Inspection on 01/08/07 for Little Haven

This inspection was carried out on 1st August 2007.

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

Little Haven 30/10/06

Little Haven 27/01/06

Little Haven 31/08/05

Little Haven 01/12/04

Little Haven 06/07/04

Little Haven 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Little Haven 66 Laleham Road Catford London SE6 2HX Lead Inspector Lisa Wilde Unannounced Inspection 11:30 1 & 14 August 2007 st 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 Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 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 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. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Haven Address 66 Laleham Road Catford London SE6 2HX 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) 0208 6974246 0208 697 4246 Elizabeth Peters Care Homes Limited Mr Martin Muriuki Mrs Sadie McLeish Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users admitted to the MD category must be between the ages of 55 and 65 years. 30th October 2006 Date of last inspection Brief Description of the Service: Little Haven is a care home for four people who have mental health problems and are aged 55 or over. The home is one of four owned by a local provider, Elizabeth Peters Care Homes Ltd. It is within a short walking distance of Catford town centre, although there are smaller shops available locally. There are four single rooms over three floors. The home could accommodate a wheelchair user on the ground floor but there is no lift to reach the upper floors. There is a kitchen/lounge on the ground floor and a small garden at the back of the home. The range of fees for a place at the home was not available at the time of writing the draft report. The home makes the reports of the Commission’s inspections available to residents in the office of the home. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day at the home in August and because neither of the Registered Managers were at the home, the inspector asked for additional paperwork to be sent on afterwards. The inspector met with all four residents and staff that were on duty, toured the building, went into some resident’s rooms. Looked through documents and checked medication stocks. Residents said they were happy at the home and had no problems. They said staff were friendly and caring. They liked their rooms and said they had everything they needed. This is a good home where residents continue to be very happy. There were no unmet requirements from the last inspection and only a few slight problems were noted during this inspection. What the service does well: The standards assessed at this inspection showed that: • • • • Staff make sure that they can meet people’s needs before they are offered a place at the home. People can come to the home to look round and stay overnight before they decide to move their permanently. Staff write care plans that describe what they will do to make sure that all service users’ needs are met. Staff support residents in different ways and service users are encouraged to attend regular GP and clinic appointments to make sure they stay healthy. Residents are supported to do what they want to do and go out when they want to. Residents choose what they want to eat and staff cook for them. Staff listen to residents and take their comments and concerns seriously • • • Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 6 • • • • • Residents are generally protected from harm by staff receiving training about what to do if they think a resident is being abused The home is comfortable, clean and homely throughout. Residents have their own rooms that they like and the communal areas are large enough. Staff receive regular supervision and an annual assessment of their work performance and individual training needs. Residents are protected from harm by the effective operation of all health and safety procedures. What has improved since the last inspection? • • There is now a thorough system that looks at developing the home and planning to make things better for service users each year. Recruitment procedures have improved. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet people’s needs before they are offered a place at the home. People can come to the home to look round and stay overnight before they decide to move their permanently. Standard 6 is not applicable as the home does not provide intermediate care. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that clear criteria for refusal of a place at the home are stated in the statement of purpose or service user guide. This had been done. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 10 There was a previous requirement that the Registered Individual must ensure that all required details of the service users’ terms and conditions are completed. This is now done. Senior staff meet with people and conduct an assessment of their needs before someone is offered a place at the home. Information is gathered and the assessment is written down. People are offered chances to visit the home for day, overnight and weekend stays before they decide to move to the home permanently and there is a trial period when someone does moves to the home. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all residents’ needs are met. Staff support residents in different ways and residents are encouraged to attend regular GP and clinic appointments to make sure they stay healthy. EVIDENCE: Residents have plans that show what staff will do to support them in all areas of their life. Residents sign these plans and they are reviewed regularly. One resident had had a recent change in their ability to walk but the risk assessment had not been updated. With an ageing resident group in a nonpurpose built home this issue is particularly important. (See Requirement 1) Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 12 Staff talked about residents’ health and personal care needs and showed they understood what residents wanted. There was a previous requirement that the Registered Manager must ensure that there is held a list of all staff who have been trained and judged as competent to administer medication which includes an example of their initials signature. This had been done. Medication to be taken “as required” was being signed for as refused when it wasn’t needed. (See Requirement 2) Medication for staff and non-prescribed medication bought by residents from the chemist was being stored in the medication cabinet and not accounted for. (See Requirement 3) Medication stocks did not always tally with the records. Homely remedies had been authorised by the GP for each resident but a current record of how much was being held in the cabinets was not maintained. (See Requirement 4) Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are supported to do what they want to do and go out when they want to. Residents choose what they want to eat and staff cook for them. EVIDENCE: Staff talked about the difficulties in getting some service users to go out but that other residents regularly go out. Records showed that some residents have reasonably full weekly plans, two residents said that they are able to go out on their own and choose to do this most of the time. One resident said they like going to the local old person’s day centre to see people two others like going out by themselves to see friends. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 14 There are residents meetings and the minutes showed that residents are given information and asked about what they want. Staff cook for most of the residents and records are kept of what they eat each day. Residents said that the food was ok and they get what they want but one said it could be more varied. The menus are perhaps not quite as healthy as they could be. (See Recommendation 1) Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff listen to residents and take their comments and concerns seriously. Residents are protected from harm by staff receiving training and understanding what to do if they think a resident is being abused. EVIDENCE: Records are kept of informal and formal complaints although there have not been any formal complaints since the last inspection. Residents use the surveys or day-to-day conversations with staff to let them know what they maybe dissatisfied with. Residents told the inspector that they had no problems with the home. Staff have been on training around protecting vulnerable adults from abuse. Staff could describe the procedures in place to protect residents and what staff should do if they thought a resident was being abused. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 16 The staff do not yet have an awareness of the new Mental Capacity Act and its effect on assessing resident’s capacity to make decisions. (See Requirement 5) Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Residents have their own rooms that they like and the communal areas are large enough. EVIDENCE: On the day of the inspection the home was clean and hygienic throughout. Residents have their own rooms that have been decorated as they choose. Residents said they were happy with their rooms. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 18 Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 19 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of residents and they hold the right qualifications and get enough training which means that residents are cared for by people who know what they are doing. Recruitment procedures are now effective enough which means that the organisation is doing enough to check up on the people who work in the home and to make sure that it is employing staff who can do the job. EVIDENCE: There are at least two staff on duty at all times and residents said there are always enough staff for them. All staff hold or are undertaking the NVQ Level 2, 3 or 4 in Care. There was a previous requirement that the Registered Individuals must ensure that the staff application form asks for a full employment history and that any Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 20 gaps in employment are investigated with records of that investigation being kept. This is now being done. There was a previous requirement that the Registered Individuals must ensure that records are kept of all interviewers notes and decisions. This is now being done. There was a previous requirement that the Registered Individuals must ensure that effective measures are taken to verify the source of all staff references. This is now being done although no reference had been gained from the most recent employer and there was no explanation in the recruitment pack as to why. (See Requirement 6) There was a previous requirement that the Registered Individuals must ensure that the POVAFirst check is only used in emergencies and not as a matter of course. This no longer occurs. There was a previous requirement that the Registered Individuals must ensure that the induction and foundation programme being used is the most up-todate version of the Skills For Care (and not TOPSS) programme. The new programme is in place although there have been no new staff yet to start using it. There was a previous requirement that the Registered Individuals must ensure that all staff have an at least annual appraisal of their work performance and training needs and that individual training plans are drawn up following these appraisals. This had been done. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 21 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is now a thorough system that looks at developing the home and planning to make things better for residents each year. Staff receive regular supervision and an annual assessment of their work performance and individual training needs which means that staff are receiving the support and training that best makes sure they can do their job better. Residents are protected from harm by the effective operation of all health and safety procedures. EVIDENCE: Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 22 There was a previous requirement that the registered provider must ensure that there is a business and financial plan for the home including an annual development plan reflecting aims and outcomes for residents. This had been done. There was a previous requirement that the Registered Individuals must ensure that there is a forward looking quality assurance system in place in the home that is based on the views of residents and which focuses on a process of continuous improvement. There has been a lot of work over the past year on drawing up a quality assurance programme for the home that covers all the areas of the service. It now meets the standard although it hasn’t yet been fully used and the information is still as it was last year, although work is being done to collate and start to transfer the information. There was a previous requirement that the Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. These are being done and now no longer need to be sent through to the Commission each month. There was a previous requirement that the Registered Manager must ensure that weekly fire system checks are carried out as planned. This is now being done. Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 & 13 (4) (a) & (c) 13 (2) Requirement The Registered Manager must ensure that risk assessments are reviewed when service user needs or abilities change. The Registered Manager must ensure that medication to be taken as required is only signed for when it is taken. The Registered Manager must ensure that only current medication prescribed for service users and authorised homely remedies are stored in the medication cabinet. The Registered Manager must ensure that effective medication stock checking systems are operated. The Registered Individuals must ensure that an appropriate policy and procedure is drawn up regarding the mental capacity act, that staff are aware of the effect of this and that effective assessments of capacity are conducted when necessary. The Registered Individuals must ensure that a reference is gained from the most recent employer DS0000025598.V342266.R01.S.doc Timescale for action 30/09/07 2. OP9 31/08/07 3. OP9 13 (2) 31/08/07 4. OP9 13 (2) 31/08/07 5. OP18 18 (1) (c) (i) 31/10/07 6. OP29 19 (1) & (4) 30/09/07 Little Haven Version 5.2 Page 25 where possible or an explanation as to why this is not done is kept on file. 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 OP15 OP30 Good Practice Recommendations The Registered Manager should ensure that staff think about creative ways to introduce more fruit and vegetables into meals. The Registered Individuals should consider ways in which in-house training can be offered to staff around mental health issues and should look into accessing more external training for staff in this area. Previous recommendation. The Registered Individuals should ensure that the Registered Manager attends further training around staff supervision and appraisal. Previous recommendation. 3. OP36 Little Haven DS0000025598.V342266.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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