Inspection on 21/11/05 for The Haven

This inspection was carried out on 21st November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Haven 31/07/06

The Haven 11/07/05

The Haven 30/12/04

The Haven 12/10/04

The Haven 23/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Haven Radley Road Abingdon Oxfordshire OX14 3PP Lead Inspector Chris Hastings Unannounced Inspection 21st November 2005 08:30 The Haven DS0000013091.V267601.R01.S.doc Version 5.0 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 DS0000013091.V267601.R01.S.doc Version 5.0 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 Adults 18-65. 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 DS0000013091.V267601.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Haven Address Radley Road Abingdon Oxfordshire OX14 3PP 01235 521801 01235 521801 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) Caretech Community Services Limited Julie Firth Care Home 6 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 6. 11th July 2005 Date of last inspection Brief Description of the Service: The Haven is a home for six adults with learning disabilities and physical disabilities. The home provides 24-hour support for the residents to meet their assessed needs. It is run by CareTech, a large private company that specialises in services to people with learning disabilities. The actual house is owned by a housing association. The home is detached and located in the outskirts of Abingdon, a market town about seven miles south of Oxford. The home is domestic in appearance, has a big garden but needs work done to promote the homely atmosphere. As the residents have become older and their physical disabilities have increased questions are being raised about the suitability of this property to meet the needs of the residents. The residents are helped to use local services and facilities. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection. This means that the home had no prior notice of the inspector’s visit. The inspector arrived in the home at 8.30am and left the home at 11.30am. During this time the inspector met and spoke with all six residents, a relative who was visiting the home and the four staff on duty. He also observed staff as they carried out their work and looked at a sample of written records and documentation. The inspector also followed up the requirements made at the last inspection. The Commission did not receive an action plan in relation to the requirements made at the last inspection, although the manager had produced one and the inspector saw it during this visit. The manager agreed to send a copy of the action plan to the inspector and to write confirming the action that had been taken in relation to the requirements. This was the second inspection at The Haven this year. During this visit the inspector looked at the standards that have been identified by the Commission as needing to be inspected during the inspection year and were not inspected at the previous inspection in July 05. Therefore, to gain a full picture of the service this report should be read in conjunction with the previous report dated 11th July 2005. Residents and staff made the inspector welcome and helped in the inspection process and the inspector thanks them for their cooperation and making him feel so welcome. Residents made very positive comments about The Haven. One lady said ‘it is like heaven’ and another lady said ‘its very nice’. Overall the inspector found the home to be providing good quality care in a homely and relaxed environment. The building in places is in need of repair and decoration and in some areas was very tatty. This distracted from the considerable work being done by staff in promoting a homely and welcoming environment. There were good relationships between the residents and staff on duty, with staff being responsive to residents’ needs in a respectful manner. Some issues were identified that need to be addressed by the home but the overall impression that the inspector gained was that the residents were being well supported by a good staff team who treated them with respect and dignity. What the service does well: Service users’ choices are acted upon by staff. Staff give service users time to communicate. Service users are respected by staff. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 6 The home has a very homely atmosphere. Staff have good relationships with service users. Staff are generally well supported. The home is clean but tatty. Residents are encouraged to assist with tasks in the home. Residents have a good diet and are involved in planning the menu. What has improved since the last inspection? 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 Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5 were inspected in July 2005. EVIDENCE: The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were inspected in July 2005. EVIDENCE: The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 and 17. Standards 12, 13, 14 and 15 were inspected in July 2005. Residents’ rights and choices are respected and they are assisted to become involved in tasks in the home. The locks on bedroom doors could put residents at risk. Residents are valued as individuals. Residents have a good diet and are involved in menu planning. EVIDENCE: During the inspection residents’ choices were respected and acted upon by staff. This was seen in relation to when to get up, going out and choices made during breakfast. The home has a system called ‘Individual Support Requirements’ (ISR) that identifies how staff meet the needs of residents and how residents like their needs to be met. These care plans are recorded in a The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 11 very personal manner and start with for example ‘I … or ‘My ….’ This makes them very powerful and individualised. Some residents have jobs that they do in the home. One lady collected the post in the morning and took pride in doing this and giving the post to staff. Staff showed their appreciation. Such jobs were agreed with residents and a record of this was seen in the minutes of a residents’ meeting and in the ISR. The ISR was signed by the mother of the resident. The inspector noticed that the locks on bedroom doors could be deadlocked from the inside. This type of lock on bedroom doors is not acceptable as they could place residents at risk if, in the event of an emergency, staff cannot gain access to the room. These locks need to be replaced. Throughout the inspection staff were observed to communicate and work with residents. It was evident that the staff knew how to work with each individual in a respectful and dignified way and they are to be commended for their work and the positive atmosphere during the inspection. Residents are involved in planning menus in the home. The inspector asked three residents about their favourite foods and these were seen to be on a current and recent menu. The favourite food of one resident was seen to be also recorded in her ISR. Copies of the current and previous menu were seen. The inspector was told that a recent audit by CareTech had identified the need to record what individuals had eaten if this differed from the planned menu and the home had started to do this. One lady told the inspector that the food was ‘nice’. The relative of a resident told the inspector that she thought the ‘menu was very good’ and ‘they ask the ladies what they’d like’. Residents were given appropriate support during breakfast and independence was promoted with the use of appropriate aids. One lady ate independently and as a result spilt some of her cereals. This was responded to appropriately by staff in a way that promoted the person’s independence rather than by being negative about the spillage. This type of positive interaction was observed throughout the inspection and staff are to be commended. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Standards 19 and 20 were inspected in July 2005. Staff support residents to meet their assessed needs in the way residents like to be supported. EVIDENCE: The ISRs clearly record residents’ care needs and how they like them to be met. Staff were seen to work in accordance with the ISRs during this inspection. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected in July 2005. The comments made in this section relate to observations made during this visit and not to the full assessment made in July 2005. The records of complaints now record actions taken by staff and the outcome. EVIDENCE: The inspector looked at the complaints book and the action taken by staff and the outcome is now recorded as required at the last inspection. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Standards 24 and 30 were inspected in July 2005. The home is clean and tidy but in need of refurbishment and redecoration. The physical environment does not meet the needs of some residents and places them at risk. EVIDENCE: All areas of the home visited by the inspector were clean. However parts of the home are very tatty and this distracts from the other good service being provided. The inspector considers that the upkeep of the home lets down both residents and staff. Missing tiles were seen in a bathroom, holes in walls and tired and damaged paintwork throughout the house. This needs to be addressed. The inspector is aware that concerns have been raised about the appropriateness of the current building to meet the needs of the residents. The manager described to the inspector three residents who are accommodated on the first floor and have mobility or sight issues. The The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 15 inspector considers that using the stairs could put them at risk. This was also raised in the July 2005 inspection report and although the inspector was informed that discussions on how to rectify the situation were ongoing, a clear action plan is required. The inspector is concerned that the longer this situation continues the greater the risk to residents. Failure to resolve the situation to ensure that the needs of all residents are met could lead the Commission to consider enforcement action, which would be unfortunate considering the positive qualities of this service. The inspector is aware that the use of the conservatory as a dining room has raised issues in the past. The conservatory was being used for some residents to have breakfast during this visit. The inspection took place on a very cold morning when the outside temperature was –3.5°c. The inspector measured the temperature in the conservatory when he arrived in the home and the recorded temperature was 21.5° c. A radiator and a fan heater were heating the conservatory and the fan heater was left on for the duration of the inspection. The heating in the home needs to form part of the audit of the premises, so a judgement can be made on its adequacy for the residents, some of whom are immobile. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 33, 34, 35 and 36 were inspected in July 2005. The comments made in this section relate to observations made and not to a full assessment. Staff are well supported but the on call system needs clarification and improvement to ensure residents are not placed at risk. EVIDENCE: The inspector sampled the supervision records of two staff that were on duty. Both records showed that these staff had regular formal supervision as indicated by good practice. The inspector also asked the manger to show him how the on call system worked. The on call system is a very important part of ensuring that in the event of an emergency appropriate advice and guidance can be sought. The manager explained that she or the deputy were on call, that the service manager would also be on call and that in addition the head office could be contacted and the call would connect to a national person who was on call. The inspector asked the manager to try the national on call system. The manager spoke to two people at the headquarters of CareTech who were not aware of this procedure. While the inspector accepts that this is primarily an out of office hours system, staff must be able to have a system that is fail safe The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 17 and one that works if the local system fails for any reason. This needs to be clarified for staff and guidance put in place so residents are not put at risk. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37, 39, and 42 were inspected in July 2005. The comments made in this section relate to observations made and not to a full assessment. CareTech are failing to send copies of their monthly visit to The Haven to the Commission. EVIDENCE: A requirement was made at the inspection in July 2005 concerning the need for CareTech to undertake monthly visits to the home in accordance with regulations and to send a copy of the reports from such visits to the Commission. During this inspection copies of reports of the monthly visits were seen in the home but they had not been sent to the Commission. This part of the requirement has therefore not been met and a new date has been given for compliance with this regulation. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Haven Score 3 X X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000013091.V267601.R01.S.doc Version 5.0 Page 20 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 YA39 Regulation 26 Requirement Copies of the reports of the monthly visits undertaken by a representative of CareTech must be sent to the Commission. (Outstanding requirement which should have been met by 31/07/05) The manager and provider must replace the locks on residents’ bedrooms with locks that cannot be deadlocked from the inside, and while this is being done take appropriate action to ensure the safety of residents. The manager and proprietor must undertake an audit of the premises to clearly identify those areas that require work and redecoration and submit an action plan of the audit and action plan to address the issues identified to the Commission. The manager and provider must write to the Commission outlying how they plan to address the issue of the building not meeting the needs of current service users on the first floor. The manager and provider must DS0000013091.V267601.R01.S.doc Timescale for action 31/12/05 2 YA24 13 (4) c 28/02/06 3 YA24 23 (2) b,d 28/02/06 4 YA24 23 (2) n 28/02/06 5 YA36 18 (2) 28/02/06 Page 21 The Haven Version 5.0 clarify the on call system for staff and provide a copy of the procedure to the Commission. Until this is done the manger is required with immediate effect to ensure that all staff in the home are briefed on the local on call system and to ensure there is an effective on call system for The Haven. 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 YA24 Good Practice Recommendations The inspector recommends that the adequacy of heating is included in any audit of the premises, to ensure that it meets the needs of the current service users, some of whom are immobile. The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 The Haven DS0000013091.V267601.R01.S.doc Version 5.0 Page 23 - 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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