Inspection on 30/10/06 for Little Haven

This inspection was carried out on 30th October 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Little Haven 01/08/07

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 11:00 30 October 2006 th X10015.doc Version 1.40 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 Little Haven DS0000025598.V306795.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.V306795.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 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.V306795.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. 27th January 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. 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 service users in the office of the home. Little Haven DS0000025598.V306795.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 in October 2006. The inspector met with the full-time Registered Manager, staff and spoke with service users. The inspector toured the building, checked records and all the medication stocks. Service users said they were happy at the home and had no problems. They staid staff were friendly and caring. They liked their rooms. The standards of care at this home are good and most of the unmet standards are so because of problems with procedures and systems and not because service users are not looked after or are not happy. What the service does well: What has improved since the last inspection? • Managers are getting better training DS0000025598.V306795.R01.S.doc Version 5.2 Page 6 Little Haven • Staff get more support from managers. 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. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet the needs of service users before they are offered a place at the home. Service users can come to the home to look round and stay overnight before they decide to move their permanently. Service users are given contracts when they move to the home but not all details are completed which means that they are not given all the information they need. Standard 6 is not applicable as the home does not provide intermediate care. EVIDENCE: The Registered Manager said that there are no clear criteria written down anywhere that state what issues the home could not accept from potential Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 9 referrals to the home such as current severe violent behaviour or who could not be accepted e.g. people under 55 years of age. (See Requirement 1) There is a contract in place for all service users but not all details are filled in such as the cost of the place at the home and the room number (or other means of identifying the rooms) (See Requirement 2). Senior staff meet with services users 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. Service users 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.V306795.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. 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 service users’ needs are met. Risks are assessed and plans put in place to make sure that any risks are managed which means that service users are kept safe. Staff support service users in different ways and service users are encouraged to attend regular GP and clinic appointments to make sure they stay healthy. Medication is given to service users as required and is recorded properly. EVIDENCE: Service users have plans that show what staff will do to support them in all areas of their life. Service users sign these plans and they are reviewed regularly. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 11 Staff talked about service users’ health and personal care needs and showed they understood what service users wanted. Medication stocks ands records were checked and all were found to be in order apart from the need for a list of all staff who have been trained and deemed as competent to administer medication. (See Requirement 3) Staff talked about how they try to make sure service users have privacy and are treated with respect. Service users said staff were friendly and caring. One example of service users having privacy was that on the upcoming holiday extra money has been paid to make sure service users don’t have to share rooms. Staff talk with service users about what they want to happen if they were to become ill or die and plans are put in place around this. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 11, 12, 13 & 14 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to do what they want to do and go out when they want to. Service users choose what they want to eat and staff cook for them. EVIDENCE: There was a previous requirement that the registered provider must ensure that service users are provided with more opportunities for individual and group activity with staff and care plans detail time spent on these activities and provide sufficient staff to cover them. Staff talked about the difficulties in getting some service users to go out but that other service users regularly go out. Records showed that some service users have reasonably full weekly plans, one service user said that they are able to go out on their own and choose to do this most of the time. The Registered Manager talked about how staff try to support service users to stay in touch with their families if they choose to. One service user said they like going to the local old person’s day centre to see people. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 13 There was a previous requirement that the registered provider must ensure that the need for any restrictions in the home is regularly reviewed and written evidence provided. This issue was not longer present at the home and the Registered Manager showed that they were aware that any restrictions on service users’ rights had to be carefully explained. There are residents meetings and the minutes showed that service users are given information and asked about what they want. Staff cook for most of the service users and records are kept of what they eat each day. Service users said that the food was ok and they get what they want. Surveys done recently showed that there were some minor negative comments about food but the Registered Manager had put in place a plan to try and make things better. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff listen to service users and take their comments and concerns seriously. Service users are protected from harm by staff receiving training and understanding what to do if they think a service user is being abused. EVIDENCE: Records are kept of informal and formal complaints although there have not been any formal complaints since the last inspection. Service users use the surveys or day-to-day conversations with staff to let them know what they maybe dissatisfied with. Service users 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 service users and what staff should do if they thought a service user was being abused. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 15 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 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. Service users 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. Service users have their own rooms that have been decorated as they choose. Service user said they were happy with their rooms. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. 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 service users. Staff hold the right qualifications and get enough training which means that service users are cared for by people who know what they are doing. Recruitment procedures are not effective enough which means that the organisation is not doing enough to check up on the people who work in the home or to make sure that it is getting staff who can do the job which means that service users may be being put at some risk. EVIDENCE: There are at least two staff on duty at all times although is may be changing in the future to better reflect the lower needs of service users at some times of the week. The Registered Manager will consult with the Commission before any changes are made. All staff hold or are undertaking the NVQ Level 2, 3 or 4 in Care. There were several previous requirements around the recruitment procedures. The inspector had checked the systems for recruitment at another of the organisation’s homes and found the following problems: Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 17 The application form does not ask for a full employment history and so gaps in employment could not be investigated. Records were not maintained of all interviewers’ notes and comments on interviewees’ performances. References were not always stamped by the organisation or on headed notepaper. Although the home applies for new Criminal Records Bureau checks on all staff, it is currently using the POVAFirst check as a matter of course, which is only supposed to be used for emergencies. The home does not destroy CRB checks after six months (or when the inspector has had the opportunity to see the checks) and then keep a central record of the dates of the CRB checks. There was a previous recommendation that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. This has not yet been done. (See Requirements 4 - 8) There was a previous requirement that the Registered Manager must ensure that the home’s induction and foundation training is in accordance with sector skills council specifications. This has now been done although the workbooks and training information being used by the organisation is that of TOPSS which is the organisation now called Skills For Care. This means that although the induction and foundation programme is almost in line with requirements, there will be a more up-to-date version of the guidelines that should be used. (See Requirement 9) Each member of staff has an individual training plan and these are drawn together into an overall annual training plan for the home although annual appraisals have not been carried out so the training plans have not been drawn up following a full assessment of their work performance and training needs. (See Requirement 10). This plan showed that staff receive the basic training required. Although the staff team has recently had some mental health training from another manager within the organisation who is a registered nurse, there may be more opportunities for the Registered Manager to offer in-house training to staff during team meetings or to access external training. The Registered Manager said they have done this at the home before and it had been very useful. (See Recommendation 1) Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are lots of checks in place at the home there is no systems that looks at developing the home and planning to make things better for service users each year which means that things do not change much for service users. Staff are supervised enough by the managers but do not receive an annual assessment of their work performance and individual training needs which means that staff may not be receiving the training that best makes sure they can do their job better. Service users are protected from harm by the effective operation of all health and safety procedures apart from the weekly fire system checks. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 19 EVIDENCE: There are two Registered Managers at this home, one of whom is part time and who was not present during this inspection. The full time manager evidenced her ability to manage the care home throughout the inspection and both managers are undertaking the Registered Managers Award NVQ Level 4. There was a previous recommendation that surveys of the views of service users and relatives be specifically designed for each purpose. Surveys do get carried out and although there is a thorough system of checks and information gathering in place in the home there is not yet a system that looks forward at planning how the home will improve in the next year in order to make things better for service user and there isn’t yet a plan in place based on what service users want. (See Requirement 11) Although the Registered Manager said that the required monthly checks of the home by the Responsible Individual are being carried out, the Commission’s records showed that these are not being received regularly by the Commission. (See Requirement 12) 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 service users. The full time Registered Manager thought that the part time Registered Manager had completed this but did not know where it was or what was in it. This work must be available and understood by all managers and staff. (See Requirement 13) There was a previous requirement that formal staff supervision must be increased to a minimum of six times a year. This is now being done although as mentioned previously the annual appraisals are not being carried out for staff. The Registered Manager said that she had watched a training video about supervising staff and had conducted joint supervisions with another manager but felt she could benefit from more training in this area. (See Recommendation 2) There was a previous requirement that the registered provider must ensure that all staff files contain proof of identity and a recent photograph. This is now done. All health and safety documentation and checks were in place and in order apart from some weekly fire system checks that had been missed. (See Requirement 14) Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 20 There was a previous recommendation that evidence that the home is registered for the storage of confidential information is kept at the home. This has now been done. There was a previous requirement that the registered provider must ensure that copies of safety certificates for gas, electrical installation and portable electrical appliances are sent to CSCI, Southwark Office on receipt of the draft report. All required documents are now in place. There were no health and safety problems noted on the tour of the building. There was a previous requirement that the registered provider must ensure; there is a clear distinction between accidents and other incidents, there is a format for each and that CSCI is notified of all incidents covered under Regulation 37. This is now being done There was a previous recommendation that an audit of the health and safety information and maintenance certificates file be undertaken to ensure that information can be accessed easily. This has now been done. Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 21 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 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 4&5 Requirement 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. The Registered Individual must ensure that all required details of the service users’ terms and conditions are completed. 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. The Registered Individuals must ensure that the staff application form asks for a full employment history and that any gaps in employment are investigated with records of that investigation being kept. The Registered Individuals must ensure that records are kept of all interviewers notes and decisions. The Registered Individuals must ensure that effective measures DS0000025598.V306795.R01.S.doc Timescale for action 31/12/06 2. OP2 4&5 31/12/06 3. OP9 13 (2) 30/11/06 4. OP29 19 (1) & (4) 31/01/07 5. OP29 19 (1) & (4) 13 (6) 31/01/07 6. OP29 31/01/07 Little Haven Version 5.2 Page 23 7. OP29 13 (6) 8. OP29 13 (6) & 17 (2) 9. OP30 18 (1 (c) (i) 10. OP30 OP36 18 (2) 11. OP33 24 12. OP33 26 (3) 13. OP34 24 and 25 are taken to verify the source of all staff references. The Registered Individuals must ensure that the POVAFirst check is only used in emergencies and not as a matter of course. The Registered Individuals must ensure that CRB checks are destroyed after six months or when the inspectors have had the opportunity to see them and that a central record is then maintained of the CRB date and number. The Registered Individuals must ensure that the induction and foundation programme being used is the most up-to-date version of the Skills For Care (and not TOPSS) programme. 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. 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 service users and which focuses on a process of continuous improvement. The Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. 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 service users. Previous requirement: Unmet timescales 31/10/04 31/01/05 30/11/05 & 30/04/06 DS0000025598.V306795.R01.S.doc 31/01/07 31/01/07 31/12/06 31/12/06 31/01/07 30/11/06 31/01/07 Little Haven Version 5.2 Page 24 14. OP38 23 (4) (c) The Registered Manager must ensure that weekly fire system checks are carried out as planned. 14/11/06 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 OP30 Good Practice Recommendations 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 The Registered Individuals should ensure that the Registered Manager attends further training around staff supervision and appraisal. 2. OP36 Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Little Haven DS0000025598.V306795.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!