CARE HOMES FOR OLDER PEOPLE
Harbour House Penberthy Road Portreath Redruth Cornwall TR16 4LW Lead Inspector
Paul Freeman Unannounced Inspection 9th 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 Harbour House DS0000053837.V340483.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. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Harbour House Address Penberthy Road Portreath Redruth Cornwall TR16 4LW 01209 843276 01209 313680 info@anson-care-services.co.uk 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) Mrs Mary Allison Anson Mr John Robert Anson Sarah Joanne Eustice Care Home 18 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (18) of places Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 5 adults aged over 65 with dementia (DE(E)) To accommodate one named service user outside the registered categories of the home To accommodate one named service user outside the registered categories of the home Total number of service users not to exceed a maximum of 18 Date of last inspection Brief Description of the Service: Harbour House cares for 18 older people and is a two story detached property that has been extended and stands in its own grounds close to the harbour. It is set in a residential area near to local amenities and a reliable bus service provides access to local towns. There is disability access on the ground floor and three lifts are provided internally. One is a full shaft lift, the second a stair lift providing access to the bedrooms on the first floor and a third upstairs to compensate for the different levels on the first floor. Sixteen of the bedrooms are single and two have en-suite facilities. The one double bedroom exceeds the recommended size. Communal space is good with a choice of two sitting rooms and two dining rooms and toilets and bathrooms are located throughout the care home. The home is committed to delivering care in a manner that meets the needs of each service users and recognises individual choice and preference. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 9 July 2007 and 10 July 2007. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 3 May 2006 and to inspect the key standards. Therefore some of the key standards that were considered include assessment and care planning, health and safety and staff recruitment. The registered manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. The providers have continued to work towards regulatory compliance. However there are three requirements that have been re-notified from the last inspection report. Residents are generally satisfied with the services and facilities and positive trusting relationships have been established between staff and residents. What the service does well:
The providers assess each prospective resident. In completing an assessment the opinions of the prospective residents relatives or representatives are taken into account as well as any professionals that are involved with the person concerned. Residents that have recently moved to the care home said they had been fully involved in the assessment process and this had given them confidence they would be well cared for at the home. Residents stated they were very satisfied with the manner in which their health needs are met. Residents had confidence in the staff diligence about their health and said that health services were accessed promptly and efficiently whenever required. The records also indicate that General Practitioners, District Nurses and other health professionals regularly visit the home. Residents were also complimentary about the sensitive and reliable support and assistance that staff provide during the periods they are unwell. Residents are also able to administer their own prescribed medicines if they wish and it is safe to do so. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 6 Residents said the staff always treated them with dignity and respect and made sure their privacy and dignity was not compromised. The residents stated they found the staff to be attentive, flexible, efficient and responsive to any assistance they require. Many of the residents said they felt in control of their day-to-day lives and the manner in which there care and support needs were met by the staff. On occasions the providers offer a range of social and recreational opportunities at the care home and in the local community that reflect residents’ preferences and choices. A varied and nutrition menu is provided that reflect residents preference and choice. Residents are given a choice of the food they have at each mealtime and residents said they were satisfied with the portions and quality of the meals. Any concerns or complaints are dealt with positively and the staff and managers are committed to making sure that residents are protected from abuse. A homely, comfortable environment is provided and the registered persons continue to consider ways of further improving the facilities available. The furnishings and fittings are domestic in nature and of a high standard. Residents said they were very satisfied with facilities provided. Two communal lounges and two dinning rooms are located on the ground floor and are valued by the residents. Toilets and bathrooms are located throughout the home and within a reasonable distance from the communal spaces. The home is clean, hygienic and free of offensive odours. Residents said a good standard of cleanliness was maintained at all times and any issues that arose were dealt with promptly. The staff at the home is enthusiastic and work well as a team and are mutually supportive. Sufficient numbers staff are employed during waking hours and each night to meet the needs of residents. Additional staff is also provided if this is required to maintain a good standard of care and support. Robust recruitment, selection and vetting arrangements are in place in order to make makes sure that new staff have the appropriate skills and abilities to provide the care and support required. Each staff member is regularly provided with training and this helps to maintain and improve the standard of care and support. The home is appropriately managed and run for the benefit of the residents. Residents are encouraged to comment upon the services and facilities provided in order to further improve the services and facilities. Two residents described their experiences at the home as “ very happy ” and “wonderful staff and food”.
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 7 The Providers have established policies and procedures to make every reasonable effort to offer a safe environment for residents and staff. Staff also undertakes training on a regular basis to make sure their skills and knowledge are up to date. Equipment and services at the home are also regularly maintained in good working order. What has improved since the last inspection? What they could do better:
The assessments of residents needs need to be more detailed to make sure the providers have a clear picture of need, preference and choice. This will also promote each resident’s health, safety and well being. In certain instances the information provided in the care plans is incomplete or needs to be more detailed to make sure that comprehensive guidance is provided to staff. This includes direct care needs and meeting social and recreational needs. The arrangements to dispose of medicine that are no longer required need improvement. The records regarding the administration of medication are also incomplete in certain instances. Both issues need to be addressed to make sure that residents are safeguarded. The Providers should continue to consult residents about their individual social and recreational preferences to make sure a varied and stimulating experience is in place. The decor in communal areas is looking tired in certain places and there does not appear to be any annual plan of redecoration. The providers have established an induction programme for new staff but the evidence indicates that some new staff were not provided with induction training. This is not acceptable and could compromise residents’ health safety and well being. The records about the Induction for new staff were also limited and insufficient in scope and detail.
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 8 Although informal consultations about the quality of the services and facilities regularly take place there are no arrangements to formally consult with residents and stakeholders. This needs to be established in order that the providers can fully consult with all the interested parties. The risk assessment and risk management arrangements have continued but there are occasions when situations that could potentially compromise residents are not risk assessed. This potentially places residents and staff at risk. 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. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 9 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 Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 10 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): The standards considered were 3 and 6. Quality in this outcome area is adequate. Each prospective resident is assessed before moving to the home but some of the assessments would benefit from more detail. This will make sure the prospective resident and the Providers are confidant the persons needs, preferences and choices can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is clear the Providers assess each prospective resident. The purpose of the assessment is to identify individual needs, preferences and choices and to be satisfied the provider’s services and facilities are suitable to meet the care and support required. The assessment records of some of the residents that had moved to the care home recently were therefore considered.
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 11 In completing an assessment consultation takes place with the prospective residents and take account of the opinions of their relatives or representatives and of any professionals that are involved with the person. At this time the individual needs in respect of equality and diversity are identified and the best arrangements about the care and support required are considered. The information provided could in certain instances needs to be more detailed and also include any preferences and choices the prospective residents many have regarding the care they receive. This will make sure the providers have a comprehensive picture of need. Residents that had recently moved to the home said they had been consulted about their assessment and had felt their views, preferences and choices and been taken into account. The Providers do not offer a dedicated intermediate care or rehabilitation service. It is evident that every reasonable effort is made to make sure that residents are able to maintain and maximise their independence. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 12 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): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is adequate. The care plans require further improvement in order to provide staff with good information, direction and guidance about the needs and requirements of each resident. The health needs of residents are well met with evidence of good multi disciplinary working taking place. The arrangements to administer medicines are not satisfactory and require improvement so that residents’ health and welfare is not potentially compromised. Residents are treated with dignity and respect and in a manner that makes sure their privacy is upheld. This judgement has been made using available evidence including a visit to this service. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 13 EVIDENCE: Each resident has a care plan that outlines the persons care needs and where appropriate any particular preferences or choices they may have about the care and support required. The information provided in care plans has continued to improve and provides staff with a clearer picture of the residents needs. However there are instances where insufficient information is in place. This is predominantly for residents with more complex needs. More detailed information will make sure that residents are safeguarded and staff are given clear guidance and direction about the care and support required. Residents said they were satisfied with the care and support provided and commented that staff were attentive and respond positively to any assistance required. There are also no barriers to residents accessing their care plans at any time. The staff said they found the plans to be more informative and provided better information and guidance about the residents care and support needs. It is the policy to hold monthly reviews of all the care plans to make sure the care arrangements are appropriate. In addition a formal review is undertaken with the resident on a six monthly basis. At this time relatives or representatives and any professionals involved would also be consulted. Many of the residents did not appear to be aware that reviews regularly took place. The care planning and review documents also did not evidence that reviews were taking place each month. Residents were very positive about the manner in which their health needs are met. Residents are confidant that medical services are access promptly when required and said staff were attentive during periods of poor health. The records show that General Practitioners, District Nurses and other health professionals regularly visit the home when required. Residents can elect to administer their own prescribed medication when it is safe to do so. In other situations the staff assist residents and the staff concerned have all been suitably trained. Records about the administration of medicines are in place but in some areas require improvement given that not all the records were complete. There were also handwritten information and guidance to staff regarding administering medicines to named residents. However there was no record to indicate a Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 14 suitably qualified medical practitioner had provided any instructions for these medicines to be administered. Although medicines are held in secure facilities the space available is limited and restrictive. It is recommended an alternative site is identified that is sufficiently spacious. The arrangements to store medicines that require refrigeration have improved and a dedicated secure fridge is in place. However the temperature of the fridge is not regularly monitored and suitable records are not maintained. Policies and procedures have been established for medicines that detail the actions required. The disposal arrangements also require improvement. Medicines for disposal are not kept appropriately and suitable records are not in place. This is considered to be an unsafe practise. The arrangements would also benefit for a comprehensive review given it is the view of the Inspector that forms of secondary dispensing are in place. It is therefore necessary the Providers review and develop the current arrangements to make sure that safe robust arrangements are in place for the storage and administration of medicines. Residents stated the managers and staff at the home always treated them with dignity and respect. The residents said they felt in control of the care and support provided and were able to determine where they met with visitors and felt fully consulted about their day to day lives. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 15 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): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Residents are treated with dignity and respect and have access to a range of social activities. A varied and nutritional diet is provided that reflects the residents’ choice and promotes healthy living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents said they able to decide how they spend their time in terms of leisure and recreational pursuits. Many of the residents decide not to participate in organised activities and prefer to make their own arrangements. The Providers do offer certain opportunities that are well supported. Wherever possible the Providers will
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 16 support residents to participate in activities of their choice but this needs to occur within the resources available. A number of residents commented they would like additional opportunities. The assessment and care planning arrangements are also not robust in relation to addressing residents’ individual needs regarding their hobbies, interests and leisure pursuits. Residents said the daily living arrangements were flexible and it is evident that residents are encouraged and supported to be as independent as possible. There are also no barriers to residents accessing their records when they wish and there are no restrictions to maintaining contact with external advocates when required. A varied menu is provided that operates on a four weekly cycle. Residents have a choice of the food at each mealtime and the Providers have continued to consult with residents about the menu. Residents said the quality of the food was good and all were satisfied about the portions. A number of residents need a special diet and therefore a suitable menu is provided. The kitchen area presented as clean and hygienic and all the equipment was said to be in good working order. Appropriate health and safety practises are in place and the kitchen staff is suitably trained. A new kitchen floor has been laid and the facilities decorated. However the paint was beginning to peel in the food preparation area and this fault requires attention. The provider is also establishing plans to further improve the kitchen facilities in the near future. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 17 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): The standards considered were 16 and 18. Quality in this outcome area is good. Robust arrangements are in place to protect residents from abuse. There are no barriers to residents raising any complaints or concerns with the staff or providers and the evidence indicates that all issues are dealt with in a satisfactory manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Robust policies and procedures are in place to deal with complaints and make sure that residents are protected. Residents’ comments showed that people are very comfortable about discussing any concerns with the providers or members of staff. The staff are also clearly aware of the action they are required to take if any complaints or allegations of mistreatment are made. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 18 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): The standards considered were 19 and 26. Quality in this outcome area is good. Continued investment provides a homely environment that is maintained to a suitable standard and is comfortable for residents. Plans need to be established to make sure the décor is maintained to the required standard throughout. Suitable standards of cleanliness and hygiene are maintained that promotes the residents health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were very satisfied with the environment and the facilities provided. The home is a detached property that has been extended over time
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 19 and is evidently maintained to a reasonable standard. The Register Providers are planning to further improve the facilities by adding a conservatory to the side of the building. Car parking facilities are provided at the front of the home and an accessible garden for residents is situated at the side of the property. Inside the home there are two communal lounges and two dining rooms on the ground floor. The furniture, fittings and furnishings are of a high standard and domestic in nature. Residents said they found the home to be warm and welcoming and appropriately furnished. The decor in the communal areas and some corridors is beginning to look tired and would benefit from redecoration. The Registered Manager said that no formal programme of redecoration has been established for 2007. There is also evidence of dampness in the smaller lounge and other remedial works are also required in this area. Bathrooms and toilets are located throughout the home and within a reasonable distance of communal areas. Some of the bedrooms are also provided with en-suite facilities and the Registered Providers are planning to increase this provision in the future. The providers are also planning to install a parker bath in the near future. The bath was prominently placed in the garden and looked unsightly and out of place. There appeared to be no definite plan when the bath would be fitted. A number of bedrooms were sampled and found to meet the standards required. A good standard of decor was evident and many of the rooms were personalised by the occupants. There are also no barriers to residents bringing their own furniture and possessions. The home was found to be clean, hygienic and free of offensive odours. Residents said their rooms were regularly cleaned and they were very happy with the standard attained. The services and equipment provided at the home are regularly maintained and serviced and suitable arrangements are in place to provided a satisfactory level of warmth and heat for residents. The storage arrangements at the home continue to need consideration to make sure a safe and uncluttered environment is in place. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 20 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): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is adequate. Sufficient numbers of staff are on duty each day and night to provide the care and support required. Satisfactory arrangements that protect residents are in place when new staff are recruited. However the Induction arrangements are not satisfactory and do not always adequately prepare staff. This could compromise residents’ safety. The staff group do have regular opportunities to develop their skills and knowledge through training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels meet the minimum requirements during waking hours and overnight and additional staff is provided when this is needed to meet the needs of residents. Residents said they were extremely well looked after and described the staff as “wonderful”, and also said “they will do anything for you”. The staff group have a wide range of experience, complementary skills and clearly work well as a team. In addition regular training opportunities are provided to each staff member to further develop and enhance the service
Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 21 provided. Staff were positive about working at the home and are clearly committed to providing a good standard of care. The Providers have established a robust policy and procedures about the recruitment arrangements to make sure that residents are protected and the records were found to be in good order. The Providers said they have a comprehensive induction programme for new staff to make sure to make sure staff have a clear understanding of their roles and responsibilities. However there was no evidence to indicate that two recently appointed staff had undertaken the entire induction programme. This is not an acceptable situation and could compromise the health safety and well being of service users. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 22 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): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is adequate. The home is managed in a manner that promotes the residents best interests. Residents are informally encouraged to contribute and comment on the manner the home is run on a regular basis. However formal arrangements to consult al, interested parties about the services and facilities do not appear to be in place. A range of safe working practices has been established to promote the health and welfare of residents and staff. Further improvements are required to make sure that every reasonable step is taken to provide a safe setting and safeguard residents.. This judgement has been made using available evidence including a visit to this service. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Providers regularly visit the care home and meet with residents ands staff and therefore play an active role in the facilities and services provided. The Registered Manager is suitably trained and is clearly valued by the residents. The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. This also means that a senior member of staff is on duty for all waking hours. Reliable on call arrangements are also in place each night. The home is run and organised for the benefit of the residents. Residents also have regular informal opportunities to comment on the quality of the services and facilities provided. However formalised Quality Assurances measures do not appear to be regularly taking place. The Providers are keen to promote equality and diversity for residents and staff. The individualised approach to assessment, care planning and review enable the Providers to deliver services and facilities that reflect each person’s requirements. In addition a range of policies and procedures are in place to promote a positive experience for people at the care home. The Providers take a responsible attitude towards any assistance they provide to residents to manage their finances. At the time of the inspection the providers were not assisting any residents to manage their personal allowances. The Providers have also established a range of policies and procedures that promotes safe working practices for staff. Generally residents and staff said they had no concerns about their safety or the manner in which the care is provided. Equipment and services at the home is also regularly maintained and serviced. The Registered Manager also stated that regular training is also provided to staff in respect of a range of health and safety practises. The risk assessment and risk management arrangements have continued to improve. However there are occasions when the appropriate risk assessments are not completed at the assessment stage or following n accident or incident. The Registered Manager said that appropriate account was taken of risks at all times but this is not reflected in the records. The fire precaution arrangements have also recently been improved. This followed an inspection by the Fire Officer who identified certain areas of nonHarbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 24 compliance with the Fire Regulations. The Registered Manager said that steps had now been taken to ensure compliance with the Regulations. The Providers have established policies and procedures to promote fire safety. The documents summarise the arrangements in place and the action required by staff in the event of an incident. In addition the Registered Manager said that staff undertake fire training and fire drills on a regular basis. However the current records do not adequately detail the events that have occurred. Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 25 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 2 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 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 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1)(ab) 15(1) Requirement More detailed assessments of need must be completed. Timescale for action 30/09/07 2. OP7 All care plans must set out in 30/12/07 detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Care plans must be kept under review and suitable records of each review maintained. Medicines not longer required must be disposed of safely and good records regarding the disposal must be in place. Accurate and up to date records must be in place regarding the administration of medicines. All new staff must undertake an induction programme. A suitable record of each induction programme must be in place
DS0000053837.V340483.R01.S.doc 3. OP7 15(2)(b) 30/10/07 4. OP9 13(2) 30/08/07 5. OP9 13(2) 30/08/07 6. 7. OP30 OP30 18(1)(a)( 2)(a-b) 18(1)(a)( 2)(a-b) 30/08/07 30/08/07 Harbour House Version 5.2 Page 27 8. OP33 24(2) Re-notified from 30/06/06 The annual review of the quality of care provided must be published and available to service users. Re-notified from 30/07/06 30/12/07 9. OP38 13(a-c) Risk assessments and risk management plans must be completed when any situation arises that could potentially compromise the health and safety of service users or staff. Re-notified from 30/07/06 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3. Refer to Standard OP9 OP12 OP19 Good Practice Recommendations The medicines should be stored in more spacious secure facilities. Care plans should provide more information, direction and guidance about each resident’s social and recreational needs and requirements. Sufficient storage areas should be provided to make sure residents are safe and are not prevented from using the registered facilities. A good standard of decor should be achieved and maintained throughout the care home. A annual programme of redecoration should be in place. 4. 5. OP19 OP19 Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 28 Harbour House DS0000053837.V340483.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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
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