Inspection on 19/01/06 for Havenfield Lodge

This inspection was carried out on 19th 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Havenfield Lodge 04/10/06

Havenfield Lodge 17/08/05

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 South Yorkshire S73 9AY Lead Inspector Mrs Sue Stephens Unannounced Inspection 19th January 2006 14:45 Havenfield Lodge DS0000006483.V276037.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 Havenfield Lodge DS0000006483.V276037.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. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Havenfield Lodge Address Highfield Road Darfield Barnsley South Yorkshire S73 9AY 01226 753111 01226 757483 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) Sun Healthcare Limited Mrs Donna Yvonne Holmes Care Home 43 Category(ies) of Learning disability (43), Physical disability (43) registration, with number of places Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 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 situated 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 DS0000006483.V276037.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection; it took place between the hours of 2:45pm and 17:20pm. The inspector spoke to residents, two staff and the manager about the home. The inspector checked a sample of records and did a partial inspection of the building. The manager Donna Holmes assisted in the inspection. A CSCI employee Sharon Reading accompanied the inspector to gain knowledge of the inspection process. The manager agreed this before the inspection took place. The home was warm and welcoming, residents were carrying out their daily routines including outings or relaxing around the home and the staff were professional and friendly. What the service does well: Residents said they were happy and settled at the home. The environment in communal areas was well decorated and comfortable. Staff had a good understanding about the residents’ needs and residents enjoyed friendly and positive relationships with the staff. Residents had their needs regularly reviewed, and their care plans were informative, they included resident preferences, action staff were to take and health needs. Person centred principles were being introduced. Staff supported and encouraged residents to make their own decisions and they could participate in the day-today running of the home if they wished. An activities co-ordinator provided support to residents in development, education, occupation, leisure and community participation. Residents received support to maintain positive friendships and relationships. The staff team were professional and caring, and residents said they could go to them with concerns. The home carried out good quality audits and used these to make improvements at the home. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 6 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 DS0000006483.V276037.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 Havenfield Lodge DS0000006483.V276037.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): 2 and 3 The residents’ had their needs assessed, and staff had the knowledge and understanding to meet individual needs. EVIDENCE: The inspector checked one care plan file. The resident had been assessed for their full needs; and the home had continued to review and identify any changes. Qualified nurses and care staff and student nurses made up the care team, they had a good knowledge and understanding about residents specific needs. This included learning disabilities and health and physical disabilities. Havenfield Lodge DS0000006483.V276037.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): 6,7,8 and 9. The Residents’ needs were reflected in their care plans; and the residents had good support from staff to help them make choices and decisions. Opportunities were available for individuals to be involved in the day-to-day running of the home. EVIDENCE: The care plan checked contained relevant information, this included action staff need to take, identified risks and the resident’s preferences. The care plan included monthly reviews. A nurse explained how person centred principles had started to be introduced into care plans. The inspector commended and encouraged this good practice. Through conversations with residents and staff the inspector concluded that the home encourages residents to make independent choices and decisions. Some residents decorated and furnished their own rooms, they chose how to spend their day, and staff supported them with friendship and relationships. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 10 Residents who were able to participate in the day-to-day running of the home were encouraged to do so. The inspector noted residents and staff discussing daily events and staff used appropriate communication to do this. Residents chaired their own meetings and the manager carried out surveys. This helped the manager get feedback about residents’ opinions on the day-today running of the home. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 the following standard(s): 11,12,13,14,15,16. There were good opportunities for personal development, education occupation and leisure. EVIDENCE: The home employed a full time activities co-ordinator. The co-ordinator was responsible for assessing the residents’ personal development, education, occupation, and social needs. The co-ordinator worked the hours the residents’ needed, for example evenings and weekends. At the time of the inspection some residents were on an outing; they were shopping and visiting the cinema. Other residents has structured programmes where they visited and helped on farms and participated in community activities. One resident said he was very happy and satisfied with the activities he was involved with. The home supported residents who attended college. And they provided specialist transport to assist residents to go out. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 12 The manager had a good understanding about how to support residents to help them maintain positive friendships and relationships. And she gave staff support and direction in line with the homes aims and objectives. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 the following standard(s): 18 and 19 A team of caring and professional staff provided good care to meet the residents’ personal and health care needs. EVIDENCE: Residents said the staff looked after them well. They said they were friendly and attentive and in the main available when they wanted them. The inspector noted good relationships between staff and residents. Staff were mindful about residents’ personal choices in personal care. For example, staff respected residents who wished to be left alone and worked around residents preferred routines. Staff understood about providing personal care in a dignified manner. The inspector noted that staff closed doors when assisting residents and they spoke to residents in a friendly and dignified manner. The care plan checked recorded the resident’s health care needs. Residents received support to access specialist services; for example mental health services, G.Ps and health care professionals. Staff escorted residents to attend appointments. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 the following standard(s): The homes complaints and protection procedures protected residents’ safety and welfare. EVIDENCE: Residents said they felt able to raise concerns if they needed, and the manager or staff would listen to them and take action. The manager had continued to provide adult protection training for staff and policies and procedures were accessible for guidance and reference. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 the following standard(s): 24,26,27,28,29 and 30. Residents were warm and comfortable and the environment was suitable to meet their physical needs. Better maintenance of some bedrooms and bathrooms will improve individual residents respect, dignity and comfort. EVIDENCE: Residents said they were comfortable and they were satisfied with their own rooms. The premises, in the main, were well maintained, the home was pleasantly furnished and decorated, and the manager oversaw the routine maintenance of the building. Wheelchair users had access to all areas of the building and aids and adaptations were provided, for example handrails, hoists and a passenger lift. A fire risk assessment and fire checks had been carried out which met local fire authority requirements. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 16 The inspector visited several bedrooms. Most of these were decorated and furnished to the residents taste and were very personalised. Some other bedrooms however were not satisfactory in décor and furnishings. One bedroom checked had old worn furniture and the décor was torn and dirty, the bedroom was sparse. The manager explained that there were six bedrooms left to refurnish, and that these were being done together with residents and their families. One toilet had a seat that was below acceptable standard for the residents’ comfort and dignity; and the flooring had exposed floorboards around the toilet. Some toilet and bathroom bins were soiled and dirty, and one bin did not have a lid. A hoist stored in a bathroom was dirty. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 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): 34 The residents’ safety and welfare was protected by the homes good recruitment practises. EVIDENCE: The inspector checked one recruitment file. The file was orderly and contained all the relevant information. A thorough recruitment check had been carried out. Systems were in place to check student nurses and the home liaised with the university to make sure students were suitable for the placement. The home carried out it’s own internal quality audits. The manager and area manager did these. The audits included surveys to residents’, family and professional for their opinions. Areas covered included meals, environment and finance. Provider visits had been carried out monthly and these were available at the home. The reports however had not been forwarded to the commission. The manager was advised about this during thee inspection. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 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 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): 39 Good self-monitoring practises take place at the home and they take into account residents and families opinions and wishes. EVIDENCE: The home carried out it’s own internal quality audits. The manager and area manager did these. The audits included surveys to residents’, family and professional for their opinions. Areas covered included meals, environment and finance. Provider visits had been carried out monthly and these were available at the home. The reports however had not been forwarded to the commission. The manager was advised about this during thee inspection. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 19 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 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X 2 X X X X Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 20 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 2 Standard YA26 YA27 Regulation 12,16,23 12,16,23 Requirement The six bedrooms must be decorated and furnished in line with the minimum standards The toilet seat must be replaced with a seat suitable to residents needs and of good quality. The toilet flooring must be replaced to cover the whole of the floor. The bins must be regularly cleaned. Lids must be provided for bins. The hoists must be routinely cleaned. The provider visit reports must be forwarded to the Commission for Social Care inspection on completion. Timescale for action 30/04/06 31/03/06 3 YA30 13 31/03/06 4 YA34 26 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. Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 21 No. Refer to Standard Good Practice Recommendations Havenfield Lodge DS0000006483.V276037.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Sheffield Area Office 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. 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