Inspection on 30/08/05 for Little Haven Nursing & Residential Home

This inspection was carried out on 30th 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

Little Haven Nursing &... 06/12/06

Little Haven Nursing &... 28/12/05

Little Haven Nursing &... 07/12/04

Little Haven Nursing &... 28/07/04

Little Haven Nursing &... 17/02/04

Little Haven Nursing &... 18/08/03

Little Haven Nursing &... 09/12/02

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

CARE HOMES FOR OLDER PEOPLE Little Haven Nursing Home Beaulieu Road Dibden Purlieu Southampton Hampshire SO45 4JF Lead Inspector Sue Maynard Unannounced 30 August 2005, 9:00 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 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 Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Little Haven Nursing Home Address Beaulieu Road, Dibden Purlieu, Southampton, Hampshire SO45 4JF 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) 02380 847222 02380 847585 wilverleyassociation@btconnect.com The Wilverley Association Limited Mrs Adele Roberts Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 No more than 23 beds may be used at any one time for service users who are in need of nursing care. Date of last inspection 07/12/2004 Brief Description of the Service: Little Haven is a registered care home that accommodates forty-three service users over the age of 65years. Twenty three service users are in receipt of nursing care and the remaining twenty are in need of assistance with personal care only. The home is the sister home to Forest Oaks and is administrated by the Wilverley Association Ltd, which is a charitable trust, and as such, all members of the governing committee are volunteers. The home was purpose built some years ago and is housed on three floors in pleasant gardens and is situated in a semi-rural area close to the New Forest. The home is close to shops and other local amenities. Many of the residential service users are independent and are able to go out into the community independently. All 43 rooms are single occupancy and have en-suite facilities and have extra facilities within them for storage. The service users who receive personal care furnish those rooms and supply all soft furnishings making each room very individual. The home has two passenger lifts installed. The grounds surrounding the home are well maintained. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was the first of two statutory inspections for the year 2005/2006. The inspection was conducted by one inspector and lasted five and a half hours. The manager for the home was on duty during the inspection. A tour of the building and the grounds took place. Records and documents were examined. The inspector spoke to a group of six residents during morning coffee in the lounge and was able to speak with four other residents individually. Discussions with staff did not take place during this inspection as staff declined to meet with the inspector. What the service does well: What has improved since the last inspection? The programme of redecoration continues in all areas of the home. The manager confirmed that new carpets are to replace the existing flooring in the Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 6 corridor of the nursing wing and the paving around the outside of the premises is to be replaced. A review of the nutritional needs of the residents is being undertaken and nutritional assessment are also being reviewed 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 Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standard 3 was not assessed during this inspection. Standard 6 does not apply to this service. EVIDENCE: Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 and 10 The home ensures that arrangements for the personal and healthcare needs of the residents promotes their wellbeing and upholds their dignity. EVIDENCE: The inspector looked at medication records. These were found to be accurate and up to date. All policies and procedures for the administration and storage of medications have been reviewed in 2005. A new policy and procedure for the disposal of all drugs has been compiled. These have been put in place to meet the new national guidelines that have been introduced for the safe disposal of drugs. The pharmacy that supplies the home is no longer responsible for the collection and disposal of unused drugs. The home has a contract with the company who collects the clinical waste from the home to perform this task. Secure facilities for the storage of the drugs prior to collection and disposal are in place. Residents in the home spoken to by the inspector confirmed that the staff are always mindful of their privacy and that the staff treated them with dignity and kindness at all times. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 10 Acknowledgement of the residents right to privacy and dignity forms part of the induction training for new staff that come to work in the home. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The management of the social activities creates a positive, varied and interesting life for the residents, which meets their expectations for living in the home. EVIDENCE: The home has a very varied programme of social activities. This is arranged by the manager for the home in consultation with the residents. Two staff members are undertaking training to enable them to be able to drive a community mini bus, which enables less independent residents to be taken out to places of local interest. Daily activities to take place in the home are documented on a notice board, adjacent to the residents lounge. These include handicraft, movement to music, quizzes and visits from an organisation that brings dogs to the home to visit the residents. The home maintains links with local churches and schools. Together with activities organised by the manager for the home many of the residents will organise their own activities during the afternoon such as playing cards and Scrabble. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 12 There are no restrictions for visitors to the home. Overnight accommodation can be provided within the home for relatives visiting from a long distance. A minimal charge for bed and breakfast is made. Residents spoken to by the inspector confirmed that they are given every opportunity to choose how they live their lives. They confirmed that staff always ask them at what time they wish to get up and go to bed, what clothes they wish to wear and that they are offered a choice of meals daily. The home employs a catering manager. She speaks with all new residents to the home to ascertain their personal food preferences. The menus are changed on a weekly basis and residents may request something different if they wish. The training officer for the home has recently undertaken a study day with regard to nutrition for the elderly. As a result, information obtained on this day, she is liaising with the catering manager to look at the types of food served to the residents and is discussing possible changes that could be made to ensure that the nutritional balance of the food served is maintained. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Procedures in place ensure all complaints are acknowledged and handled objectively. The vulnerable adults procedure ensures that any allegation of abuse will be addressed appropriately. EVIDENCE: The home has a detailed complaints procedure that is available in the home’s Statement of Purpose. No complaints against the home have been received by CSCI since the last inspection. Residents spoken to confirmed that their concerns are always taken seriously and acted upon. Robust policies and procedures for the reporting of allegations of abuse within the home are in place. Training for the awareness of abuse of vulnerable adults forms part of the induction training for new staff. This training is ongoing for all staff as part of the training programme for the home. The manager for the home is to attend a course, Abuse Training for Managers, in November 2005. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The ongoing review of services provided in the home ensures that all residents are enabled to live in a clean, safe and comfortable environment. EVIDENCE: The home was clean, bright and homely on the day of the inspection. There is a continuing programme of redecoration and refurbishment. New carpets are due to be laid in the main corridors of the nursing wing of the home. The inspector noted that many of the paving slabs around the outside of the home were lose and uneven. The manager was able to confirm that external walkways are to be completely renovated and new paving slabs are to be laid. This work is scheduled to commence in November 2005. In the interim period resident who use this are aware of the problems of the uneven surfaces. The manager for the home stated she had undertaken risk assessments for those residents who are at risk. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The arrangements for the numbers of staff on duty at any one time appear to be sufficient to meet the needs of the residents. The staff undertake training that enables them to be competent to do their jobs. EVIDENCE: Staff rotas provided the inspector with evidence that staff are on duty in sufficient numbers as to be able to meet the needs of the residents over a twenty four hour period. The manager confirmed that the staff were always prepared to cover any shortfalls in staff numbers due to sickness or annual leave. Agency staff is rarely used in the home. Residents spoken to stated that the staff was always attentive to their needs and that they responded to the call alarm promptly. The inspector examined staff recruitment records. These were found to be in order. Written references had been obtained, proof of identity was documented and evidence was seen that checks with the Criminal Records Bureau had been undertaken for all staff working in the home. The home employs a training co-ordinator who undertakes training for all staff in both the homes owned by the Wilverley Trust. The training includes: Fire safety Manual handling Health and safety including infection control First aid Abuse awareness. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The manager and her deputy provide strong leadership in the home providing guidance and direction to the staff to ensure that standards within the home are maintained at all times. Close monitoring of practices within the home safeguard the health, safety and welfare of residents, staff and visitors to the home EVIDENCE: The manager currently undertakes a review of services within the home through an annual questionnaire for the residents. Due to poor response from the residents and their families she is going to re-format the questionnaire and make the topics to be addressed more specific in hopes that she will get a more positive response. A monthly newsletter for the home is compiled by one of the residents in the home. The home is administered by a charity and the manager confirmed that communication within the organisation is very good. Regular meetings are held and the manager is able to discuss and put forward any proposals that are Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 17 relevant to the running of the home enabling her to maintain the high standards of care within the home. The manager told the inspector that she operates an “open door” policy for staff to be able to bring to her attention any issues as they arise. She told the inspector that staff meetings had been poorly attended so these are not taking place at this time. A senior staff member confirmed that communication within the home is good and staff are always aware of any changes to be made. Inspection of records indicated that regular tests are undertaken of fire safety equipment, including emergency lighting and extinguishers. The records also demonstrated that fire drills and instructions take place regularly. New guidelines have been given to those residents in the home, who are fully independent, regarding the procedure to be followed in the event of a fire. This has been introduced on the advice of the fire safety officer and has been discussed fully with the residents themselves. Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations Little Haven Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Hampshire Area Office 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Nursing Home H54 S11432 Little Haven Nursing Home V240840 300805 Stage 4.doc Version 1.40 Page 21 - 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!