Inspection on 21/11/06 for The Haven

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

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 19/06/07

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 Tanya Newton Unannounced Inspection 21st November 2006 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.V322593.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.V322593.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 Leslie Dean Serteece 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.V322593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 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.V322593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out between the hours of 10:00am and 4:30pm. Records were looked at and a tour of the building was carried out. The inspectors (Tanya Newton and Susan Lowther) spoke to some of the service users living at The Haven to ask their views of living at the home. All key national minimum standards were looked at. What the service does well: What has improved since the last inspection? What they could do better: Assessments and care plans need to contain information, which supports staff in meeting residents needs. Resident’s dignity must be maintained and all service users, including those with dementia must have their rights respected, this includes their spiritual needs. Service users should be asked about their social needs and this information included within their care plan. Residents meetings should be held so that their views, wishes and opinions can be taken into account. All staff need to receive training in adult protection. The environment was in a very poor state of repair and was potentially unsafe for the residents living at the home. The fire officer and environmental health officer visited the home and will produce their own reports. The home must ensure that they take the correct action to comply with these. Standards of cleanliness must also be improved upon. Staff training needs to be updated in a number of areas and the manager needs to gain an NVQ level 4 in care. Quality assurance systems need to be developed to gain feedback from the residents living at the home. Health and safety systems were also extremely poor and must be improved upon so that service users are not put at risk. Eleven requirements have been made as a result of this inspection. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 6 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.V322593.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.V322593.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): 3&6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Assessments did not contain sufficient information detailing the way in which the home could meet service users needs. EVIDENCE: Assessments need to contain comprehensive information so that peoples needs can be fully met. The assessments viewed were not written with sufficient information to enable staff to meet resident’s needs in an effective way. The home does not provide intermediate care to residents. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents cannot be assured that all of their care needs can be met. Records within the home did not contain the required information. Medication systems were satisfactory. Some service users rights to privacy and dignity were compromised. EVIDENCE: The manager said that all of the residents who live at The Haven Care Home had a care plan. Three care plans were inspected. They were not written in enough detail to ensure that staff could fully understand service users’ needs. It was sometimes difficult to decipher what care service users were receiving. It was difficult to gain from written care plans how the home were meeting residents health needs. This information needs to be recorded with input from residents where possible. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 10 The administration of the medication was checked. The medication administration records had been completed accurately and a random audit of resident’s medication was done. This was found to be satisfactory. Although none of the residents raised concern regarding their privacy and dignity, the poor standards of cleanliness and the environment generally did not promote people’s dignity, health and well being. Resident’s dignity must be maintained and all service users, including those with dementia must have their rights respected, this includes their spiritual needs The Haven DS0000046459.V322593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides some activities to residents. Information relating to peoples social interests should be included within their care plans. Comments about the menus were positive. EVIDENCE: Comments about the activities taking place in the home were mixed and included “there’s very little entertainment and excitement” and “I play dominos and different games and “there is an activities girl for three days each week we play dominos, bingo, cards and darts”. There was no information in residents care plans detailing their social interests. Although some residents had there spiritual needs met by visiting clergy this was not made available to all residents within the home. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 12 Most of the residents spoken to during the inspection said that they were able to make choices and decisions about their daily lives, this included meals, how often they wanted a bath and what time to get up and go to bed. One resident said “staff treat me as an individual and don’t make me do anything I don’t want to do”. One resident said, “There are no residents meetings, the manager’s put orders down and we obey them”. Residents meetings should take place to enable residents to express their choices and wishes. Comments about the food were positive all residents spoken to say that they like the food and that a choice of meals was available. One resident said, “I have put too much weight on as the meals are great”. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 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. Staff would benefit from training in adult protection. EVIDENCE: There had been a number of concerns, which had been brought to the attention of the inspectors prior to visiting the home. Some of these related to the poor standards in the environment and standards of record keeping within the home. The home does have procedures for managing complaints and these are displayed throughout the home. Policies to safeguard residents were also present within the home, staff need to receive training in adult protection to ensure that the procedures are adhered to. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Standards of cleanliness were poor and the home was not well maintained. This posed a risk to service users and staff at the home. EVIDENCE: The home is undergoing a programme of refurbishment. However on the day of the inspection this was not being managed in a safe manner. Many rooms, which were unlocked, were full of furniture some of which was broken, and equipment such as drills and other tools were lying around the home, this poses a potential risk to service users. Bathrooms were dirty and equipment such as bath chairs were in very poor condition. The hot water in the bathrooms was extremely hot, service users The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 15 were at risk of scalding themselves with this. The registered provider must ensure that the thermostatic valves are maintained to ensure service users are kept safe. There was evidence of communal toiletries being used in the bathrooms. Studs in bath chairs need to be moved to make them safe, as there was a risk of entrapment. The boiler room next to the smoking lounge was unlocked and the smoke detector taped up. This is very dangerous practice and must be stopped. Some of the bedrooms smelt strongly of urine and one room had faeces all over the carpet. The home must take the appropriate action to address this. Many of the toilets and commodes were covered in faeces. The taps in one of the bathrooms was broken and the wooden surround at the bottom of the bath was loose. One toilet had no flooring. There was no extractor fan in the smoking lounge, some of the furniture in the home was falling apart. Radiator covers were loose which meant that service users in the home could burn themselves. Some of the carpets were raised and posed a trip hazard to both residents and staff. Cupboards, which had signs stating, “keep locked” were unlocked. The programme of maintenance must be risk assessed and managed in a safe way. One service user had been moved to a room where another service users possessions were in place, this is unacceptable practice. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the needs of the residents living at The Haven. Staff training needs to be updated to ensure service users and staff’s safety. Staff files in the main contained the required information. EVIDENCE: Staffing numbers seem sufficient to meet the numbers of residents currently living at The Haven. Staff files were looked at. All new files contained the required information such as references and a police check, which helps to keep service users safe. Some of the files for people who had been employed for longer periods did not contain references. All of the care staff working in the home have achieved an NVQ at level 2 or above this is commendable. Staff training must be kept up to date and include manual handling, first aid, food hygiene and infection control so that the needs of service users are fully met. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There were a number of Health and Safety issues which have been overlooked and which place service users at unnecessary risk. EVIDENCE: The home is not being managed and run in a way, which protects service users and staff. There were a number of health and safety issues, which needed to be addressed. The manager needs to gain an appropriate qualification in care (NVQ level 4 or equivalent). The manager is well liked by service users and staff and there were a number of positive comments made about him during the inspection, which included “he’s a lovely chap”. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 18 Quality assurance systems should be further developed to gain the views of service users, relatives and other professional. The results of these should be published within the home. The manager said that the home does not look after service users financial interests and that service users and their relatives were encouraged to retain financial control. Health and Safety practices in the home were poor and placed service users and staff at risk. There were no records of fire training for staff and no up to date maintenance certificates in the home. Many doors were wedged open and fire exits were not accessible. Appropriate fire signage was not available in the home and there was no fire resistant glazing in the smoking lounge. The home are not complying with their own smoking procedures, these should be updated to reflect actual practice within the home. One of the smoke detectors was taped up. Advice was sought from the fire officer and the environmental health officer during the inspection, the home must comply with any action requested in their reports. Staff training was not up to date, many staff require training in first aid, manual handling, food hygiene, fire, health and safety, adult protection and infection control. The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 19 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 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP3 OP7 OP8 Regulation 14(1)&(2) 12(1)(2) (3) 15(1) & (2) 12(4)a&b Requirement Each service user must have an in depth assessment to ensure the home can meet their needs. Each service user must have an in depth care plan which sets out how the home will meet all of their needs The home must ensure that resident’s privacy and dignity is respected and maintained by staff. Service users must be consulted about the activities being provided and this information included within the care plan. All staff must receive training in adult protection. The standards within the environment must be improved. The home must supply CSCI with an action plan detailing how the following matters will be addressed and in what order the work will be carried out: • Rooms which are not in use or being used for storage must be kept locked • Equipment such as drills DS0000046459.V322593.R01.S.doc Timescale for action 28/02/07 28/02/07 3 OP10 31/12/06 4 OP12 OP14 16 m&n 28/02/07 5 6 OP18 OP19 OP26 13(6) 23(1) & (2) 28/02/07 15/01/07 The Haven Version 5.2 Page 21 • • • • • • • • • • • • • • The Haven and other tools must be kept in a safe Bathrooms must be kept clean Equipment such as bath chairs must be maintained in a good condition The hot water in the bathrooms must be maintained at a safe temperature The registered provider must ensure that the thermostatic valves are maintained to ensure service users are kept safe. Each resident must have his or her own toiletries. Studs in bath chairs need to be moved to make them safe. The boiler room next to the smoking lounge must be kept locked and the smoke detector must not be taped up. Bedrooms, which smell strongly of urine, must be properly cleaned with alternative flooring put down where this is required. Toilets, commodes and bedrooms must be kept clean. The taps in one of the bathrooms was broken and the wooden surround at the bottom of the bath was loose. These must be fixed. One toilet had no flooring. This must be replaced. An extractor fan is required in the smoking lounge. Some furniture needs Version 5.2 Page 22 DS0000046459.V322593.R01.S.doc immediate replacement as it is falling apart. • Radiator covers must be properly attached to the wall. • Some of the carpets were raised and posed a trip hazard to both residents and staff. These must be made safe. • Cupboards, which had signs stating, “keep locked” must be locked. The programme of maintenance must be risk assessed and managed in a safe way. A copy of this risk assessment must be sent to The Commission. 7 OP19 OP26 OP38 16(2)(j) & 23(4) Advice was sought from the fire officer and the environmental health officer during the inspection. The home must confirm in writing to the Commission as to how they have addressed any issues identified in these reports. Staff training must be kept up to date and must include manual handling, first aid, food hygiene and infection control. The manager needs to gain a qualification in care at NVQ level 4 or above. The home must ensure that it has effective quality assurance systems in place, which seek the views and wishes of service users, their relatives and other professionals visiting the home. The results of any surveys should be made public in the home. The owner must carry out visits under Regulation 24 & 26 and provide The Commission with a copy of the report. DS0000046459.V322593.R01.S.doc 28/02/07 8 OP28 OP30 OP38 OP31 OP33 18(1) 31/03/07 9 10 10(3) 24 & 26 30/06/07 31/01/07 The Haven Version 5.2 Page 23 11 OP38 13(3) & (4) The home must ensure the health, safety and well being of service users and staff. The following must be carried out. • Regular maintenance checks must be carried out and include gas safety checks, electrical wiring, servicing of the hoist, fire safety checks, water temperature checks and a record of all checks must be maintained. • Staff training must be kept up to date. • The refurbishment of the home must be carried out in a planned and structured way to safeguard the people living there. 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Haven DS0000046459.V322593.R01.S.doc Version 5.2 Page 24 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.V322593.R01.S.doc Version 5.2 Page 25 - 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!