Inspection on 13/06/05 for South Haven Lodge

This inspection was carried out on 13th June 2005.

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 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

South Haven Lodge 27/02/07

South Haven Lodge 15/11/05

South Haven Lodge 22/02/05

South Haven Lodge 12/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE South Haven Lodge 69 - 73 Portsmouth Road Woolston Southampton SO19 9BE Lead Inspector Clare Jahn Unannounced 13 June 2005 10:00 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. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service South Haven Lodge Address 69-73 Portsmouth Road Woolston Southampton SO19 9BE 023 8068 5606 023 80449092 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) New Century Care (Southampton) Ltd Care Home 45 Category(ies) of OP-45 registration, with number DE-45 of places DE(E)-45 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category of dementia (DE) must be at least 55 years of age. 2. The home is not registered to take patients detained under the Mental Health Act 1983 - as amended. 3. The home may accommodate up to 45 male and female service users in the categories DE, DE (E) and OP at any one time. Date of last inspection 22 February 2005 Brief Description of the Service: South Haven Lodge is a care home providing nursing care and accommodation to 45 people who require care through old age or a diagnosis of dementia. It was bought in May 2004 and is now owned by New Century Care (Southampton) Ltd. The home is located in the residential area of Woolston and has good links to public transport systems. Local shops and community facilities are easily accessible. South Haven Lodge has accommodation over two floors connected by two stairways and two passenger lifts. There is a mixture of single and double bedrooms. At the rear of the property is an extensive well-maintained garden, which is accessible to the service users. Car parking is available at the front of the home. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager was off duty on day of the inspection but came to speak to the inspector for feedback at the end. The inspection was conducted over one day. The inspector had discussions with two ancillary staff; seven care staff, the manager, the administrator, the activity co-ordinator and one volunteer. Discussions were also held with eight service users, three relatives and two relatives of a prospective service user and feedback was sought from quality assurance questionnaires. Records and documents were reviewed and a tour was undertaken of the premises. Discussions with staff and residents were undertaken on a group and individual basis. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure that admissions to the home are within the criteria of the home’s stated purpose. The home requires extensive redecoration and refurbishment including the replacement of flooring and management of odours. A plan outlining the proposed dates for completion must be made available. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 6 The home’s heating system also needs to be addressed so that service users can control the heating in their rooms individually, as they prefer. The staff must be provided with adequate smoking, changing and meal break facilities. The home’s documentation needs to be completed consistently and the staff must review their procedures for the crushing of prescribed medications and for the covert administration of medications. The provision for regular staff meetings must be addressed. Night staffing levels must be reviewed and appropriate numbers of trained staff employed to meet the demands of the service. 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. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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) 1,2,3,4 Information regarding the service is easily available and service users have the necessary information pertaining to conditions of residence. EVIDENCE: The Home has a very comprehensive information folder, statement of purpose and service user guide for service users and their relatives. There is extensive information regarding the home available in each of the service user’s rooms and in the main hallway. Prospective relatives visiting the home were observed accessing this information and relatives confirmed where further information could be sought. Service users contracts were examined and were signed and dated. Relevant information was available to the service users. The contracts on files included the room to be occupied and the terms and conditions of occupancy but service users were unable to recall the details when asked. Prospective relatives were observed being given a guided tour of the premises, room to be occupied and facilities and introduced to staff. One service user was found to be outside of the homes category for registration. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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) 7,9, Documentation when completed is of a good standard but this needs to be consistently undertaken. Administration of medications, covertly and by altering their state, is not done in accordance with appropriate professional guidance and in a risk assessment framework. EVIDENCE: South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 10 Four service users records and care documents were viewed during the inspection. Some of the documents were comprehensive, detailed and care plans indicated a date of the identified need with a review date when completed. These plans demonstrated the current needs of the service users including expected outcome, goals and actions. Care plan evaluations when completed were detailed. Some of the service users files identified a food profile, falls risk assessment, night care plan, dependency assessment form, continence assessment, waterlow, manual handling risk assessment, oral assessment, nutritional risk assessment monthly observations, life histories and wishes upon death. Service users were unable to recall discussing the plans but signatures were seen of service users and /or their representatives following consultation. Discussions with staff indicated that the on going and current care needs of service users were reflected in the written documentation and staff were aware of the current needs of the service users. There was a lack of consistency in the standard of record keeping as some records and assessments had not been completed. When completed they were detailed, organised and all events were well recorded. The manager said this would be addressed. Six service users spoken to said that the service has improved a lot since the take over and that they were all happy with the care. One other lady said “There is such a nice atmosphere generally and the girls are lovely”. During discussion with staff it was indicated that staff are crushing medication and do administer medicines covertly. Prescriptions stated that certain medications must be given whole and these were being crushed. Medication must be administered in line with the relevant guidance. On visiting the medication area the door was not secured and the staff identified a service user who is at risk when wandering of ingesting anything that is laying around. Medication must be kept securely. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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, Consideration is given to the social, cultural, recreational and occupational characteristics and needs of the residents, and to individual preferences and capacity. Residents are supported to maintain skills. EVIDENCE: South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 12 Discussion with the home’s activity co-ordinator established that there is a client centred activity programme, which was also displayed in the Home’s lounge. Each resident undergoes a period of assessment where a detailed and comprehensive account of their abilities, likes, dislikes, preferences, triggers, specialist needs including communication are assessed. Families are involved in the process and confirmed that life histories are sought and input provided for by those closest to the resident. Activity reports are written every 6 months and both of these were seen on the files. The co-ordinator was observed interacting with the residents in a group and on an individual basis and described in great detail the support given on an individual basis to residents in the home by helping encourage and support skills. The residents confirmed that usually there is a visiting chaplain who comes regularly to the home to speak with service users of any denomination but that he has been unwell recently. The Home has a hairdressing salon and the hairdresser comes twice a week. Service users were seen having their hair done. Residents confirmed that as well as having televisions provided in all the lounges the service user could choose whether to have one in their room. The Home provides a DVD player, stereo and video. The care documentation viewed supports an interests and hobbies sheet and there is a visiting library providing large print books. Service users were seen engaging in a number of activities but were not able to recall the exact details of the activities programme. Residents confirmed that they can choose whether to engage in activities or not and that they can choose how to spend their time, where to spend there time and a number confirmed that there routines and specific and preferable seating arrangements were respected. Family members and friends were seen coming and going through out the day. One service user told the inspector that residents ”do their own thing” and described how when she has a bath she is able to bath herself but the staff just sit closely by to ensure she’s safe. One staff member described how one resident is able to do her own washing as she chooses and is able to do so, which is good practice. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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) 16,17,18 The home’s procedures protect service users from abuse and ensure their legal rights are protected. EVIDENCE: There has been one formal complaint made to the Commission since the last inspection. The manager, in response to the complaint, has undertaken a full quality assurance questionnaire to establish areas which need to be improved, and the results are available to view at the home. A copy has been sent to the Commission. A complaints form is available if the home needs to record complaint details and the home has a complaints procedure, which was easily found and discussed with two visitors during the visit. Of six staff spoken to, all were aware of the adult protection procedures .The appropriate policies and procedures were confirmed by staff to be available. Discussions with administration staff and viewing files confirmed that appropriate checks (POVA) have been undertaken on staff during the recruitment process to ensure that staff are suitable to work with vulnerable adults. The policies and practices of the home ensure that physical and/or verbal aggression by service users is understood and dealt with appropriately, and the nurse in charge stated that physical intervention is not undertaken. The home’s records indicated that policies and practices are in place regarding service users’ money and financial affairs. Records seen indicated safe storage of money and valuables. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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) 19,21,25,26 The home needs major improvements in the redecoration and refurbishment of its current facilities. Improvements have been made but require further clarification for the proposed timescale for completing all outstanding work. The homes heating and thermostatic control system needs to be reviewed and its facilities for the staff improved. EVIDENCE: Redecoration and refurbishment has been started at South Haven Lodge and during a tour of the premises the inspector was shown the newly decorated service user’s rooms. One of the residents’ lounges was being redecorated during this visit. The Home requires refurbishment and redecoration throughout and visiting relatives stated that the main communal areas were dark and they felt the ceiling was “closing in on them”. The manager said the ceilings to the lounges would have new lighting. The main corridors, flooring, wall decoration and skirting especially near the kitchen are soiled, tired and worn. The manager confirmed all the areas were incorporated in the programme of refurbishment. The inspector discussed on South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 15 going work with the maintenance man and he explained the process for on going maintenance issues, which were confirmed by staff to be logged in the maintenance book, and signed off when dealt with. The home’s bathrooms and toilets on the lower floor are not suitable for the client group and in a poor state. The inspector was informed at the last inspection that these would be refurbished but remains the same. The full programme for refurbishment has not been forwarded to the Commission. Staff confirmed that a number of these bathrooms are not practical and are not being used, as they are not suitable. The manager agreed during the visit to review the current outside smoking/seating area for staff as this is situated outside a service users room on the ground floor. Smoke and conversations emanate through to this service user’s room. Six staff spoken to stated that there was no male changing area and no lockable female changing /staff room. Male staff said they changed in the resident’s toilets and female staff stated they had been walked in on when changing. The staff do not have an allocated area where they can take their meals. Staff and visitors commented to the inspector about the odours present in some areas of the home. A number of service users rooms have odours. The manager said that with the replacement of the old carpets, which do not respond to regular cleaning, this problem should be alleviated. The inspector was informed that service users and their relatives have complained about the temperature of the rooms on the ground floor. Following discussion with the maintenance man it was established that a group of rooms have set temperatures from a thermostat located in the hall and for room temperatures to be changed the maintenance man needs to get into the room remove the panel and adjust the thermometer accordingly. Residents are not able to thermostatically control the environment themselves. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 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 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) 29,27 Service users are supported and protected by the home’s recruitment policy and practices. Staff feedback was positive but the manager must ensure appropriate numbers of staff are employed to meet the needs of the service and that staff are given the opportunity to meet regularly. EVIDENCE: Discussion with staff and viewing records indicate that all necessary checks have been undertaken on staff prior to their employment. Staff described the process of induction and opportunities for supervised practice. Staff did state that there were not enough staff meetings or opportunities to discuss express concerns changes etc. Staff described themselves as a “happy bunch who communicate and get on well and help each other”. One area of concern raised was that there is only one member of trained staff on night duty in charge of the shift, responsible for supervising all residents and staff. The inspector was not satisfied that one member of staff can supervise everyone and take adequate breaks. In the event of an emergency there would not be any other trained member of staff to manage the home should this one nurse be busy. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 17 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) 33,38 Effective quality assurance and quality monitoring systems are undertaken are in place. EVIDENCE: The Home currently conducts over sixteen audits to monitor the quality of the care provided within the Home. Regulation 26 visits are undertaken and the Home is commended for its active approach in continuously finding ways to audit the care and provision of the quality of the service they provide and aiming to improve their service. Full analysis of feedback is on display in the main hall. An up to date employers liability insurance certificate was seen in the entrance area. During a tour of the premises a number of wardrobes in the residents bedrooms had equipment stored on the top of them, which could pose a safety hazard. The manager agreed to address this. South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x 2 x x x 2 2 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x x x x 2 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.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 1 Regulation 14(1) Requirement The manager must not admit any service user whose needs are not described by the conditions attached to the registrationfor the home. An application to vary conditions must be made in respect to the person currently accomodated. The registered person must submit a detailed plan of the homes proposed refurbishment and redecoration to include all communal areas kitchen and bathrooms, subject also to the recommendations given by the fire authority and to address the homes heating provision and odours. Medication must be given as recommended by appropriate personel to comply with legal requirements for covert and crushing of medication. Medication must be stored safely. Staff must be provided with appropriate changing, rest and smoking facilities. The registered person must ensure appropriate numbers of trained nurses are employed to Timescale for action 30.08.05 2. 19 23(1)(2)1 2(1)16(1) 30.08.05 3. 9 13(2) 12(2) 30.08.05 4. 5. 19 27 23(1) 18(1) 30.08.05 30.08.05 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 20 6. 7. 32 38 12(5) 13(4) meet the needs of the service at night and that those staff receive the appropriate cover when taking their meal/rest breaks. Regular staffs meeting must be 30.08.05 undertaken Equipment must be stored safely 30.07.05 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 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 South Haven Lodge H55-H03 S59970 South Haven Lodge V218659 130605.doc Version 1.40 Page 22 - 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. 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