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Inspection on 19/07/07 for Derbyshire Haven Care Home

Also see our care home review for Derbyshire Haven Care Home for more information

This inspection was carried out on 19th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Everyone who wishes to move to the home is assessed prior to moving in and the care plan is created from that information staff have access to care plans and understand the needs of people in the home and how to support them. Care plans are written in sufficient detail to enable staff to meet the needs of residents as they wish. Residents are supported to make choices about their daily life. Meals are provided that are nutritious and appetising. There are enough staff to meet the needs of the residents at the home. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care. The manager is qualified and was praised highly by residents as being kind, helpful and approachable. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected.

What has improved since the last inspection?

Evidence is now provided that residents and their families are involved in reviews and the creation of plans. Where Medication Administration sheets are hand written that they are signed and countersigned to ensure that they are correct. Some bedrooms have been decorated and carpets have been replaced to ensure the service remains clean and tidy for the people who live there.

What the care home could do better:

The daily menu could be displayed in the home so that residents know what is available and can make informed choices at meal times All concerns however minor should be recorded to provide evidence that complaints are dealt with appropriately.Criminal Records Bureau checks must be carried out prior to a person starting work at the home to ensure that they are suitable to work with vulnerable people. A quality assurance system should be developed and used to ascertain residents` views of the home and an action plan created to ensure that the home is run in their best interest. The Registered Individual should make visits to the service and carry out his duties under regulation 26 of the Care Home Regulations 2001. All accidents and incidents that adversely affect the health and well being of residents must be reported to the Commission of Social Care Inspection to ensure that proper monitoring of the service can take place.

CARE HOMES FOR OLDER PEOPLE Derbyshire Haven Care Home 2 Brendon Road Wollaton Nottingham NG8 1HW Lead Inspector Susan Lewis Unannounced Inspection 19th July 2007 10:00 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 Derbyshire Haven Care Home DS0000002195.V341238.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. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derbyshire Haven Care Home Address 2 Brendon Road Wollaton Nottingham NG8 1HW 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) 0115 9282110 0115 9133595 barbarahadfield@hotmail.com The Trustees of the Lucy Derbyshire Annuity Fund Barbara Mary Hadfield Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: Derbyshire Haven is an eleven bedded purpose built home for older people situated near to Wollaton Park. The home is owned by the Lucy Derbyshire Annuity fund. The manager assesses the service users and they can reside at the home for as long as the staff and facilities can meet their needs. The home is near a local church; park and bus ride to the city centre. The individual accommodation for the service user comprises of a bed/sitting room and shower/toilet. The home has two floors the first floor can be accessed by a lift. There is a communal lounge and dining room with access to a small garden at the rear of the home. The fees for 2007/08 are £420 per week. The latest report is available in the reception area. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 7 hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Some of the people who live at this home have a limited ability to understand and communicate. Therefore some judgements in this report are from observation of staff and resident interactions Two members of staff and two sets of relatives were spoken with as part of this inspection. In addition the views of two other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Questionnaires were sent to the manager for distribution to residents and their relatives before this inspection to give them the chance to air their views and speak to an inspector directly. Four relative and Four resident responses were received. What the service does well: Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 6 Everyone who wishes to move to the home is assessed prior to moving in and the care plan is created from that information staff have access to care plans and understand the needs of people in the home and how to support them. Care plans are written in sufficient detail to enable staff to meet the needs of residents as they wish. Residents are supported to make choices about their daily life. Meals are provided that are nutritious and appetising. There are enough staff to meet the needs of the residents at the home. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care. The manager is qualified and was praised highly by residents as being kind, helpful and approachable. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected. What has improved since the last inspection? What they could do better: The daily menu could be displayed in the home so that residents know what is available and can make informed choices at meal times All concerns however minor should be recorded to provide evidence that complaints are dealt with appropriately. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 7 Criminal Records Bureau checks must be carried out prior to a person starting work at the home to ensure that they are suitable to work with vulnerable people. A quality assurance system should be developed and used to ascertain residents’ views of the home and an action plan created to ensure that the home is run in their best interest. The Registered Individual should make visits to the service and carry out his duties under regulation 26 of the Care Home Regulations 2001. All accidents and incidents that adversely affect the health and well being of residents must be reported to the Commission of Social Care Inspection to ensure that proper monitoring of the service can take place. 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. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 8 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 Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 9 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 and 6 Quality in this outcome area is good. People are assessed before they are admitted to the home to make sure their identified needs can be met This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed and each had a social services care management assessment and the manager had assessed each resident prior to moving to the home. The assessment informed the care plan and staff spoken with were aware of the assessments and said that they found them useful. They felt able to support any new person moving to the home. This was also supported in the Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 10 pre inspection questionnaire received from relatives who felt their loved one received support and kindness during the change. ‘Staff were very supportive to us and my relative to ease the transition’. Intermediate care is not provided in this service. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents’ health and personal care needs are addressed in a way, which is consistent, safe and respectful, this ensures that any identified risk is minimised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All care plans viewed followed the same format and provided consistent information regarding residents likes dislikes, how they liked to spend their day and how staff should meet the needs of the person including how many staff it needed to ensure the person’s safety. There was evidence that residents and families were involved in the creation of plans and in discussion with a relative it was confirmed that they were Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 12 consulted in ensuring their loved one received the support that was needed at times convenient to them. Peoples health care needs were monitored closely and diary notes showed that doctors were contacted when residents felt unwell or staff were concerned about someone’s health. This shows that the staff are proactive in ensuring that residents health care needs are met. Residents spoken with said that if they felt unwell the staff always asked them if they wanted to see a doctor and relatives said that they were kept informed about their loved ones health and well being. A medication round was observed and staff were seen to follow good practice and ensure Medication Administration Records were not signed until the person had taken the medication. Staff spoken with regarding medication said that they receive training before they can administer medication and felt that practice was safe within the home. Residents spoken with also confirmed that staff were helpful when it came to administer medication and they always received it on time. A recommendation at the last inspection to sign and countersign all handwritten amendments to the records has been completed ensuring that errors are not made when notes are handwritten. Throughout the day staff were observed interacting with residents and were polite yet relaxed and shared jokes with residents and sat and chatted with them. Residents spoken with were very positive about the staff describing them as ‘marvellous’ and ‘kindness itself’. Relatives were also very positive about staff again describing them as being ‘like angels’. Derbyshire Haven Care Home DS0000002195.V341238.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 and 15 Quality in this outcome area is good. People have their lifestyle choices recorded and respected, everyone is supported to make choices about their lifestyle and the social, cultural and recreational activities provided address their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ social and religious preferences are recorded on the care plan and activities are arranged both in the morning and afternoon. These range from quizzes to entertainers coming into the home to sing. Photographs are around the home showing a variety of seasonal events that residents have been involved in. Residents spoken with said that they enjoyed the quizzes but one resident commented that she felt that there could be more to do during the day. This was also indicated on the pre inspection questionnaire. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 14 Residents preferences for meal times are indicated on care plans but from observation it appeared that all residents ate their mid day meal at the same time, however from discussion with staff and observation it was evident that that residents were able to eat their breakfast at times convenient and preferred by them. Visitors spoken with said that they were made to feel welcome and they were encouraged to visit when they wanted to. One visitor was observed taking her loved one out for a walk and in discussion with the manager this was something that was encouraged to maintain contact with family and friends. Diary notes also indicated that families phoned the service to make arrangements to take loved ones out for lunch or visit home. Residents spoken with said that they get up mostly when they want to and staff often wake them around 7am and then they lie in bed until they are ready to get up. Each resident has a shower in their bedroom and if they want a shower daily they can and this was recorded in their care plan and diary notes showed when this took place. This indicates that the care is individual to the person. The midday meal was observed and it smelt appetising and looked nutritious. It was sausages, mashed potatoes and fresh vegetables. Residents spoken with were positive about the food and said that they had plenty of it but were unsure if they had a choice. The menu was not displayed in the dining room to remind them of what was available, but in discussion with staff they said that the cook asked residents what they wanted in the morning but if they changed their mind when they saw what someone else was having then it did not matter and they were usually able to give them their choice. Menus were in the kitchen and in discussion with the manager she said that she regularly sat with residents to discuss the menu and make changes in response to their requests. Derbyshire Haven Care Home DS0000002195.V341238.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 and 18 Quality in this outcome area is good. Residents’ concerns and complaints are responded to appropriately, staff are aware of their responsibilities in terms of safeguarding adults and whistle blowing on poor practice and this ensures residents are protected from abuse and harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no reports of concern about this service. Residents spoken with all felt able to raise any concerns with the staff or the manager, one residents said that she had raised some small issues about laundry and staff had resolved these promptly. ‘Nothing is too much trouble’ ‘I am not made to feel uncomfortable’. Staff spoken with were all aware of the complaints procedure and were aware of their responsibility to support residents in making a complaint. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 16 Residents said that they felt safe and staff never snapped at them or shouted that they were always treated with respect. Relatives spoken with said that they felt confident that the manager would deal with any complaint and that they were leaving their loved one in safe care. Staff spoken with said that they had never witnessed any staff being inappropriate with residents speaking to them harshly and knew exactly what to do if she witnessed it including if it was the manager. Staff were aware of where the policies were in regard to this matter. The manager does not act as appointee for any one and all finances are kept secure with records. Training records show that staff have received training on adult abuse awareness. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The home is fit for purpose and people live in a well-maintained and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the accommodation was made and a sample of bedrooms were seen to make sure that the home is clean, safe and comfortable for residents Bedrooms were spacious and personalised and all with ensuite shower facilities. Residents spoken with said that they liked their rooms and that they Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 18 were kept clean and tidy by staff. Domestic staff were seen during the inspection going round the home ensuring that it was clean. The communal areas were pleasant and domestic in nature with furniture that was safe and in good order. The small garden to the rear of the home is accessible. A recommendation to clear the pathway was made at the last inspection and evidence was provided to show that an application for a grant to convert the garden into a sensor space has been made with the local authority and the registered manager is awaiting the outcome. The pre inspection questionnaires were mostly positive about the environment but one relative commented that ‘in some areas of the home the decoration could be brightened up’. Evidence was seen that bedrooms were repainted regularly to ensure they remained in good order and the carpet in some parts of the home had been replaced and the carpet in other parts due for replacement shortly. This ensures that residents live in a clean and well-maintained environment. The laundry was away from the lounge and dining area ensuring that soiled laundry was not taken through areas where residents were eating or where food was prepared. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. Recruitment procedures are not robust and do not protect residents from people who may abuse them. Staff receive training to enable them to carry out their caring duties. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet the needs of residents. Evidence was seen following a risk assessment of two residents that night rotas have been amended to reflect their changing needs and there is now two waking night staff. This shows that the manager responds appropriately to residents changing needs to maintain their safety. Staff spoken with said that they felt there were sufficient staff on duty to assist residents and observation showed that residents were not rushed when staff were assisting them and that staff still had time to sit and ‘chat’ to residents. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 20 Residents also confirmed that staff gave them plenty of time, but one resident did comment that sometimes the younger carers did rush them. Evidence was provided in the pre inspection information that 50 of staff have National Vocational Qualification level 2 in care training this shows staff are trained to a minimum competence level. Staff spoken with confirmed that they were supported to attend training that was relevant to their work. This includes all mandatory training such as Moving and handling, infection control and First Aid as well as more specialist training such as Palliative Care. This ensures staff have the skills and the knowledge to care for the people who use the service Two staff recruitment files were viewed to ensure that suitable checks had been made prior to them starting work at the home. A requirement was set at the last inspection to ensure that suitable checks were made prior to person starting work. One new member of staff file showed that not only did the Criminal Records Bureau not come until after the person started but the Criminal Records Bureau check showed that there were issues of concern. A risk assessment had been carried out but it was inadequte and did not provide evidence on what grounds the person was believed to be of no risk to residents. This was discussed with the manager and the manager agreed that the member of staff should be suspended until further investigation could take place followed by a more detailed risk assessment. The manager did this during the inspection and provided evidence by the date required of 23/07/07 of what she had found out as well as a more detailed risk assessment. As a result the member of staff was able to be re instated. It was discussed with the manager that if she is having difficulty recruiting and getting Criminal Records Bureau checks back in time then she should use POVA First checks to evidence that she has been pro active in maintaining the safety of the residents from potential abuse. Staff spoken with said that she had received an induction and that received support to access training. Pre inspection surveys from relatives felt that staff were trained and experienced to care for residents. Derbyshire Haven Care Home DS0000002195.V341238.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 and 38 Quality in this outcome area is adequate. The manager is kind and approachable, but does not always carry out her responsibilities to ensure that the home is run in the best interest of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has her registered manager’s award and there is evidence from training records that she is continuing to update own knowledge with a view to providing good care to residents. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 22 Staff, residents and relatives all said she was kind, approachable and supportive Staff said she provided clear leadership and they were aware that a high standard of care was expected from them at all times. Following a discussion with the manager it was clear that the Trustees from the Board of Derbyshire Haven visit regularly but they do not carry out a formal Registered Person Regulation 26 of the Care Homes Regulation 2001 function and the Registered Person does not visit. This would ensure that the Registered Person knew what was happening within the home and that he could ensure that National Minimum Standards were followed and requirements were met. There is no quality assurance survey and regular residents meetings do not take place. The manager said that she regularly sits with residents and talked about what was happening in the home and what they wanted to do, however these discussions are not recorded it was suggested that this is done to evidence that the home is run in the best interest of the residents. Residents spoken with said that their families look after their and the manager said that the only money that is held by the home pays for residents hair and chiropody services. Records were seen to confirm this. This shows that residents are protected from financial abuse. Records seen showed that fire safety training and maintenance was carried out and the Environmental Health Officer visited 1/06/07 and carried out an inspection of the kitchen this report stated that there was a good level of compliance inspections would be every 18mths. The records of Health and Safety servicing and checks were inspected to ensure that residents’ are properly protected. These were all up to date and well recorded. The staff have all completed their statutory training courses and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. From accident records there was evidence that residents had experienced a number of falls but the Commission had not received any notifications to enable monitoring of the service. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 19(16)Sch 2 Requirement The Registered Person must carry out appropriate recruitment checks are carried out prior to the person starting work at the home. (Outstanding from 01/09/06) The provider must develop an effective quality assurance system and make a report on the quality assurance available to the residents at the home. This is to demonstrate that the home is being run in the best interests of residents The provider should make visits to the service according to this regulation. To ensure that the service is run in the best interests of the residents. All incidents, which fall within this Regulation must be notified in writing to the Commission without delay to enable monitoring of the service provided to residents. Timescale for action 23/07/07 2 OP33 24(1)(b) (2) 01/09/07 3 OP33 26 01/09/07 4 OP38 37 01/09/07 Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP16 Good Practice Recommendations The daily menu should be displayed in the home so that residents know what is available and can make informed choices at meal times. All concerns however minor should be recorded to provide evidence that complaints are dealt with appropriately. Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Derbyshire Haven Care Home DS0000002195.V341238.R01.S.doc Version 5.2 Page 27 - 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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