Inspection on 14/06/05 for Fair Havens Christian Home

This inspection was carried out on 14th June 2005.

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 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

Fair Havens Christian Home 23/12/08

Fair Havens Christian Home 15/01/08

Fair Havens Christian Home 19/02/07

Fair Havens Christian Home 11/01/06

Fair Havens Christian Home 09/02/05

Fair Havens Christian Home 03/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Fair Havens Christian Home 468 Winchester Road Southampton Hampshire SO16 7DD Lead Inspector Jan Everitt Unannounced 14 June 2005 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 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. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fair Havens Christian Home Address 468 Winchester Road, Southampton SO16 7DD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 02380 790874 02380 777478 Keychange Charity Fair Havens Christian Home Mrs Christine Newman CRH 23 Category(ies) of DE(E) 23; PD(E) 8; OP 23 registration, with number of places Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 8 service users may be accommodated in the PD(E) category who are in receipt of personal care only. 2. A maximum of 10 service users in the OP category may be accommodated who are in receipt of nursing care. Date of last inspection 9th February 2005 Brief Description of the Service: Fairhavens Christian Care Home is a small homely care home with nursing that accommodates twenty-three service users. The age range for admission to the home is 65 years and over. Fairhavens is registered to accommodate up to eight service users who are physically disabled but are in need of personal care only and up to ten service users in the old age category who are in need of nursing care. The home is registered to care for twenty-three service users over 65 years of age with dementia. The home is managed by Keychange, a nationally registered charity and has a strong Christian ethos, which is reflected in the atmosphere of the home and the delivery of care. The home consists of a two-storey building with a newer purpose built ground floor extension. Seventeen of the twenty rooms are single occupancy accommodation and three rooms are double occupancy. Eight of the twenty rooms have en-suite facilities. The home has a well maintained landscaped garden and patio areas for sitting in. Fairhavens Christian Care Home is situated in a residential area on the outskirts of Southampton city and has easy access to all of the local amenities . Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Fair Havens Christian Care Home took place on the 14 June 2005 and lasted 6.5 hours. It was undertaken by one inspector who was assisted throughout the process by the registered manager. Twenty-one standards were assessed on this occasion, fifteen of which are the core standards to be assessed during each twelve-month inspection programme. . During the inspection 3 service users were spoken with individually and other service users in small groups. The analysis of the interviews with the service users indicated that there was high level of satisfaction with the care and services received in the home. The inspector assessed that given a large number of the service users were unable to verbalise their opinions, from observations of the care practices and interactions between service users and carers, the care and services received by the service users was of a good standard. Two staff were interviewed individually and from these conversations the inspector concluded that there was a high level of motivation and job satisfaction within the staff group. All communal areas were seen as well a most of the service users’ rooms. The lunchtime meal was observed. Care and staff records were examined. What the service does well: The premises are both well maintained and well decorated and provides a welcoming, homely environment within which service users live, one service user described their life as being ‘very comfortable here’. The cleanliness and hygiene around the home is maintained to a high standard. The care records are well maintained and service users expressed their confidence that the ’matron’ will organise it all. The manager is well respected by her staff and service users alike and demonstrated a good knowledge of their needs. The mealtime observed demonstrated to the inspector that wholesome attractively presented meals are served in a pleasant environment and that service users were observed to be enjoying their meal and using this time as a social occasion creating a friendly atmosphere. The staffing levels are high enough to enable staff to spend time with service users and service users have described the staff as being part of a ‘big family’. The service users spoken with highly praised the staff group and said they were ‘kind and responsive to their wishes’. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 3. Standard 6 is not applicable to this service. Service users sign and receive a copy of the statement of terms and conditions of residency. Service users are assessed prior to admission to the home to ensure the service can meet their needs. EVIDENCE: Each service user signs the statement of terms and conditions of residency as an agreement to those terms. A copy is held in the service users’ personal file. The inspector viewed a sample of service user’s files that evidenced that a contract is signed and maintained in each file. Room numbers are not identified in these contracts. The registered manager undertakes a full assessment of the potential service user prior to their admission to the home. This is generally done in the clinical area with the service user and information shared with nursing staff. The needs assessment tool was viewed by the inspector and is based on a dependency assessment that includes the holistic needs of the service user. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 9 3 service users were asked about their admission to the home. One remembered the manager visiting them whilst in hospital and explaining what the home was like. One service user visited the home for a number of hours and both the service user and the home assessed at that time whether the home could meet their needs. She reported that her niece was also involved with the assessment process and had commented that she could not do better than this home. This service user commented ‘I am glad I came to the home it is my sort of place’. The third service user commented ‘ I cannot remember, I was in hospital and then came here but my daughter chose the home and I am happy here’. The care manager will send a copy of the service user’s needs assessment if they are involved with the admission to the home and the manager reports she receives a good response from them should she request information. The inspector evidenced a copy of a needs assessment undertaken by the care manager in a service user’s file. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 &10 Care plans are in place to set out how to meet the health, personal and care needs of the service users Support is offered to meet the service users health, personal and social needs in such a way as to promote their privacy, dignity and independence. Service users can be confident that the systems and procedures of the home ensure that their medication is ordered, stored and administered in a safe manner. EVIDENCE: The inspector viewed a sample of three service user’s care plans and the service users were also spoken with. The assessment following admission is comprehensive and care plans are based on identified needs following risk assessments. The care plans provided detailed information on the service user’s abilities and the level of support they need and this would suggest that service users independence is promoted. Service users are invited to be involved with the assessment and care planning process and some sign the care plans as evidence of their participation. One service user commented ‘I have come here to be looked after I do not want to be involved with all that’. A service user spoken with informed the inspector that she had been involved with the care planning and that she identified that the bed was too low, which Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 11 was promptly replaced. Care plans are reviewed monthly or if service user’s needs change. Service users reported to the inspector that the GP visits the home regularly. One service user reported if she requests to see the GP, she is seen promptly. The physiotherapist visits the home weekly to review service user’s exercise needs. One of the service users commented that she looks forward to the walk up the road with the physiotherapist at which time she is able to look at the gardens and ‘it makes me feel human’. Service users spoken with confirmed that they have access to a range of healthcare services such as podiatry, dentist and optician that do visit the home and the inspector evidenced that these visits are documented in the care plans. Nutritional assessments are not undertaken routinely and service users are not weighed regularly. This was discussed with the manager who reported that new sit-on scales had now been purchased to enable service users weight to be monitored in a safe manner. A recommendation will be made. The inspector observed the manager administering medication by the correct procedure. Medication records were viewed and were observed to be well recorded. Service users reported that they receive their medication appropriately and the trained nurse gives it to them. One service user only, chooses to self-medicate their own inhalers. Service users reported that they consider their privacy and choices are respected. Staff were described as ‘ wonderful’ and ‘they do all they can’ and that the christian ethos of the home is practiced. One service user said that she did choose when to get up in the morning and go to be bed but that she did not need too much help, as she was lucky to have the equipment aids to help her be independent. Another service user reported that staff are aware of her early morning waking and always invite her to get up whenever she chooses which is usually very early. Another service user confirmed that he prefers to stay in his room between meals, as he does not know the women that sit in there. The inspector observed staff interacting with the service users in a respectful quiet manner and knocked on doors before entering. From the conversations with service users and staff and observations by the inspector, it would suggest that the service users have their rights, privacy and independence promoted to the full and that staff are aware of the core values of care. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 & 15 Service users maintain contact with their relatives and friends and go out into the community as and when they choose. Visitors are welcomed at any time. Service users can choose how to spend their days. Meals are well-balanced offering choice and variety and are enjoyed by all service users. EVIDENCE: The inspector observed that the visitor’s book was well maintained confirming that many visitors come to the home during each day. Service users can choose to see their visitors in the quiet lounge or their own rooms. Committee members from the previous charity continue to be involved in the home and its activities and visit the home weekly to give a church service or sing favourite hymns. This took place during the inspection. Service users are able continue to go out to clubs etc in the community independently with the use of taxis. The inspector observed one service user going out to a coffee morning with friends. A service user spoken with reported that she attends the Arthritis care support club as much as she can. The same service user commented that she belonged to the local parish church as did one of the other service users and that they have become friends and are both pleased the home is run with such a strong Christian ethos. Service users can choose where and how they spend their day. It was observed that most prefer to sit in the large lounge area, of which there are Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 13 two, with a quiet small lounge in the extension of the home. Service users reported to the inspector that they are well supported to maintain their independence and to do whatever they choose to do if it is within their capacity and that they feel safe and happy with their home. Many of the service users spoken with commented on the excellent food served in the home and spoke highly of the chef. The chef reported that a cooked breakfast is offered most days. A menu is not displayed each day but the chef visits each of the service users during the morning to inform them of the day’s menu and to ascertain if they have other preferences. He also visits the service users in the afternoon to give them choices for their tea and supper meals. One service user reported that she enjoys fish and the chef ensures that she has that twice a week and in her sandwiches for tea. The chef confirmed that likes and dislikes are observed and that his menus are planned around these but that there is always an alternative choice if the service users request it. A service user spoken with reported that she has to have a special diet because of her medical condition and that the chef is ‘marvellous’ and that he always produces an appetising meal. Another service user reported that she enjoys the homemade cakes that are served every day, but has been told to ‘cut down’ because of increase in weight. The inspector observed a very good relationship exists between the chef and the service users and he readily chatted about cricket to a service user whilst taking his preferences for supper. The inspector observed the lunch-time meal and this confirmed that the standard of food served and the manner in which it is served is such that the service users receive nutritious well presented meals in the pleasant surroundings of the dining room or where ever they choose to eat their meals. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Satisfactory policies and procedures are in place for service users, staff and relatives to address any concerns or complaints that they may wish to raise. Service users are protected from abuse EVIDENCE: The home has a complaints policy that is displayed in the entrance hall informing people of their rights to complain and how they can go about this. This policy is contained in the Statement of Purpose. Service users spoken with said they would go to a member of staff or the matron if they should wish to raise an issue. One complaint has been logged in the records and was resolved satisfactorily by the manager within 24 hours. Staff spoken with were also aware that the manager or nurse in charge would be the first person to go to if they or a service user wished to make a complaint. The home has the protection of vulnerable adults policy in place and staff spoken with were aware of the policy and how to report any allegations or witnessing of abuse and described that process to the inspector. The manager has undertaken training from the city council and has disseminated this to all staff. The home has a policy available on dealing with aggression and one service user has a specific plan in place for their occasional verbal aggression. Restraint is used in the home in the form of bedrails. The inspector observed that bedrails bumpers were not in place and a requirement will be made from these findings. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 & 26 Service users live in a comfortable clean environment that is well maintained and safe. Service user’s bedrooms are made personal by the service user’s own belongings, are decorated pleasingly and are furnished to a good standard. The home has sufficient and appropriate toilet and bathrooms facilities to meet the needs of the service users in residence. EVIDENCE: The home is well maintained and has recently completed a redecoration programme throughout all the public areas with all new floor coverings, lighting and curtains. The home is having difficulty employing a maintenance person and therefore trades people undertake the general repair of the building. Bedrooms are redecorated as and when they become vacant or if they are in need of refurbishment. Locks are fitted to all bedroom doors and lockable storage facilities are supplied in each room. All bedrooms contain adequate furnishings of a good standard and the inspector observed that service users have been able to personalise their rooms with their own pieces of furniture and belongings. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 16 The home is surrounded by a garden that was very colourful at the time of the inspection. Contract gardeners maintain high standards throughout the gardens, which service users make use of throughout the better weather. Toilet and bathroom facilities are adequate and appropriate and three of the lavatories have access for wheelchairs. The new shower room is now being used to its full potential and service users spoken with reported to the inspector that they enjoy showers frequently or whenever they request them. Two housekeepers maintain a high standard of cleanliness every day. Service users spoken with said they were satisfied with the cleanliness of their room. The inspector observed that staff were wearing gloves and aprons appropriately and changed into a linen tabard to serve food. Staff spoken with confirmed that gloves and aprons are supplied readily in the home and that they had received training in infection control. The inspector visited the laundry, which was observed to be fit for purpose. Service users were asked how they considered their clothes and the laundry to be maintained. One service users said the laundry is done every day and that his only criticism was that they wash his clothes too often. Another service user commented that her clothes are returned promptly and that they are laundered very well. This was confirmed by her inviting the inspector to view her wardrobe. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing levels are maintained to appropriate levels in relation to the dependency of the service users currently in residences. Care is delivered by a caring staff that are appropriately trained and are responsive to the needs of the service users. The recruitment procedures focus on the safety of the service users. EVIDENCE: The inspector viewed staffing rotas which showed one trained nurse and 5 carers on duty in the morning, one trained and 3 carers in the pm shift and one trained and one carer at night with a sleep-in carer on call. This was observed to be sufficient staff to meet the needs of the service users. Staff were observed not to be rushing and service users were up and about at appropriate times through the morning if that was their wish. A separate staff is employed to clean the home but carers do undertake the laundry duties. Service users comments about the staff were, without exception, very complimentary, with comments such as ‘I get on well with all the staff’. They respond quickly if I ring the bell’. ‘I am fortunate to be treated so well’. ‘I worry about them being so busy all the time’. ‘I feel we are a big family’. A sample of staff personnel files was viewed. Information required to be maintained and stated on Schedule 2 & 4 of the Care Home Regulations were in place. Staff spoken with were satisfied with their recruitment to the home and have signed an employment contract. It was noted by the inspector that the immunisation records for a nurse from abroad were not recorded and a recommendation will be made from these findings. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 & 38 The manager strives to maintain the interests of the service users at the heart of the service. Staff performance is monitored regularly and staff take part in individual annual appraisals. Service users’ financial interests are safeguarded. Staff are provided with appropriate training to ensure that the health and safety of both them and the service users is promoted and practiced. EVIDENCE: The organisation has no quality control system in place. The manager undertakes internal audits on care plans and medicine records, which are also undertaken by the community pharmacist. The manager reported that no service user satisfaction survey is sent out but she is in the process of designing a form for this purpose. A recommendation will be made from this discussion. The manager reported that service user meetings take place twice yearly and it is at these meetings that issues and open discussions take place, Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 19 but she does realise that a personal survey would be more appropriate to ascertain the level of satisfaction within the service. The inspector viewed cards and testimonies from relatives, friends and one from the local GP generally thanking the manager and staff for the ‘wonderful care’ that is given by the staff. The cards express gratitude for the ‘care and respect’ shown to a dying relative. From conversations with the service users and observations of staff interacting with service users there was evidence of a high level of satisfaction with the care and services delivered in the home. Service user’s monies that are maintained by the home were checked and records of transactions and receipts were seen to being recorded accurately with each service user monies being stored separately. Service users confirmed during conversation that they are able to manage their own monies if they so wish but a number reported that relatives undertake this task. The staff spoken with reported that they are supervised and that the manager’s door is always open and they can chat to her about their training needs. Yearly appraisals take place and the manager is in the process of implementing regular supervision for all staff. The staff describe feeling well supported and are offered opportunities for training. Another staff member spoken to reported that she considered the home to be ‘ well run’ with staff moral being very high because they work together as a team and have a ‘good manager’. Regular staff meetings are held and minutes of these recorded, the inspector viewed these records. The home has safe working practices in place to address the health and safety of the home. There is no environmental risk assessment, which has been discussed in previous inspection reports and will be a requirement from this report. Appropriate mandatory health and safety training is in place for all staff. The home has an in-house moving and handling trainer who ensures all staff update their practices yearly. The fire logbook was viewed and demonstrated that all fire training and system testing takes place at appropriate intervals. The kitchen was toured and the inspector observed that it was clean and well organised. Appropriate temperature monitoring of equipment and food was recorded and demonstrated safe working practices within the kitchen. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 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 x 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 3 x 2 Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? 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 St 18 St 38 Regulation Reg 12(4)(a) Reg 13(4) Requirement Bedrails bumpers must cover all bedrails in use to prevent entrapment. An enviromental risk assessment must be undertaken and recorded. Timescale for action 30.8.05 30.9.05 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. Refer to Standard St 7 St 33 St 36 Good Practice Recommendations It is recommended that nutritional assessments be undertaken for all service users at the time of admission. It is recommended that a service user satisfaction survey be distributed to form part of the homes quality assurance system. It is recommended that staff supervision continue to be developed with the aim of staff supervision taking place six times a year. Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fair Havens Christian Home H55 H04 S11425 Fair Havens Christian Home v216898 100605 stage 0.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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