Inspection on 19/06/07 for The Haven

This inspection was carried out on 19th June 2007.

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

The Haven 21/06/10

The Haven 11/06/10

The Haven 12/03/10

The Haven 01/03/10

The Haven 14/09/09

The Haven 26/11/08

The Haven 04/06/08

The Haven 21/11/06

The Haven 29/08/06

The Haven 19/09/05

The Haven 10/12/04

The Haven 27/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Haven 6 - 10 North Terrace Seaham Durham SR7 7EU Lead Inspector Mrs Sue Lowther Unannounced Inspection 19th June 2007 09:30 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 The Haven DS0000046459.V337109.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. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 6 - 10 North Terrace Seaham Durham SR7 7EU 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) 0191 5816305 0191 5130377 Haven Hommes 2003 Ltd Position Vacant Care Home 43 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (36) of places The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: The Haven is a two storey building situated near the seafront at Seaham. It is a well-established care home and can accommodate people over the age of 65 years (36) with the addition of a smaller unit for people over the age of 65 years with dementia (7) making a total of 43 places. Accommodation is provided within single rooms (37) and double rooms (3) each containing washbasins. Toilet and bathing facilities are conveniently distributed with easy access from communal and private areas. There are a number of lounge and dining areas and access to a closed courtyard to the rear with sea views and a promenade walkway to the front across a main road. The current provider is Haven Hommes 2003 Limited. The current cost of living at the home ranges between £364 and £417 and does not include hairdressing, chiropody and toiletries. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of The Haven took place on the 19h June 2007. Since the last key inspection two random inspections have been carried out. The first one on the 16 February 2007 found that limited progress had been made since the inspection in November 2006 and eleven requirements from that inspection were outstanding. A further visit took place on 11 May 2007. At that time there were still nine outstanding requirements from the inspection in November 2006 and three new requirements were made. During this inspection records were examined and a tour of the building took place. Time was spent talking to service users, staff and relatives. The acting manager supplied some information on a pre inspection questionnaire. What the service does well: What has improved since the last inspection? All of the people who live in the home have now been reassessed and have care plans in place which sets out how the home will meet all of their needs. Some of the staff have had training in adult protection. Further training has been planned for new staff. A lot of progress has been made with regard to the refurbishment of the home. The ground floor bedrooms, corridors and bathrooms have had new flooring laid. There are plans to continue with this programme throughout the home. A new acting manager has been appointed. Staff and the people who live in the home said that she is approachable and that she listens to any concerns raised. Some quality assurance systems are now in place to seek the views of the people who live in the home, their relatives and visiting professionals. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 6 All of the outstanding maintenance certificates required at the last inspection have now been supplied to the CSCI. 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. The summary of this inspection report can be made available in other formats on request. The Haven DS0000046459.V337109.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 The Haven DS0000046459.V337109.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. The home does not provide intermediate care and therefore assessment of Standard 6 is not required. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessment procedures are in place, which should make sure that the home can meet all of the needs of the people who go to live there. EVIDENCE: All of the people who live in the home have a contract. However there is no reference in these as to who is responsible for paying the fees. This information needs to be made clear so that people know who is paying the fees and the amount that needs to be paid. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 9 There have been no admissions to the home since the last inspection. The last key inspection report required the home to have an in depth assessment for each person. All of the people living in the home have now been reassessed. The acting manager told the inspector that she intends to assess new admissions to the home prior to them going to live there. If she were on holiday this would be done by one of the carers. Where people are assessed by social services, that plan will also be available. The Haven DS0000046459.V337109.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate systems are in place to ensure that health care needs of the people who live in the home are met. EVIDENCE: Each person now has a care plan in place to cover health and personal needs. This makes sure that all of the staff know haw to look after people on an individual basis. Evidence was seen in files of involvement with other people for example district nurses, doctors, and care managers to confirm that other professionals are involved. However some district nurses have recently raised some concerns with the home about personal care. The home are investigating the issues raised and intend to put an action plan in plan to address them. One person who lives in the home said, “The care is getting better”. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 11 The medications of four people were checked and found to be in order. People said that staff treat them with dignity and respect. They said that staff now knock on bedroom doors and call them by their preferred name. One person said, “ The staff always knock and talk to me nicely”. The Haven DS0000046459.V337109.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities are limited and do not provide suitable recreation for the people living in the home. Family and friends can visit the home at any time and are made to feel welcome. Menus are varied and service users are given a choice. EVIDENCE: Care staff currently organise activities. The people who live in the home generally felt that there were not sufficient activities available. Some of the comments made were “ We were supposed to go out to the parade on Sunday but we could not because there were not enough staff”. Another said “I would like to go out more but there is not always enough staff”. One person said, “I would like to have a greenhouse and grow tomatoes and cucumbers”. On the day of inspection some people were playing dominoes or watching television. The acting manager said that she is consulting people on an individual basis about how they would like to spend their day. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 13 Relatives said that they could visit at any time and that they are always made welcome. One said, “I can come and go anytime and I am always made to feel welcome”. People said that they have a choice about what time they like to get up and go to bed and when they would like to have a shower or bath. One person said, “I like to have a lie down after breakfast and I am allowed to do this”. Another said, “I can to choose have a bath or shower and can have a one at any time I like”. The lunch looked nice. One person said, “The food is great I have no complaints, although it would be nice to have more seafood, crabmeat and lobster tails”. Another said, “The food is good and you get a choice”. The Haven DS0000046459.V337109.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies in place for dealing with complaints and adult protection. EVIDENCE: Information about complaints, how and who to make them to, is made available to people through information displayed in the entrance to the home. It is also in the ‘Service Users Guide’. However this should contain details of how to contact the local social services department and the ombudsman. This is to make sure that people know that there are other agencies who can deal with their complaint. One person said, “The manager comes around and talks to people. You can tell her if you have a problem and she sorts it out”. Another said, “I can approach any of the staff now and they listen to me”. As stated previously there has been one complaint since the last inspection. This is being investigated using the procedure available within the home. The home has adult protection procedures in place. Copies of these were seen to be available for staff use. Some staff have had training in adult protection and further training is planned. Staff interviewed said that they were committed to protecting people who live in the home. One member of staff confirmed that she knew about the procedure with regard to safeguarding The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 15 adults. She said that he would have no hesitation in reporting any incident if she suspected someone was being abused. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is undergoing a major refurbishment programme. Those areas completed are to an adequate standard. However a cleaning schedule needs to be implemented. EVIDENCE: During the tour of the building and whilst talking to people in their bedrooms, the inspector saw that people could bring in their own furniture and belongings should they wish to do so. There is an ongoing programme of redecoration. One member of staff said “There have been loads of improvements. The home is really starting to look nice”. One of the people who lives in the home said, “This is home from home”. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 17 There are sufficient bathroom and toilet facilities available for the people who live in the home. During the tour the inspectors found that some of the areas that had been refurbished were not being maintained to an adequate standard of cleanliness. Two recently fitted bedroom carpets were dirty and had an unpleasant smell. In one bathroom the floor area around the bottom of the hoist was very dirty. A cleaning schedule needs to be implemented to make sure that the cleanliness of the home is maintained. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care staff are employed in sufficient numbers to meet the health and personal care needs of the residents living at The Haven. Staff files contained all of the required information. EVIDENCE: The acting manager said that there are usually three staff on duty during the day and two at night. There is at least one senior carer on duty at all times. As previously stated whilst there are sufficient number of care staff to meet the basic care needs of the people who live in the home, people felt that there were insufficient numbers to meet their social and recreational needs. A cleaning schedule is also required to maintain the home to an adequate standard of cleanliness. Sufficient staff need to be employed to cover both activities and cleaning. The home had staff files in place, which provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 19 A high proportion of care staff are trained to NVQ (National Vocational Qualification) in care at level two or above. All staff are encouraged to enrol on this course when they are recruited. The acting manager now uses the induction pack recommended by “Skills for Care”. Recent training has taken place in fire safety. Future training is planned in protection of vulnerable adults, moving and handling and first aid. One member staff confirmed that he was booked to attend first aid and moving and handling training. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 20 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, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An acting manager is currently providing support and leadership for the staff. EVIDENCE: The acting manager has moved from another home, which is owned by the same people who own The Haven. She has made application to be registered with the CSCI. She told the inspector that she has applied to study for an appropriate management qualification. People said that she was very approachable. One person said, “The new manager is nice person. She keeps my family up to date”. One staff member said, “ The new manager is really good. She is always there for support”. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 21 The acting manager said that she intends to carry out resident, relative and staff surveys to find out what changes people would like to be made within the home. She said that where possible these would be implemented. The owners visit the home on a regular basis. They carry out a complete audit on a monthly basis and send a copy of the report to the CSCI. Regular meetings are planned for both staff and people who live in the home. This will give people another opportunity to say what changes they would like to be made in the home. Regular staff supervision has commenced. One member of staff said “I get regular supervision from one of the seniors”. The home has had a recent audit from the contracting department at social services. The acting manager said that the owners are making some changes as to how the monies of the people who live in the home are managed as a result of that audit. This is to make sure that people are protected from financial abuse. The home have had recent visits from the Environmental Health Department and the Fire and Rescue Service. Both reports indicated that the home are making satisfactory progress with regard to the requirements made following previous inspections. A random sample of policies and procedures were viewed. All of the policies and procedures need to be reviewed to ensure that they are up to date and relevant to the home. Some maintenance certificates were still outstanding at the last random inspection. Copies of all maintenance certificates have now been supplied to the CSCI. The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X 2 2 The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(a) Requirement The contract must include a breakdown of fees. This must include the amount paid and who is responsible for paying them. Timescale for action 31/08/07 2. OP26 23(2)(d) A cleaning schedule must be 31/07/07 implemented to make sure the home is cleaned to an acceptable standard. Sufficient staff need to be 31/08/07 employed to cover both activities and cleaning. The acting manager must 30/06/08 complete an appropriate management qualification. The home must further develop 31/08/07 the quality assurance system to seek the views of the people who live in the home and their relatives. (The requirement made at the last inspection has been met in part). 3. OP27 18(1)(a) 4. 5. OP31 OP33 10(3) 24 & 26 The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 24 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 OP12 OP16 Good Practice Recommendations Service users need to be consulted about the activities being provided and this information should be included within the care plan. The complaints procedure should contain details of how to contact the local social services department and the ombudsman. All of the policies and procedures should be reviewed to ensure that they are up to date and relevant to the home. 3. OP37 The Haven DS0000046459.V337109.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. Extracts may not be used or reproduced without the express permission of CSCI The Haven DS0000046459.V337109.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!