Inspection on 23/06/08 for Green Haven

This is the latest available inspection report for this service, carried out on 23rd June 2008.

CSCI found this care home to be providing an Good service.

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

Green Haven 31/08/06

Green Haven 23/01/06

Green Haven 18/07/05

Green Haven 11/02/05

Green Haven 26/08/04

Green Haven 19/01/04

Green Haven 26/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Green Haven 18 Montpelier Road Ealing London W5 2QP Lead Inspector Sarah Middleton Key Unannounced Inspection 23rd June 2008 09:55 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 Green Haven DS0000027707.V364126.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. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Green Haven Address 18 Montpelier Road Ealing London W5 2QP 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) 0208 997 2142 0208 997 4235 greenhavenhome@btconnect.com Haven Green Housing Association Limited Manager post vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th June 2007 Brief Description of the Service: Green Haven provides a service for 22 older people. The home is well established and has been in operation since 1961. A voluntary committee manages Green Haven and meets every other month. The home is supported by a group of volunteers known as the Friends of Green Haven. The home aims to support the residents in maintaining links with the community as far as is practical and in accordance with the residents’ wishes. Green Haven is a large detached property in a quiet residential area of Ealing. The home has parking to the front of the building and a large garden and veranda at the back. It has three floors, with bedrooms on each floor. Those above the ground floor are accessed using the passenger lift. All bedrooms are single and one has en-suite facilities. The home has a large lounge and separate dining room. Fees range from approximately £441-£556 per resident per week. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out in one day from 9.55am-6.40pm. We spoke with ten residents, one visitor and two members of staff. Thirteen residents and one relative had also returned postal surveys to the Commission. Comments and contributions have been included in the inspection report. The Manager has yet to register as the Registered Manager and will be referred to in this report as the Acting Manager. The Acting manager completed an Annual Quality Assurance Assessment for this year. This is a self-assessment looking at aspects of the home and the care being provided. The previous eight requirements had been met and seven new requirements were made from this inspection visit. The Pharmacy Inspector’s six previous requirements had also been met. All of the key National Minimum Standards were inspected. What the service does well: What has improved since the last inspection? Some aspects of the medication systems had improved, with the home taking steps to be more vigilant when supporting residents with their medication. See below for further details of the shortfalls identified in relation to medication. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 6 There was an ongoing maintenance programme that was updating and refurbishing several areas of the home. Health and safety checks had improved with a fire risk assessment now in place. 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. Green Haven DS0000027707.V364126.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 Green Haven DS0000027707.V364126.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 is N/A. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: The Acting Manager confirmed there was a process for prospective residents to view the home and meet other residents and staff prior to making a decision about moving into the home. The Annual Quality Assurance Assessment stated the home was looking to encourage prospective residents to have an overnight stay before making a decision. A resident spoken with confirmed they had visited the home before they moved in. We viewed a pre-admission assessment and this covered a wide range of needs, such as, the prospective resident’s health and social needs. In addition, the home seeks to obtain information from the referrer, such as relevant reports and risk assessments. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 9 All recently admitted residents move in on a six week trial and the placement is reviewed to ensure both the resident and the home are happy for the move to then be made permanent. Green Haven DS0000027707.V364126.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans need to consider and record the resident’s needs. Health needs had been recorded and were being met. The medication shortfalls could place the residents at risk. Residents feel they are treated with respect and their privacy is upheld. EVIDENCE: Three care plans were viewed. These were with regards to the most recently admitted residents, two of these residents was staying in the home for a short respite period. Overall the files were detailed, recording next of kin along with health and social care needs. Care plans are reviewed on a monthly basis and a more detailed review is then carried out every six months. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 11 The Annual Quality Assurance Assessment confirmed that care plans are reviewed on a regular basis so that changes in residents needs are quickly identified and amendments are then made accordingly. The Acting Manager showed a “mini- care plan” that is completed on respite residents. This outlines the main areas of care and support the resident will need. It was noted on one care plan that there was no record of the resident’s personal care needs. This was brought to the attention of the Acting Manager and a requirement was made for this to be addressed. Risks are considered and assessed, such as risk of falling, moving and handling and nutritional risks. Risk assessments are updated as and when needs change. The Deputy Manager is considering completing all the care plans and risk assessments, in conjunction with keyworkers. The Acting Manager is looking into whether this would work and be beneficial for the staff and residents. All residents have access to a GP and other health professionals, such as, Dentist, Optician and Chiropodist. Medical appointments had been recorded onto daily records. It was discussed with the Acting Manager the benefit of devising a medical appointment form that would record appointments and outcomes of visits. Recording appointments and outcomes of health visits in one clear place would make it easier to monitor the health of a resident. Appropriate risk assessments are carried out on resident’s health needs, such as risk of developing pressure sores and continence assessments. Medication was viewed. The Pharmacy Inspector had visited the home shortly after the last key inspection carried out in 2007. She had found several shortfalls and had made six requirements. The home has actively addressed these areas of concern, such as updating the medication policy, securing the medication trolley to the wall and keeping records of medication that has been disposed of. Known allergies are now noted on the resident’s Medication Administration Records. Senior staff administer the medication and all staff had received medication training after the last key inspection in June 2007. It was discussed with the Acting Manager the need for senior staff to receive ongoing training on this subject so that they are kept informed of any legislative changes and good practice guidance. We viewed a sample of medication, some were in relation to the residents’ files we had earlier looked at, or relating to residents we had spoken with. The home now holds on to all resident’s medication, with none being kept in residents’ bedrooms. One resident, staying in the home on respite for two weeks, had their medication given to them, by staff, but the resident was administering it to themselves. Staff observed this administration but had not been recording that it had been observed on the Medication Administration Records. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 12 The Deputy Manager was advised that this should be recorded to evidence that it had been given to the resident for them to self-administer each day. This same resident’s medication was being kept in a fridge in the small office. The fridge was not lockable and the office was noted as being kept open during the inspection. The Acting Manager and Deputy Manager agreed that this office would from now on be locked and was done so during the inspection visit. All medication must be kept locked away from residents and any other people visiting the home. The home has controlled drugs and this is stored safely and separately from the main medication. Two members of staff sign the controlled drugs form. One member of staff administers the medication whilst the other witnesses it being given. It was recommended for the home to purchase a bound and numbered controlled drugs register. The home had not obtained an up to date BNF and this was also made a recommendation. Subsequent to the inspection we were informed that the Acting Manager had ordered the controlled drugs register and a new BNF book. The quantities had been recorded on the Medication Administration Records, but for one resident the amount recorded as being in the home did not match with the medication that had been signed for as being administered. This was raised with the senior member of staff who had counted the delivered medication. By failing to record the correct amount delivered, it was difficult to assess if the resident had actually received the right medication on a daily basis. A requirement was made for the recording of medication to be accurate and checked. The Deputy Manager, in charge of counting and keeping an audit of the medication in the home had not carried out a check since the end of April 2008. A requirement was made for this to be done on a more regular basis. It is essential regular spot checks be carried out so that any errors can be noted and action can then be taken. The welfare of the residents must be paramount at all times. Errors can place the residents at risk. The Acting Manager was made aware of the above shortfalls. Following on from the inspection we were informed that a full medication audit had been carried out and no further errors had been identified. The Annual Quality Assurance Assessment had not made reference to the medication Standard or describe how the home was meeting this Standard. It is important for the home to reflect on procedures and practice in all aspects of care, to ensure systems are robust and safeguard the residents. Those residents asked confirmed they receive their own personal mail and can make calls using the public telephone. One resident has their own mobile phone, whilst others can have telephones in their bedrooms. Residents do not have to share their bedrooms with another resident. Those residents asked said the staff treated them with respect and courtesy. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. Overall there are opportunities for residents to engage in social activities. Residents are supported to maintain social relationships with family and/or friends. Residents are supported to make daily choices about their lives. The meal provision is varied and offers residents with a balanced diet. EVIDENCE: There are set activities that are planned for each day, such as quizzes, sing-alongs and games. At times throughout the year external entertainers also visit the home. The day after the inspection a person was visiting who provides musical entertainment. It was brought to the attention of the Acting Manager that in two postal surveys, one from a resident and one from a relative, a lack of activities were mentioned. Both surveys commented that due to staff shortages, (looked at later in the report), activities did not always occur. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 14 The Acting Manager and those staff spoken with said there were activities taking place in the home and that there were sufficient numbers of staff working on a shift to encourage residents to engage in the activity on offer. Those residents asked, said there were some activities on offer if they so chose to take part in them. On the day of the inspection there was a quiz being run by a member of staff and a resident. Many of the residents said they enjoyed reading the newspaper or talking to each other. One resident visits the local drop-in centre and family members or friends also take residents out in the community. Visitors were seen throughout the inspection and we met with one. The visitor said they were happy with the home and that staff were friendly. The visitor stated that the resident had told them that they were happy living in the home. Visitors can meet residents in private or in the communal areas. Residents, within reason, are able to bring their own personal belongings into the home. There are no residents who manage their own finances independent of support from the home, family or the Local Authority. The staff team and those residents asked confirmed residents could make decisions about their everyday lives. We met with the assistant cook who was preparing the lunch. Fresh produce is made on a daily basis. There was evidence that a fresh dessert had been made. Meals are varied and incorporate the resident’s favourite meals. Residents can choose to eat something other than what is on the menu. Evidence was seen that the assistant cook does prepare alternative meals from the main meals on offer. The assistant cook stated that she knew the residents’ likes and dislikes. Those residents with diabetes receive a special diet to ensure they maintain good health. We sat with the residents during the lunchtime period. Staff were seen to assist some residents with feeding. This was carried out in an unhurried manner. Those residents asked said they enjoyed the meals. One postal survey completed by a resident commented that the “meals were delicious”. Fresh produce is used where possible and many meals are freshly prepared on the day. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are aware of how to make a complaint. Systems are in place to protect residents from abuse. EVIDENCE: The home had received one complaint since the last inspection. All of the returned postal surveys stated the resident or relative knew how to make a complaint. Those residents asked said they would speak with staff or the Acting Manager if they had any concerns. There have been no allegations of abuse in the home. Some staff had not attended refresher training on adult abuse for sometime. This was raised with the Acting Manager who will look for all staff to be up to date with this subject. The Acting Manager confirmed policies and procedures on abuse were in the home. These were not viewed at this inspection visit. Green Haven DS0000027707.V364126.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents would benefit from sitting in a bright and updated dining room. The home was clean and tidy on the day of the inspection. EVIDENCE: The home continues to be updated and refurbished. There was new carpet along the hall of the first floor. New garden furniture had been purchased. The ground floor toilets were in the process of being updated, with plans to update the bathrooms and have a walk-in shower room on the top floor. There were still areas needing to be addressed, for example, the small hall leading up to the top floor and the dining room were in need of painting, as the walls were stained and marked. A requirement was made for this to be addressed. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 17 We discussed with the Acting Manager the kitchen, as this room would benefit from being updated. The Acting Manager was agreeable to this plan but stated that it would have to be a longer -term goal once other more essential maintenance work had been carried out. The home has two domestic staff that keeps the home clean. They both attend training courses and are studying for NVQ’s. The parts of the home seen were clean and tidy on the day of the inspection. Green Haven DS0000027707.V364126.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by sufficient numbers of competent staff. The recruitment checks need to be more robust in order to protect the residents. To ensure staff are skilled and appropriately trained, the training programme needs to be offered to staff on an ongoing basis. EVIDENCE: The rota was viewed in light of the earlier comments noted in the report about the staff shortages. The Acting Manager explained he had recently recruited two new members of staff, who have yet to start working in the home. There are soon to be staff changes as two members of staff are retiring, another has reduced their working hours each week and another member of staff is due to go on maternity leave in the near future. The rota showed that there are four members of staff working in the morning and three in the afternoon. At night there is a sleeping in person and a waking night member of staff. The sleeping in person is usually a senior member of staff or the Acting Manager. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 19 Senior staff work on a shift so that they can administer medication and supervise the care staff team. There are some days where permanent staff work a long day from the morning until the evening. On these occasions staff are given a two-hour break half way during the day and this was seen on the day of the inspection. The Acting Manager said the home avoids using external agency staff, but acknowledged there was a need for casual staff to be recruited to cover sickness, holidays and vacancies. There was no evidence that the home is short staffed and those staff asked said there were sufficient staff working in the home at this moment in time. The Acting Manager will need to monitor the imminent staff changes to ensure there will be sufficient numbers of competent staff working in the team. Staffing numbers will also need to be monitored as and when the residents’ needs change. The Acting Manager has actively promoted all staff studying for an NVQ. The Deputy Manager is studying for an NVQ level 4. Other senior staff are studying for NVQ level 3. Once new staff have worked through their probation period they will have the opportunity to study for this qualification. The main staff employment files were not accessible on the day of the inspection. The Acting Manager explained he did not hold a key to where these files were stored. This practice must change, as the Acting Manager must have access to all areas of the home. We did view information on two new potential people who would be joining the staff team once all the required information was available for the Acting Manager. Completed application forms were viewed. These had been updated and included health declarations checks. We were informed that all new staff, once they have completed a three-month induction period, visit an independent doctor to assess their health. References were seen and discussed with the Acting Manager. One applicant had given a work reference and a personal reference. This person had worked in two previous care settings and so the Acting Manager should be actively seeking references from both these places of work. The other applicant had given two personal references, as their last job was not in the UK. This was discussed with the Acting Manager, as the expectation would be to request where possible, employment references. Subsequent to the inspection the Acting Manager confirmed that he had made contact with one of the other care homes to seek a reference and would be making attempts to contact the other applicant’s previous employers who are not in the UK. The Acting Manager needs to be more vigilant when looking at recruiting new staff. All possible attempts must be made to seek as much relevant information about a new member of staff. Although the above two people had not yet started working in the home, a requirement was made for this Standard to be fully met, as the previous inspection had also highlighted similar shortfalls in this Standard. No new staff had joined the staff team since the last inspection. The induction the home goes through with new staff had been viewed at the last inspection and so it was not viewed at this inspection. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 20 Samples of individual training records were seen. Each member of staff had a list of training they had attended. Certificates were not in the files, as the Acting Manager explained that staff keep these. Copies of the certificates need to be available for inspection, so that there is evidence of the training attended. The Acting Manager acknowledged that this should be in place and would seek to obtain the certificates from the staff team. It was recommended that an overall training plan be developed. This could then show at a glance the staff team’s training and can be used to monitor when staff need to attend refresher training courses. The majority of the training is provided by an external organisation that visits the home. The Acting Manager was happy with the quality of the training being provided. It was noted that some staff had missed training on moving and handling, protection of vulnerable adults and fire awareness. The Acting Manager must ensure staff have the annual training needed to meet the needs of the residents. A requirement was made to ensure all staff are up to date with these courses. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The home is well managed. In order to run the home in the interests of the residents, residents’ views need to be obtained. Procedures and checks are in place to protect resident’s personal finances. Health and safety checks promote the welfare of the residents. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Acting Manager is still in the process of applying to be the Registered Manager of the home. There have been ongoing delays but he is now hopeful that he will be registered with the Commission in the near future. He has almost completed the NVQ level 4 and is also an NVQ Assessor. Feedback from staff and residents regarding the Acting Manager were positive. The Acting Manager meets with members of the Committee on a regular basis and completes a report for these meetings. We were informed that monthly Regulation 26 visits take place, but we had not seen these reports for sometime. The Acting Manager will forward copies on to the Commission. The Acting Manager had completed a six-month review report about the home. This looked at various areas, such as the environment and staffing. We were informed that residents were verbally asked about their views on the home. Surveys are available to use and would be a more formal way of gathering residents and other people’s views about the home. Answers from these surveys could then form part of the review report. The Annual Quality Assurance Assessment stated that detailed questionnaires are used to obtain the views of visitors and members of staff. However focus needs to be on asking residents their views. A requirement was made to evidence that residents can contribute their opinions and these are then acted on. We met with the Finance Manager. She explained that many of the resident’s finances are managed by either the Local Authority or by relatives. Receipts are obtained when there have been financial transactions and regular counts and checks on the money are carried out. Two residents money were counted and were correct at the time of the inspection. We viewed a sample of health and safety checks. Portable Appliance tests, Gas safety records and testing for Legionella were all up to date. Fire drills had been held with different staff and at different times of the day and evening. Individual fire risk assessments on the residents had not been carried out. It is recommended for this to be completed so that there is a clear record of the individual needs of the residents, in relation to responding to a fire. A monthly fire risk assessment is carried out. We discussed with the Acting Manager the possibility of looking to an external professional organisation carrying out a detailed fire risk assessment on the home. The Acting Manager agreed to look into this. The Acting Manager had developed an accident form that is used when there has been an incident or accident. This form also evidences any action taken following on from the accident. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 23 Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 24 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 25 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. Standard OP7 Regulation 15(1) Requirement Timescale for action 07/07/08 2. OP9 3. OP9 4. OP19 5. 6. OP29 OP30 To ensure residents are cared for appropriately, care plans must include the personal care needs of the resident. 13(2) To safeguard residents, the quantities of the medication that is delivered to the home must be recorded accurately. 13(2) To protect the welfare of the residents, regular checks and counts on all the medication must be carried out. Evidence of these checks must be made available. 23(2)(d) To provide a pleasant place to eat in, the dining room and small hall leading to the top floor needs to be updated and painted. 19(5)(d) To protect residents, satisfactory (i) employment references must be obtained. 18(1)(a)(c Residents need to be supported )(i) by a competent staff team. Staff must receive refresher training regarding moving & handling, fire awareness and Protection of Vulnerable Adults. 24/06/08 30/06/08 31/10/08 07/07/08 30/09/08 Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 26 7. OP33 24(3) The home must seek directly the views of the residents, to ensure the residents can contribute and voice their opinions about the home. Evidence of this must be made available. 30/09/08 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. 3. 4. Refer to Standard OP9 OP9 OP30 OP38 Good Practice Recommendations That the home keeps an up to date copy of the BNF. The home records Controlled Drugs in a bound numbered CD register. The home has an overall training plan to show the training the whole staff team has attended. It is recommended that individual fire risk capability assessments be completed on those residents who do not respond to the fire drills, or need assistance from staff. Green Haven DS0000027707.V364126.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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