This inspection was carried out on 5th July 2005.
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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOME ADULTS 18-65
Haven Lodge 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY Lead Inspector
Sharon Rosenfeld Unannounced 5 July 2005 @ 09:15
th 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 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 Stationary 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 C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Haven Lodge Address 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY 0115 962 1675 0115 910 9879 Telephone number Fax number Email 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 Mr Wesley John Stala Care Home - Private 11 Category(ies) of MD - Mental Disorder 11 registration, with number MD (E) - Mental Disorder over 65 3 of places Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1, The 3 named service users should be accommodated within the establishment. 2, A Variation must be submitted to CSCI for any additional out of category service users. Date of last inspection 08th March 2005 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. and a variety of communal facilities 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 C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. 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. The proprietor was not present at the inspection. He had accompanied three residents on holiday to Spain. One resident, over 65 years of age was transferred to a local nursing home. What the service does well: What has improved since the last inspection?
The requirements set at the inspection on 8th March 2005 have been achieved. Self-medicating residents are monitored to ensure compliance with taking prescribed medicines. The call bells have been fitted to toilets and bathrooms used by the older residents. Additional appropriate heating has been supplied to the ground floor. Two written references had been obtained for the newly appointed staff member and monthly emergency lighting checks have been undertaken. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 standard(s) 2 Care Management Assessments are undertaken prior to admission and there is close collaboration between the local Mental Health teams and the home to determine levels of need. EVIDENCE: New residents needs are properly assessed and planned for prior to admission. There is a record of needs assessments on all of the files seen. The staff are aware of the needs of the residents. He homes own needs assessment is comprehensive and covers all of the required areas. (See National Minimum Standards 2.3). The home works closely with the local Mental Health Teams and there are seven people whose assessment of needs is integrated with the Care Programme Approach. (CPA) Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 standard(s) 6, 7. The Assessments of need are translated into a care plan to ensure that the health care needs of residents are identified and met. Residents make decisions for themselves with support if necessary. EVIDENCE: The care plans for the younger adults accommodated are written following a comprehensive needs assessment. This does not only cover problems but identifies positive aspects of, for example, their mental disorder. The care plans should be reviewed every six months or sooner if necessary. The care plan of one person who had been living at Haven Lodge for over a year had not been evaluated within these timescales. Suggestions are made for the management of cognitive problems and include details of supportive social and personal relationships. The resident’s view of need is also documented and this is good practice. A discussion took place between a resident a staff member of the inspector. The relationship between the staff and the resident was very positive and respectful. The resident clearly made decisions for himself and was guided and supported by the care staff.
Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16, 17. The residents plan their own social arrangements wherever possible and attend activities and resources in their community if they wish. The home could not demonstrate that meals are nutritional and balanced although the residents stated they enjoyed the food prepared. EVIDENCE: Social, recreational and educational activities are planned and supported on an individual basis and according to the wishes of residents. Some people are not motivated to attend these activities and it is the staff’s responsibility to ensure that up to date information is available on a broad range of activities that can then be discussed with people individually. Two residents talked about the resources they use everyday in their local community. They use public transport confidently and plan how they spend their own time, with support and encouragement of the staff. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 11 Discussions with one resident showed that existing relationships are encouraged if this is what the residents want. People are welcome to visit the home at all reasonable times. The daily routine is flexible and is influenced by the residents themselves. Some people have a key to their room and to the front door. People take some responsibility for housekeeping tasks. There are rules on smoking, the use of alcohol and drugs on the premises. Two people said they really enjoyed the meals prepared however the home do not consistently follow the menu and do not keep records of alternative meals provided. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The residents right to privacy and to exercise control over their lives is supported EVIDENCE: The residents feel supported by the staff and free to make choices and decisions for themselves. One resident confirmed that staff respect their preferences but do offer support and guidance when necessary. The home needs to be clear about how it will manage ageing, illness and death. This should be discussed with the two residents who are approaching this transition so that their wishes can be determined and the home can be clear about the limits of the services it can offer. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 standard(s) Not assessed on this inspection. EVIDENCE: Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 standard(s) 24, 26 The home generally provides a safe, comfortable and homely environment in which to live. EVIDENCE: Haven Lodge provides a comfortable and homely environment. One resident said he was very happy with his room and took great pride in arranging his belongings and furniture. Although he was not concerned that he didn’t have a mirror above his sink it is recommended that fixtures such as this be provided in all bedrooms. One resident was disappointed about a previous decision by the regulatory authority to replace strip lighting with domestic style lighting. The dim lighting affected his ability to participate in games and other activities. The registered person must ensure that the domestic style lighting meets the needs of the residents. Advice should be sought from a qualified electrician about ‘pendant’ style fittings in the bathrooms and shower rooms. These should be replaced with sealed units. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The procedures for the recruitment of staff are not robust and do not offer adequate protection to people living in the home. EVIDENCE: The staff file of the newest staff member was seen. This person commenced work before the Criminal Records Bureau (CRB) Enhanced Disclosure was received. The Registered Person must obtain up to date guidance regarding CRB’s and recruitment of staff. Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed on this inspection. EVIDENCE: Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x 3 x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Haven Lodge Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 18 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. 2. Standard 24 17 Regulation 23 17 Timescale for action The lighting in the home must be 30/09/05 bright enough for residents needs. A record must be kept of the 02/07/05 food provided to demonstrate that the diet provided is satisfactory and meets individuals assessed needs. New staff must not commence 02/07/05 work before an up to date CRB has been received. Requirement 3. 34 19 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 Good Practice Recommendations Haven Lodge C03 C53 S2232 Haven Lodge V236249 050705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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
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