Inspection on 17/08/05 for Havenfield Lodge

This inspection was carried out on 17th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Havenfield Lodge 04/10/06

Havenfield Lodge 19/01/06

Havenfield Lodge 01/02/05

Havenfield Lodge 01/09/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Havenfield Lodge Highfield Road Darfield Barnsley S73 9AY Lead Inspector Sue Stephens Unannounced 17 August 2005 09:30am - 4:00pm 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. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Havenfield Lodge Address Highfield Road Darfield Barnsley S73 9AY 01226 753111 01226 757483 None Sun Healthcare 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 Donna Yvonne Holmes N Care home with nursing 43 Category(ies) of PD Physical disability (43) registration, with number LD Learning disability (43) of places Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st February 2005 Brief Description of the Service: Havenfield Lodge provides nursing and personal care and accommodation for adults with physical or learning disabilities. The home is located in the Darfield area of Barnsley, close to the countryside and within easy access to local shops, a church and public house. The building has two levels with lift access to the first floor, there are ramps and handrails stiuated around the home and easy access to the gardens. There is an enclosed well maintained garden at the centre of the building, this has been designed for people with sensory needs. All bedrooms are single, two with en-suite facilities. Communal rooms are spacious and suitable to accommodate wheelchair users. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 and 1/2 hours, between 09:30am and 16:00 pm. An inspection of the premises was carried out. Consultation with residents, one relative, student nurses, staff and the manager took place. Samples of records, including three residents’ records, were checked. Ten residents were consulted, either individually or in small groups; and observations were made of the resident’s daily routines, and their relationship with staff and the manager. Staff were observed carrying out their duties. An additional visit took place on 11.07.05 following a complaint received by the commission, records were checked and the manager and operations manager were interviewed. The complaint was unsubstantiated, however the home had improved information and recording systems as an outcome of the complaint. An application to increase bed numbers from 41 to 43 has been accepted by the commission. Two rooms have been provided with en suite facilities, the manager said the rooms are intended for rehabilitation purposes. The residents, relative, staff and manager are thanked for the welcome and their assistance during this inspection. What the service does well: Residents and a relative consulted were happy with the care provided; assessments and plans of care were well carried out, and confidentiality was respected. Opportunities were available for leisure, and activities and outings were provided regularly. Resident’s wishes about activities were respected and efforts were made to meet different needs and preferences. Residents were treated with respect; identified limitations on freedom of choice was recorded, and residents given encouragement and support. Residents said they were satisfied with the meals and choice of snacks offered, meals were nutritional and plentiful. Staff were caring and flexible in their approach, they listened to residents wishes and understood residents needs. Complaints and concerns were acted up on and adult protection procedures were followed where risk of harm was suspected. The home was clean and comfortable; residents said they were satisfied with the environment, their own rooms and the furniture and fittings. Excellent training opportunities were provided for staff and the home had achieved 100 of care staff with national vocational qualifications in care. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 6 Staff were positive and professional in their approach. There were good leadership and management systems in place. Student nurses said the home provided them with good care practices to follow, and a good induction and training package, which fitted well with their training requirements. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI 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 Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI 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 The home was efficient at identifying resident’s needs; and their needs were regularly reviewed to reflect changing needs. EVIDENCE: The assessments checked included the homes own assessments and assessments carried out by external agencies. The assessments had been reviewed and plans of care had been developed to reflect reassessed and changing needs. The homes own assessment tool was adequate; however some good practice improvements were discussed with the manager. (See recommendations for standard 2) One relative said they were satisfied with their family member’s assessments and felt staff recognised and understood the residents needs well. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI 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) 6,7,9 and 10. Resident’s needs were reflected in the care plans, however improvements are needed to reflect individuals personal goals, preferences and assessed risks. Personal and confidential information was handled appropriately. EVIDENCE: In the main, the plans of care checked contained well-recorded and relevant information. They reflected assessed needs, focused on positive outcomes, and included personal care and health care needs. Specialist requirements, for example from psychology and multi disciplinary team outcomes were included in the plans and staff were aware of these. Plans of care had not been developed using a person centred approach and did not include resident’s preferences in each plan, however one staff member had been allocated to review and update the design. Some records were not up to date, for example dental and optician visits and the outcome; one care plan did not contain daily records to reflect the requirements of the plan of care. Individual’s risk assessments were insufficient to reflect the activities and needs of the individual, for example escorted and unescorted outings, hobbies and personal choices. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 10 Residents and a relative said they felt confident that staff understood how to handle personal information confidentially. The manager and staff interviewed demonstrated that they had good values and understanding about maintaining confidentiality. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 11 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) 13,14,15,16 and 17 Residents were supported to be part of the community, partake in leisure activities, and maintain family and friendship links. Their rights were respected, and they were provided with nutritious and enjoyable meals. EVIDENCE: Leisure opportunities were provided; these included regular outings for example shopping, pubs and meals. Activities at the home included cooking and bingo; and support was provided for residents to have holidays and daytrips. The manager and staff said residents were offered opportunities to participate in activities, however they recognised that some residents preferred not to, and this was respected. The relative acknowledged that the home tried hard to offer a variety of activities to suit people’s different needs. Residents said families and friends were supported and made welcome at the home. Residents consulted said they felt they were treated with respect, and they could choose how they spent their day. Restriction on freedom of choice, for example drinking alcohol on the premises, was discussed with relevant residents and recorded agreements kept available in the care plans. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 12 The manager was noted to be fair and thoughtful towards residents who had limitations on freedom of choice. Residents were consulted about their meals and mealtimes. Residents said meals were tasty and plentiful and drinks and snacks were regularly offered. The relative confirmed this and said residents were never refused when they asked for extra drinks. Dietary needs were recorded in the plans of care including consultation and guidance from speech and language therapist for residents with specific needs. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 13 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 and 19 Residents said they were satisfied and happy with the care they received; this has resulted from good personal support and health needs being monitored and met. EVIDENCE: Residents consulted all spoke positively about the care they received, they were happy with the care staff and nurses and said staff listened and took action if they said they felt unwell. Care plans demonstrated that access to NHS healthcare facilities, and other specialist services was sought following assessing and identifying individual needs. One resident and their relative gave positive feedback about the care at the home. They said staff were very caring and flexible with what the resident wants. They felt listened to and said staff always considered their views. Comments about care included “I cannot speak highly enough of this place” “staff are very good at how they respond” and nursing care is “spot on”. Health Action Plans (Department of Health guidance) for residents with learning disabilities had not yet been implemented; advice and information was given to the manager. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 14 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) 22 and 23 Havenfield lodge was proactive in protecting residents. Concerns and complaints could be raised and the home took action to address these; adult protection procedures were followed when it was identified that residents could be exposed to possible harm or risk. EVIDENCE: Residents said they could raise concerns with the staff or manager and action would be taken, residents consulted said they felt confident about this and found the manager and staff very approachable. The relative confirmed this and said staff were always prepared to listen and solutions had always been found to any concerns or queries raised. One staff member was consulted about the complaints procedure, and demonstrated that she understood what action to take. Adult protection procedures were in place. Local authority protection procedures were followed effectively by the home following an incident; records were maintained and action to safeguard individuals had been carried out. The manager continued to monitor this closely and said good progress had been made. An additional visit took place on 11.07.05 following a complaint received by the commission, records were checked and the manager and operations manager were interviewed. The complaint was unsubstantiated, however the home had improved information and recording systems as an outcome of the complaint. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 15 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) 24,25,26,27,28,29, and 30 Havenfield Lodge was comfortable and clean; the residents said they were satisfied with the environment and their own rooms. Some resident’s rooms need to be improved to maintain good hygiene and safety standards. EVIDENCE: The home was clean and well decorated, residents said they were happy with the environment, furniture was comfortable and some residents said they appreciated the new décor, as this was bright and looked better. The home had its own transport and the gardens were well maintained and accessible to wheelchair users. One visitor stated that an additional quiet room would be useful for residents to meet guests, if they preferred not to use their own rooms. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 16 Four bedrooms were checked in detail. Two of the bedrooms were well furnished, the residents said they had chose the décor and furnishings and they had everything they wanted in their rooms. The two other bedrooms checked were basic in furnishings and the décor was worn and discoloured, one room had damage to the wall near the bed, and the bed had a metal framework, which was rusted. The manager said new décor and furnishings had been offered to residents, some residents had stated they did not wish their rooms to be disturbed. Bathrooms and toilets were clean and well maintained; one room was in the process of repairs and redecorating. Some bathrooms and shower rooms were without low mirrors, this was not suitable for wheelchair users. The Kitchen was commercial in scale and residents did not access the area. Adaptations and equipment were provided based on residents assessed needs, residents were invited, when their equipment was due for renewal, (for example beds, mattresses and chairs) to contribute towards high quality and top of the range goods of the resident’s choice. Residents and family consulted said they were satisfied with these arrangements. The laundry was well maintained and infection control procedures were in place. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 17 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) 31,32,33 and 35 Havenfield lodge had an effective staff team, residents benefited from well trained and supported staff. EVIDENCE: Residents spoke highly of the nurses and care staff and said they were friendly and responsive. A resident’s relative said Havenfield had a good staff team. The manager confirmed all staff had National Vocational Qualification in care at level two or above, new starters were automatically enrolled on to the training and cooks and cleaners were provided with the relevant NVQ training. Residents and a relative said staffing levels were sufficient and the manager said there was a good pool of bank staff. One to one support was provided for residents with specific assessed needs and these were provided in addition to existing staffing levels. One staff member said training opportunities were good, this was reflected in the training records and the manager maintained good training links and resources. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 18 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) 37,38,40,41 and 42 Havenfield Lodge was well run; residents benefited from the homes good management and health and safety systems. EVIDENCE: The manager demonstrated good leadership skills; she understood the needs of the residents and the staff team well; residents and staff said the manager was supportive and approachable. A relative commented that the manager was often seen checking what was happening in the home and was available when needed. Policies and procedures were in place; and records, in the main, were well maintained (see standard 6 for required improvements and standard 2 for recommendations). Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 19 Staff had received training in safe working practices and a training schedule was in place to keep staff updated. Fire protection procedures were carried out and servicing and maintenance of equipment and systems was up to date or renewals were arranged. Advice was given to improve fire practice drills, see recommendation). Environmental risk assessments were in place including radiators, which were not covered. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 20 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 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 4 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Havenfield Lodge Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 2 2 x J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 and 41 Regulation 13 and 17 Requirement Daily records of care provided must be kept up to date. Timescale for action 30.09.05 2. 3. 9 26 13 and 14 16,23 Health appointment records must be kept up to date. Risk assessments must be 30.09.05 carried out which reflect residents needs and activities. The two identified bedrooms 31.10.05 must be redecorated and suitable furnishings provided, this must be done in consultation with the residents. 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 2 Good Practice Recommendations The homes assessment tool should include, space for residents to sign, the residents preferences and all the areas highlighted in standard 2, (including accommodation and compatability with other residents). Person centred approaches should be introduced following appropriate training. Health Action Plans in line with government recommendations should be introduced. J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 22 2. 3. 6 19 Havenfield Lodge 4. 5. 24 42 Consideraton should be given to creating a quiet room/small lounge for residents and visitors. Fire drills should include using alternative escape routes, these should be recorded. Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 Havenfield Lodge J51 S6483 Havenfield V241633 170805 UI Stage 4.doc Version 1.40 Page 24 - 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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