Archived: Haven Lodge

Updated 3 May 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, to look at concerns we received about the service and to provide a rating for the service under the Care Act 2014.

We inspected the service on 22 and 30 November 2017. The inspection was unannounced. The inspection team consisted of three inspectors.

Prior to our inspection we reviewed information we held about the service. This included information received from local health and social care organisations and statutory notifications. A notification is information about important events which the provider is required to send us by law, such as, such as allegations of abuse and serious injuries. We also contacted commissioners of the service and asked them for their views. Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used this information to help us to plan the inspection.

During our inspection visit we spoke with six people who lived at the service. We also spoke with two members of care staff, the manager and the provider.

To help us assess how people's care needs were being met we reviewed all or part of six people's care records and other information, for example their risk assessments. We also looked the medicines records of five people, four staff recruitment files, training records and a range of records relating to the running of the service, for example, audits and complaints. We carried out general observations of care and support looked at the interactions between staff and people who used the service.

Updated 3 May 2018

We inspected the service on 22 and 30 November 2017. The inspection was unannounced. Haven Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Haven Lodge accommodates up to 12 people in one building. On the day of our inspection 12 people were using the service.

At the last inspection in August 2016, we asked the provider to take action to make improvements to the safety of the service, leadership and quality assurance. During this inspection we found the required improvements had not been made.

The service is operated by an individual and so does not require a registered manager. The registered provider is the ‘registered person.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered provider had employed a manager who supervised the day to day running of the service.

During this inspection we found the service was not safe. Environmental risks were not consistently identified or addressed, consequently people were exposed to the risk of serious harm. People were not always protected from risks associated with their care and support. Action had not been taken to protect people from the behaviour of others living at the home. Systems to review and learn from accidents and incidents were not consistently effective and this meant we could not be assured that action was taken to protect people from harm. Action was not always taken to protect people from improper treatment or abuse. There were a number of safeguarding investigations underway at the time of our inspection visit.

Medicines were not stored or managed safely. There were enough staff to provide care and support to people when they needed it. However, safe recruitment practices were not followed.

Where people lacked capacity to make choices and decisions, their rights under the Mental Capacity Act (2005) were not always respected. Staff felt supported, but did not receive sufficient training to enable them to effectively meet people’s individual needs. People were supported to attend health appointments. However, there was a risk that people may not receive appropriate support with specific health conditions, as support plans did not contain enough information. People were supported to have enough to eat and drink, however choices were limited.

People did not always receive person centred support which met their needs. Staff had a limited understanding of how to support people with mental health needs and this resulted in people not receiving appropriate support. People were subject to institutionalised practices. Policies and practices were not person centred. Staff respected people’s privacy.

People were at risk of receiving inconsistent support as care plans did not provide an accurate or up to date description of people’s needs. People’s feedback about opportunities provided by the service was mixed and we found there were limited opportunities for meaningful activity. People knew how raise issues and concerns, however some people did not feel comfortable doing so.

The service was not well led. Systems in place to monitor and improve the quality and safety of the service were not effective and this placed people at risk of serious harm. There were no systems in place to record, analyse and investigate incidents which posed a risk to the health and wellbeing of people who used the service. Swift action was not always taken in response to known issues. Staff felt supported and were able to express their views in relation to how the service was run.

You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe, so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.