Inspection on 27/06/05 for Haven Lodge Nursing Home

This inspection was carried out on 27th June 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.

Other inspections for this house

Haven Lodge Nursing Home 05/07/07

Haven Lodge Nursing Home 07/08/06

Haven Lodge Nursing Home 24/01/06

Haven Lodge Nursing Home 07/12/04

Haven Lodge Nursing Home 16/06/04

Haven Lodge Nursing Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Haven Lodge Nursing Home Reckitts Close Holland Road Clacton on Sea Essex CO15 6PG Lead Inspector Lysette Butler Unannounced Monday 27th June 2005 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 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 Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Haven Lodge Nursing Home Address Reckitts Close Holland Road Clacton on Sea Essex CO15 6PG 01255 435777 01245 475680 admin.havenlodge@careuk.com Care UK Community Partnerships Limited 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) Mrs Pauline Teresa Goh Care home with nursing 50 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Physical disability (26), Physcial disability of places over 65 years of age (26), Terminally ill (3) Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical illness (not to exceed 26 persons) 2 Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 26 persons) 3 Persons of either sex, aged 60 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) 4 Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) 5 Persons of either sex, aged 55 years and over, who require general palliative care (not to exceed 3 persons) 6 One person, under the age of 60 years, who requires care by reason of dementia, whose name was made known to the Commission in April 2003 7 The total number of service users accommodated in the home must not exceed 50 persons Date of last inspection 7 December 2004 Brief Description of the Service: Haven Lodge is a purpose built, two-storey nursing home set in its own grounds. It provides care for up to 50 service users. The home is divided into two distinct units. Lanemile Ltd owns Haven Lodge and is part of the national company Care UK. The home is situated in its own grounds, in a quiet residential cul-de-sac, approximately a mile and a half from Clacton town centre. The local bus services pass at the end of the drive and the railway station is in the town centre. The sea front is a short walk from the home. Speedwell, the first floor unit, cares for up to 26 service users over the age of 60 who require nursing care for a physical illness, or disability and includes up to 3 service users over the age of 55 who require general palliative care. Mayflower, the ground floor unit, cares for up to 24 service users over 60 who require care for a progressive mental disorder. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took five hours on one day in June 2005. Sixteen of the thirtyeight National Minimum Standards were inspected during this visit. It was found that many of the standards had been met or partially met. The overall care and well being of the residents was very good; staff and residents were welcoming and happy to speak to the inspector. During this visit the inspector spoke to four residents; three relatives/visitors; fourteen staff members including the administrator; one of the housekeeping staff; a kitchen assistant; two of the activities coordinators; three Registered Nurses and four care assistants. The inspector also spent time with the registered manager and her deputy. Documentation and care plans were reviewed. Completed resident and visitors survey forms were received by the inspector following the visit, but before this report was compiled. Residents and their relatives expressed satisfaction with the care they received and with the quality of the food offered. What the service does well: What has improved since the last inspection? Care plans are now regularly reviewed and comply with company policies and procedures. Personnel file layout had improved and all files reviewed during this visit were complete. Reference procedures had also improved. Adequate privacy curtains had been hung in the double rooms since the last inspection. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 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 Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 8 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 standard(s) 6. Intermediate care is not offered at this home. EVIDENCE: This home had recently accepted a resident for long-term assessment concerning falls prevention. The aim of the assessment was to consider the need for nursing care. However, whilst being assessed, the resident was attending rehabilitation outside of the home and a physiotherapist was visiting the home on a regular basis. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7 & 10. Health and personal care of residents was well documented. Privacy and dignity was considered in all interactions with residents. EVIDENCE: All evidence examined during this inspection illustrated that residents’ health and personal care needs were well cared for. Care plans throughout the home were generally good and there had been significant improvement in the care documentation on Mayflower. Care plans throughout the home were regularly reviewed and there was evidence of appropriate changes made to care as needed. Care UK policies and procedures were being followed. Recent Regulation 26 documentation evidenced company assessments that the staff of Haven Lodge were now meeting the company standards of care planning. Copies of Care UK best practice guidelines were now in the front of each of the care plan folders and included a list of what documentation should be included. Daily records had improved throughout. The documentation regarding funeral arrangements is still ’patchy’ on both units. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 10 During this visit the inspector spent time in the lounge areas of the home observing the interactions between residents and staff; talking to residents and staff and all interactions demonstrated a good understanding of the needs of the residents, allowing them to be treated with dignity. New dignity curtains for shared rooms had been received and fitted at the time of this inspection; the curtains were approximately six inches short of the floor and opaque. Residents and visitors spoken to all stated that the staff were “caring”, “helpful”, “nice” and respected service users’ privacy in all aspects of care. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 & 14. Residents were enabled to have control over their daily lives and were offered appropriate activities. EVIDENCE: This home employs two part-time activities coordinators who work a total of 36 hours between them. Each one worked predominantly on one of the units, however they also worked together to give the best service to the residents. During this visit the inspector spoke to both the coordinators who worked together for some of the week. They sometimes worked for the home in their own time to ensure that all residents take part in activities of their choice. Some of the activities arranged combined residents from both units; these joint activities were popular with all the residents who take part. They arranged fund raising activities to finance further activities for the residents. The coordinators had attended short courses on activities specifically for residents with a dementia, run by Care UK. The coordinators had started to use one of the techniques taught during this session with some success. However, neither of the coordinators had been on a specific dementia course. This was discussed with the coordinators and the manager during this visit, who stated that there were more coordinator hours accounted for in the new business plan/budget for the home. There had been a recent trip to Colchester Zoo that had been very popular. Some of the residents spoken to during this visit had attended the trip and said that they had really enjoyed getting out of Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 12 the home and the staff helped to make it a fun day. Documentation was generally poor partly because of the lack of available hours. There was good contact with the local community and visitors were always welcome. Those visitors spoken to said that they were always offered a drink on arrival and a meal if they were there during main meal times. Visitors and residents in the local community were encouraged to attend events in the home. The week following this visit the home was holding an ‘Alternative Therapies’ day open to all. The local paper had published an article about the day in the previous weeks edition. All residents were on the electoral register and some had been enabled to vote in the recent general election. None of the residents were looking after their own financial affairs. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 13 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 standard(s) 18. The protection and complaints procedures in the home were good ensuring the residents were safe. EVIDENCE: The protection and rights of the service users was observed to be inherent in the way the staff acted. There had been one allegation of abuse since the last inspection, which was not proved, but was well handled by the manager of the home. The lead inspector was kept informed throughout and details are on file at the local offices of the Commission for Social Care Inspection. There had been no Protection of Vulnerable Adults referrals since the last inspection, but one registered nurse had been referred to the Nursing & Midwifery Council conduct committee. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26. The environment of this home is suitable for this group of residents. EVIDENCE: All areas of the home were toured during this visit. There had been no change to the fabric of the building since the last inspection. New carpets were on order for the first floor corridors and communal areas; carpets in residents’ rooms were being replaced as required. There was evidence of ongoing decoration being carried out as necessary, but the home as a whole would benefit from a structured re-decoration throughout. The grounds are accessible by all the residents and contain the smoking area for the home. During this visit the weekly fire alarm testing was undertaken. Maintenance records checked were up to date and detailed. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 15 The communal areas were well used and suitable for their purpose. Storage areas were well utilised. Both sluices were clean and tidy at the time of this inspection. All rooms contained nursing beds with a variety of mattresses in use dependant on the dependence needs of the resident. Various equipment for the prevention of pressure sores was in use throughout the home and there was only one resident with a pressure sore at the time of this inspection. Hoists were observed in use and servicing was up to date. The home was clean and odour free throughout. The day of this visit was very warm but the home was light and airy; most windows were open and some of the residents were sitting in the grounds. Staff stated that they had regular infection control updates; hand washing and MRSA instructions were observed prominently displayed in staff areas. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. Staffing numbers and skill mix generally ensure that the residents’ needs are met in this home. EVIDENCE: Staffing levels were adequate at this home with an even balance of care staff and Registered Nurses. Staff spoken to stated that the management of the home were quick to respond to shortages of staff due to sickness, annual leave, etc. They felt supported and said that extra staff were brought in as necessary, especially for the regular GP visits on a Monday when an extra registered nurse was on duty. A registered nurse leads all shifts on both floors. Residents and visitors spoken to said that staff were “all lovely and very helpful”. “I think the staff are very caring and do a wonderful job. I’m very pleased with the home.” Four personnel files were reviewed during this visit and they were all found to be complete, up to date and tidy. There had been a noticeable improvement since the last inspection. References were regularly double checked; if a verbal reference was accepted this was followed up with a written version from the referee. Both the notes from the verbal reference and the written one were kept in the individual’s personnel file. The inspector and manager discussed registered nurses Personal Identification Number checks, which should be carried out more frequently. The inspector also suggested that the manager might wish to complete these checks on-line to speed up the process. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 17 Staff stated, “lots of training is offered”. The training matrix showed that most staff were up to date with manual handling training, but there were some staff who still required other statutory training. There was a planned ‘mop up’ session of statutory training being offered a few days after this visit for these staff. Residents thought that the staff were well trained and they felt safe. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 & 36. There is good teamwork in this home, but this could be improved, for the benefit of the residents, by better supervision procedures. EVIDENCE: The staff worked well as a team and supported each other. Residents said that staff were “supportive of each other, which benefits us.” One care assistant commented that she didn’t mind helping out on either floor, “after all we are one home.” Staff tended to cover each other’s shifts if they could to minimise the use of agency staff. Although there were frequent staff meetings at the home some care staff were confused about what supervision is and did not have one to one sessions on a regular basis. (This was most pronounced on Speedwell.) However, there was documentary evidence that some staff on Mayflower had been having supervision. The manager was clear what was required by the standards. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 x x x 2 x x Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 20 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 12 Regulation 14(1a) Requirement The registered manager must arrange for the activities coordinators to attend courses in activities for residents with a dementia. The registered manager must review the activities coordinator hours, with a view to increasing the number of hours available for the fifty service users. (Timescale of 31/3/05 not met.) The registered manager must ensure that all staff have regular supervision. (This would normally be on at least six occasions each year.) Timescale for action 31st December 2005 31st December 2005 2. 12 16(2m-n) 3. 36 18(1-2) 31st December 2005 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. 2. Refer to Standard 12 29 Good Practice Recommendations The registered manager should ensure that activities are properly documented in the individual resident care plans. Qualified nurse Nursing & Midwifery Council Personal Identification Numbers should be checked on a regular basis by the manager, not just on starting and when next I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 21 Haven Lodge Nursing Home 3. 36 due. The registered manger should ensure that all staff have an understanding of what supervision is and what the expectations of this standard are. Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 1st Floor, Fairfax House Causton Road Colchester Essex, CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haven Lodge Nursing Home I56-I05 S15324 Haven Lodge Nursing V235363 270605 Stage 4.doc Version 1.40 Page 23 - 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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