962 1675 0115 910 9879 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) Mr Wesley John Stala Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 3 named service users be accommodated within the establishment. A Variation must be submitted to CSCI for any additional out of category service users. Date of last inspection Brief Description of the Service: Haven Lodge is a three storey converted, semi-detached building, offering accommodation for 11 service users with mental health problems, 2 of whom are now over 65 years of age. (The registration has been amended to reflect that these individuals can be accommodated for as long as their needs continue to be met).The care home accommodation is on two floors, and there is no lift access to the second-floor, this may pose difficulties for persons with physical mobility problems. There are 11 single bedrooms now that the double room has been converted to provide two single bedrooms. A variety of communal facilities are also provided. There is a garden area to the rear of the building and paved area to the front of the building. The home is situated in a mixed residential and office area, a short distance from the city centre. There are good transport links in the area. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report needs to be read in conjunction with the report of the unannounced inspection 05/07/05 to gain a broader picture of the service. This unannounced inspection took place over half a day. The focus was upon key standards and to review progress made in relation to the inspection requirements made at the last inspection. What the service does well: What has improved since the last inspection? The registered manager has ensured the introduction of more robust procedures for the recruitment of staff. A number of staff training courses have been identified that are relevant to the work that carers undertake. Haven Lodge Care Home DS0000002232.V283415.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 Care Home DS0000002232.V283415.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 Care Home DS0000002232.V283415.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): EVIDENCE: National minimum standard 2 was assessed and met at the last inspection. Haven Lodge Care Home DS0000002232.V283415.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): 9 Resident’s potential for independent living is promoted within a risk management framework. EVIDENCE: National minimum standards 6 and 7 were assessed as met at the last inspection. The residents spoken with confirmed that as far as possible they are supported to make choices and decisions for themselves. Staff provide discrete support to those who require it. They also routinely offer choices and encourage residents to become involved in the day to day running of the home if they wish. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 10 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): 17 The home could not demonstrate that daily meals are nutritional and balanced although the residents stated they enjoyed the food prepared. EVIDENCE: Positive comments were made by residents’ spoken with regarding the home cooked meals provided. A menu is not followed and no records are kept to confirm that the residents are provided with a nutritionally balanced diet. This requirement remains unmet from the previous inspection. The dining room is attractive and welcoming. Meal times are appropriately spaced and there is flexibility to accord with residents’ preferences. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 11 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, 20 Arrangements are in place to ensure that the residents healthcare needs are met through local GP surgeries and mental health teams. Not all staff are confident in their knowledge of residents healthcare needs and how they are to be met. EVIDENCE: Residents’ are supported to access mental health care support. Physical health care is accessed via the local GP Practice and the resident’s are receiving a comprehensive health care service. One resident who self injects insulin attends a specialist diabetes clinic regularly. One staff member was not however aware however of the number of people who have a diagnosis of diabetes. This staff member did not know where the stocks of insulin were stored. A reminder of the emergency management of one person’s diabetes is displayed in the kitchen. Staff need to be confident in their knowledge of the residents heath care needs and well informed through training and guidance about the management of illnesses such as diabetes. Some people receive medical consultations in private, others require the support of the staff. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 12 Medicines are stored within a locked cupboard. The medicine cupboard was tidy and well ordered. The medicines are placed in named pots and taken to the residents in the dining room. This practice does not meet with the guidance provided by the Royal Pharmaceutical Society for the management and administration of medicines in care homes. Medicine Administration Records were inspected and indicated a good standard of recording. Some services users can and do self –medicate in accordance with documented risk assessments. One service user requires more careful monitoring as he does not always take his prescribed medication and has hoarded it in the recent past. The staff responded appropriately to this when it was discovered and sought medical advice. It is recommended that this monitoring be documented within Risk Assessment / management plans. The medication chart must only be signed once the staff are satisfied that the resident has taken the medication. There is a separate policy and procedure file maintained for medication issues. Some staff are administering medication without first receiving relevant training. Only staff who have received appropriate training can administer medication to the residents. It was reported that a certificated course has been identified for all staff to attend in the near future . Haven Lodge Care Home DS0000002232.V283415.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): 22, 23 The complaints procedure ensures that concerns will be handled properly and within appropriate timescales. A casual approach has been taken toward the management of residents finances which did not guarantee accountability or protection. EVIDENCE: The home has a complaints procedure with appropriate timescales for investigation, which is displayed in the home and included in the “welcome pack” for prospective service users and their representatives. No complaints have been made under the complaints procedure. There is an appropriate adult protection policy with links to the approved local procedures and the whistle blowing policy. The registered manager does support some people to manage their finances. The record keeping for this was not satisfactory. There is no reliable audit trail of receipts and expenditure. Service users money was not managed separately but kept by the manager with his own personal finances and returned to them on request. An immediate requirement was made to establish a reliable and transparent system to manage service users finances whenever the registered manager or other staff handles them. Haven Lodge Care Home DS0000002232.V283415.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): 24, 30. The accommodation provides comfort to residents. The lighting in the communal rooms is not bright enough for residents needs. EVIDENCE: The premises are homely in style and décor, and are generally well maintained. Areas seen were clean and tidy, and no unpleasant odours were noticed. It was confirmed that the lighting in the dining room is still too dim to meet the needs of all the residents. The registered person must ensure that the domestic style lighting provided is bright enough. There is a domestic style laundry room with a washer and dryer. A lockable facility in this room is used to store hazardous substances. Some substances had not been returned to the cupboard after use and therefore presented a risk. The infection control procedure is displayed in the laundry. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 15 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): 32, 34, 35. The procedures for the recruitment of staff have improved and are more robust which offers greater protection to residents. The staff are not receiving appropriate training. EVIDENCE: The files of four staff were seen and showed that the necessary recruitment checks had been made for the staff. Previous inspections have highlighted the need to have a more systematic approach to the planning of staff development. This remains a concern. There are no records to confirm that new staff receive an appropriate induction. Training in first aid, food hygiene and infection control are out of date. None of the care staff have attended mental health awareness training. The senior carers confirmed that this was discussed at induction however there are no records to confirm the content of this and when it took place. As previously mentioned, medication training is required before people take on this responsibility. There are plans for 6 care staff to enrol to do their NVQ 2 training. This plan must be implemented to ensure that care staff have the necessary competencies to meet the needs of the people in their care and so that the service can achieve the objectives within the provider’s statement of purpose. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. The risks associated with living and working in the building have not been fully assessed. The absence of a quality monitoring system means the registered manager cannot measure how well the service is meeting peoples’ needs. EVIDENCE: Training at the home has not kept pace with requirements. Six care staff are to be enrolled to undertake their NVQ 2 and the senior carer will enrol to undertake her NVQ 4. The registered manager’s progress in achieving the relevant NVQ 4 qualification or equivalent was not confirmed at the inspection. The current CSCI guidance is that where current registered managers did not achieve a combination of care and management qualifications by December 31st 2005 they should have registered and be working towards these qualifications unless there are particular individual circumstances that render this impracticable. Registered managers should have completed their qualification by September 30th 2007. This will be assessed at the next inspection. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 17 There are no structured quality monitoring systems in place to measure the success of the home in achieving it’s aims and objectives. The views of the residents and other stakeholders about the quality of the services provided are not routinely sought. The staff’s role does not include assisting people or objects to move therefore this training has not been provided. The registered manager does not keep records of assessments undertaken to identify environmental risks in the building for staff and service users and how they are to be managed. Emergency procedures to manage problems with gas, electricity and water supplies are in place. Infection control guidance is located in the laundry. The registered manager could not locate the records to confirm that steps are being taken to monitor and reduce the risk of legionella. The emergency lighting tests are not being undertaken on a monthly basis. Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 18 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 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 1 X 2 X 1 X X 2 X Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation 17 Requirement The registered manager must keep records of the food provided for residents in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory.(This requirement remains unmet from the inspection on 05/07/05) The registered manager must ensure that staff receive training and are clear about their role in the management of resident’s diabetes. The registered manager must ensure that staff receive appropriate training, and are competent in the management and administration of medicines before becoming responsible for undertaking this task. The registered manager must establish a reliable and auditable system of recording the management of resident’s money by any staff member. The lighting in the home must be bright enough for residents needs. (This remains unmet from the inspection on DS0000002232.V283415.R01.S.doc Timescale for action 20/03/06 2 YA19 13, 18 24/02/06 3 YA20 13, 18 31/03/06 4 YA23 16, 20 28/02/06 5 YA24 23 20/03/06 Haven Lodge Care Home Version 5.1 Page 20 05/07/05) 6 YA32 18 The registered manager must plan and arrange training to ensure the staff always have the necessary competencies to meet the needs of people in their care. This includes training in: First Aid; infection control; medication management and administration; adult abuse; food hygiene. The registered manager must ensure that staff receive an induction to their work at the home in line with the requirements of Skills For Care. The registered manager must establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered manager must establish and maintain a system for assessing the risks associated with living and working at the home. 31/03/06 7 YA35 18 31/03/06 8 YA39 24 31/03/06 9 YA42 13 31/03/06 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 YA20 Good Practice Recommendations The registered manager should implement the guidance produced by the Royal Pharmaceutical Society of Great Britain on the Management and Administration of Medicines in Care Homes. The registered manager should provide the CSCI with confirmation of his qualifications or his intention to achieve the relevant qualifications that are equivalent to NVQ4 in management and care. 2 YA37 Haven Lodge Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000002232.V283415.R01.S.doc Version 5.1 Page 22 - 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. 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