Inspection on 14/12/06 for Harefield House

This inspection was carried out on 14th December 2006.

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.

Other inspections for this house

Harefield House 23/02/06

Harefield House 25/11/05

Harefield House 20/01/05

Harefield House 28/06/04

Harefield House 08/01/04

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

CARE HOMES FOR OLDER PEOPLE Harefield House 47 Harefield Road Brockley London SE4 1LW Lead Inspector Sean Healy Unannounced Inspection 14th December 2006 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 Harefield House DS0000025622.V301524.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. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harefield House Address 47 Harefield Road Brockley London SE4 1LW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 6926923 maggiestone@tiscali.co.uk Mrs Margaret Rose Stone Mr Raymond Julian Stone Mrs Margaret Rose Stone Care Home 13 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (13) of places Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 13 elderly people of whom up to 2 may have dementia 23rd February 2006 Date of last inspection Brief Description of the Service: Harefield House is a privately owned registered care home, located in a quiet residential area of Brockley, South London. The home provides support and care for up to 13 older women, with elderly care needs. The home takes only women, two of who can be suffering from dementia. The home also provides respite care for up to one service user. There is lots of street parking available near the home. The home is comprised of three floors, with bedrooms on the ground floor and first floor. All accommodation is in single rooms, all of which have a sink and one of which has a shower en-suite. There is no lift access between the ground and first floor. The ground floor has four bedrooms, two large living rooms, and a dining room. There is a toilet/bathroom with a hoist, which is wheelchair accessible, and a separate toilet. The first floor has nine bedrooms and one bathroom/toilet with a mobile hoist. The second floor consists only of an office/sleepover room for staff, with toilet facilities. There is a basement, which is used mainly for freezer storage. There is a garden to the rear of the home. Public transport links include a bus service, which stops in Harefield Road, with main line train service and Docklands Light Railway in nearby Lewisham. Lewisham centre is also close by with a selection of shops, cafés and bars. The provider’s email address is: harefieldhouse@tiscali.co.uk Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide, which are given to all service users. The recent CSCI report is kept in the lobby area of the home open for viewing. A reference is also included in the homes newsletter. At 14th December 2006, the homes fees range from £400 per week, for some longer standing service users, to £ 435 per week. These fees cover all of the homes charges including food. Residents have to pay extra for other personal expenses such as hairdressing, transport, and personal shopping. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and took place over one day. It was facilitated by the Registered provider, the registered manager and the assistant team manager. The inspection included a tour of the home and examination of records on care plans of three service users, building maintenance records, and three staff training and recruitment records. Observations were made of staff working with service users in the living room/dining room area, where many of the service users were present throughout the inspection. Four service users also spoke with the inspector. Two staff contributed information, and there was a brief group discussion with all service users present. Two visiting relatives also gave their views on how the home is run. At the time of this inspection there were three service user vacancies. Comments were also received from a visiting chiropodist involved with the home. What the service does well: The home provides well for service users’ healthcare and has good involvement from healthcare professionals such as GP, district nurse, continence advisor, psychiatry and dentists, many of whom visit the home regularly. A chiropodist from the primary care trust, who regularly visits the home, commented that staff in the home communicate very well, are very friendly, and said that this is “one of the best homes she visits”. Care is taken to make sure that service users’ wishes about food are taken into account and a healthy and varied diet is offered. Comments from service users included: “The food is good and staff are very friendly and helpful”. They also said that activities had improved and that staff are helpful in taking them out in the community. Two visiting relatives said that staff are excellent and helped their mother settle in quickly, and that her health and wellbeing have improved substantially since moving into the home. Service users themselves or their families are responsible for their own financial affairs, and small amounts of money left in the care of staff, is well protected. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information about fees to be paid and who pays these fees, and what these fees include must also be included must be clearly described in the home Statement of Purpose so that current and possible new service users can understand how charges are made. The home must have a manager who is qualified to the required NVQ level 4 in care and management, in order to fully demonstrate that management in the home is well informed. The home also needs to develop a good system for ensuring that the views of service users are included in development plans for the home. There needs to be some information about how the home provides support and access for people registered as disabled, so that there is a clear understanding about how the home does this. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 7 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. Harefield House DS0000025622.V301524.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 Harefield House DS0000025622.V301524.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users need more information in order to make an informed decision about whether to live in the home. Each service user has a written contract or statement of terms and conditions, and all have had their needs assessed before moving into the home. Prospective service users have had the opportunity to visit the home to help make a decision as to moving in. The home does not provide a service for intermediate care. EVIDENCE: There was a recommendation at the previous inspection for the home to consider adding more information to the ethos and values of the home to the Statement of Purpose, to include information such as empowerment, consultation and inclusion of service users’ views. This is met. The home’s Statement of Purpose now includes a section on ethos and values which described providing a skilled service looking at the staff team and protecting people from abuse, recruiting staff to reflect the age and ethnic Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 10 make up of the service users. However it is recommended that some further additions be included as follows. 1. Some more description on how the home’s quality assurance system works, such as carrying out surveys, annual audits and production and development plan. 2. Include monthly reviews in the service users’ consultation section on page 8. 3. Include the home’s practice on involving service users and maintaining independence in the Statement of Purpose section on ethos and values page 2. (Refer to recommendation OP1.) The Statement of Purpose does not adequately show fees to be paid, what is included or who will pay the fees. As there is a new Regulation requiring this information to be included since September 2006 this is now a requirement. (Refer to requirement OP1.) The home provides all service users with a Statement of terms and conditions which includes the fees to be paid and describes the services to be provided, and identifies who will pay the fees. Currently fees stand at £425 per week. These contracts are clearly written and contain all the information service users need, including room numbers, and have been signed by service users or their family. The home demonstrates that it only admits new service users on the basis of a full assessment of health and social care needs. Examination of three service users’ files showed that there were admitted to the home following a complete assessment by the registered manager. These assessments were also supported by a separate social services assessment of need. These assessments are clearly written and include details of health and personal care support as well as food preferences, a brief life history and social and leisure interests. Two relatives and three service users said that they were asked about their needs by the home before coming to live there. There is clear and well organised documentation to show all health and social care needs are being fully assessed. It is part of the home’s resettlement policy to offer potential service users the opportunity to come and visit the home before making their decision whether to move in. Two relatives said that they and their mother have been fully consulted by the home before moving in, and they said they were very pleased with how the home managed the move. They also said that the service user settled in very quickly and soon began to refer to the placement as “her home”. The home does not provide for intermediate care. There was a requirement from the previous inspection for the home to ensure appropriate risk Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 11 assessments and support plans be put in place for two service users on respite care. This was done. Harefield House DS0000025622.V301524.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and social care needs are set out in an individual care plan, and their health care needs are being fully met. They are offered the opportunity to be responsible for their own medication, and are protected by the homes policy and procedures for managing medicines. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: There was a requirement from the previous inspection for the home to ensure that care plans be written in a format and type size which is easily understandable to service users and staff. This has now been done. The manager has now installed a new system for care planning and has begun the process of transferring all service users’ plans on to this system. These care plans are easy to read and the type size is large enough for service users to read. The home currently carries out monthly care plan reviews and family and service users are fully involved. There are good records being kept at these reviews and all care plans are being agreed and signed by the service users or their family. Two visiting relatives confirmed that they were fully involved and consulted in these monthly reviews. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 13 There was also a requirement at the previous inspection that all guidance for staff about how to support service users with mobility support needs be reviewed. This has now been done and there is guidance for staff in each service user’s care plan. There was a recommendation that the home should consider using more individual activity plans for each service user and monitor the levels of activity. This was to ensure that service users were being offered consistent opportunities to do things that interested them. This recommendation is met, and there is now an activities plan and activities folder for each service user reflecting agreed activities, and showing when these should happen. A record is also kept showing whether these activities were offered, and whether they actually happened. There was also a recommendation that the home should ensure that risk assessments be presented in type rather than hand written. This has now been done. There was a recommendation that the registered manager should ensure that service users are offered the opportunity to have dental visits within the home as opposed to having to travel to the dentist. This recommendation is now met. The home has established a contract with a NHS dental practice who now visits the home at least annually. The home provides well for service users’ health care needs, and a full range of health care professionals are involved with service users. The home has a policy for the administration and handling of medication, and where appropriate service users are offered the opportunity to self medicate. All service users’ medication needs are fully assessed on admission and there is a record of their abilities and wishes regarding self medication. All medication is supplied by Boots Pharmacy, and the Boots’ blister pack system is used to administer medication. Sharps are not used by the home and medication is disposed of by returning it to the pharmacist. The pharmacist does an annual inspection and the last report showed no issues of concern. Each service users’ care plan includes a personal care plan describing to staff how to provide care such as bathing, washing, toileting and mobility support. Three service users and two family members, and one visiting chiropodist described the home’s staff and management as being “very respectful, very pleasant and very supportive”. All service users are able to choose their own clothes and have access to the privacy of their own bedroom at all times. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides for service users individual expectations and preferences regarding social, cultural, religious, and recreational needs. Contact is maintained with family and friends, and service users are supported to exercise choice and control over their lives. The home provides a good diet and meals are served in a flexible manner. EVIDENCE: There was a recommendation at the previous inspection for the home to expand the role of the activities co-ordinator to include more individual weekly or daily plans for service users, and a means of recording activities. This was done. Activity routines are flexible and most activities in the home take place in the living room and dining room areas. Until recently there has been a visiting exercise co-coordinator; this role has now been taken up by one of the staff. Activity and leisure interests of service users are clearly assessed and recorded on admission to the home, and people’s interests are now recorded in an individual activities file for each service user. Records show when activities are offered and whether they have been taken up by each service user. The activities co-ordinator oversee these records. Activities include music, exercise, church attendance, visits to and from families. Two visiting family members said that the home has been very successful in motivating and Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 15 encouraging their mother to participate in activities in the home, and that this has greatly improved her feeling of well-being and happiness. They also describe the staff as being very good at encouraging service users without pushing them too hard. The home’s Statement of Purpose and Visitors’ Policy states that the home allows and encourages visits by family and friends at reasonable hours. Three service users and two visiting relatives said they are able to visit the home whenever they like and are welcomed by staff. Service users’ financial support needs are assessed on admission and support to manage finances is offered when necessary. All of the service users or their family are responsible for their bank accounts and DSS benefits. The home only manages small amounts of cash deposited with them for personal spending such as hairdressing, or small shopping. In these cases receipts and records are being maintained. The home provides a wholesome and nutritious diet for service users and offers a choice of food on a daily basis. Four service users said the food is good and they are offered a choice every day. The home employs two cooks to provide the food on site and good records of food eaten are maintained as part of the home’s system for monitoring healthy diets. A record is kept in each service user’s own individual file. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and acted on, and all staff are fully trained in and aware of the homes policy for protecting service users from abuse. EVIDENCE: The home has an adequate complaints policy which was last reviewed in October 2006. It is simply and clearly written and has a timescale of 72 hours to respond to a complaint and 21 days to complete the investigation. This policy is displayed in all service users’ rooms and on the notice board in the dining area. There have been no complaints since the previous inspection. There was a requirement at the previous inspection for the home to revise and update its adult protection and whistle blowing policies. This has now been done. The adult protection policy was reviewed in March 2006 and now reflects the requirements of the Lewisham Adult Protection Policy. The policy covers areas such as what is abuse, confidentiality, recording and reporting. The system for making referrals to POVA was also included. The home has produced separate, clearly written guidelines for staff to follow and all staff have been given a copy. Training records show that all staff have received training in adult protection. Harefield House DS0000025622.V301524.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, comfortable, and well-maintained environment, which is clean pleasant and very hygienic. EVIDENCE: There was a recommendation at the previous inspection for the home to address issues raised by the occupational therapist’s visit. This recommendation was met. The home provides support for up to 13 service users who are elderly. Currently there are no wheelchair users resident in the home. All the currently service users are women. The occupational therapist’s report was available and the report showed that the physical support systems provided by the home do meet current service users’ needs. The home is not wheelchair accessible above the ground floor, but any service users with mobility support needs have their bedrooms located on the ground floor which is wheelchair accessible. Service users resident on the first floor are monitored monthly to ensure safe use of the stairs. The home is maintained to a high level of cleanliness and safety. It is recommended that the home write a policy Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 18 statement on how it will meet the requirements of the Disabilities Discrimination Act 1995. (Refer to recommendation OP19.) The home is adequately heated and well lit. Ventilation is provided by opening windows as appropriate. The water supply and fire safety equipment including emergency lighting, is fully maintained under contract. There are maintenance visits carried out by environmental health, London Fire Brigade and the fire equipment maintenance company. Electrical and gas testing and water testing have been carried out at regular intervals and documentation maintained by the home shows this. The Home has central heating throughout and is warm and comfortable. Water temperatures are controlled and the temperature is tested by staff before service users bathe or shower. Radiators are covered to prevent burning. The home is very homely and safe, and visiting relatives said that they feel it is a comfortable place to live. The home is very clean and well maintained throughout. In order to lower the risk of infection the home has contracted out the work of doing laundry which is collected and delivered three times a week. Staff were seen to wear gloves when cleaning, and handling laundry. The home has a responsible attitude to safety and hygiene. Harefield House DS0000025622.V301524.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets Service users needs, and service users are in safe hands at all times. They are supported and protected by the homes recruitment practices. Staff are trained and competent to do their jobs. EVIDENCE: The home employs eight care staff, one assistant manager and a registered manager to provide the care. In addition to this two cooks and two cleaners are employed. The manager, service users and visiting relatives said that the staff communicate well in spite of cultural differences. All of the service users are female and all of the staff support is provided by women. All of the care staff have NVQ level 2 and one is working on level 3. The assistant manager is doing NVQ level 4. This demonstrates a high commitment by the home to having qualified staff. A TOPSS inductions programme is used by the home to induct new staff. Despite the staff’s cultural make up consisting of five different nationalities they communicate well and work well together. Six service users, two family members and a visiting professional said that staff communicate very well with them and the atmosphere within the home is good. There was a requirement at the previous inspection for the home to update its recruitment policy to ensure it best reflects how to protect service users. This was done, and the policy was reviewed in March 2006 and included guidance Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 20 for carrying out CRB checks, employment history, medical checks, references, identification and working permits as appropriate. Examination of staff files showed good recruitment are now happening prior to employment. The staff files are now very much better organised and contain all of the information regarding recruitment of staff. The home has an induction programme for staff which meets the NTO workforce requirement and all new staff receive a minimum of five days paid training per year. Harefield House DS0000025622.V301524.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an experienced manager but the manager does not hold the required NVQ qualification. The home cannot fully show that it is run in the best interests of service users. Service users financial interests are safeguarded. The health, safety and welfare of staff and service users are promoted and protected. EVIDENCE: There was a requirement at the previous inspection for the registered manager to achieve an NVQ level 4 qualification in management and care. This was a requirement of three separate inspections and the home has taken the decision for the current manager to step down and for the current provider to apply to become the registered manager. This has not yet been formalised and the requirement is repeated. Should this application be successful the provider must ensure that the newly appointed manager enrol on a NVQ level 4 course in management and care. (Refer to Repeated Requirement OP31.) Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 22 There was a requirement at the previous inspection that the home use a recognised quality assurance system based on seeking the views of service users, to include an annual audit and annual development plan. This was partially met. The home now conducts surveys of the views of service users’ families, service users themselves and of professionals who visit the home. There is also an annual building audit is carried out to ensure the fabric of the building is well maintained. The manager is currently awaiting the return of relatives’ and professionals’ questionnaires, and now plans to produce a report on the findings of these surveys, and to include these findings in the home’s development plan. This shows good progress in developing a quality assurance system for the home, and this process is ongoing. (Refer to repeated requirement OP33 partially met.) The home has adequate facilities in place for protecting service users’ money and valuables. All service users or their families are responsible for their financial affairs and small amounts of money is left with the provider for purchasing small items on behalf of the service users. Receipts and records are kept of all of these transactions. Service users and families who participated in this inspection confirmed this to be the case. The home has an adequate health and safety policy in place which is currently under review. There is evidence of a range of health and safety professionals being involved in monitoring health and safety in the home (refer to Standard 19 to 26 in this report). There is a new Food Standards package being implemented in the home to ensure healthy food is being offered. The kitchen is maintained to a high level of cleanliness with good methodical daily checks on ‘fridge temperatures and cleanliness. The home carries out a monthly health and safety audit and good records are kept of action taken. Laundry is contracted out to minimise the risk of infection and two cleaners are employed to maintain hygiene standards. There have been no reports under RIDDOR. Health and safety within the home is well managed. Harefield House DS0000025622.V301524.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 2 3 3 X 3 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 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 24 Yes 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 Standard OP1 Regulation 5 Requirement Timescale for action 30/06/07 2 OP31 9.2 3 OP33 12.3 & 24.1,2 ,3 The registered provider and manager must ensure that adequate reference to fees, how they are to be paid and what is included, is contained in the home’s Statement of Purpose. The registered person must 30/06/07 ensure that by 2005 the home has a manager with qualification to the level of NVQ 4 in management and care. This is a repeat of a requirement from the last two inspections, Timescale 31/12/05 and 30/06/06 unmet. Continued failure to meet this requirement may result in enforcement action. Timescale is now revised. 31/03/07 The registered individuals must ensure that an appropriate, professionally recognised quality assurance system based on seeking the views of service users is operated within the home, to include an annual audit and annual development plan. This is a repeat of a requirement from the last three inspections. Timescale DS0000025622.V301524.R01.S.doc Version 5.2 Harefield House Page 25 31/12/05 unmet, and 28/02/06, and 31/03/06 – partially met. Timescale is now revised. 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 OP1 OP19 Good Practice Recommendations It is recommended that the registered manager include the issues described in this report Standard 1 in the home’s Statement of Purpose. The registered provider and manager should clarify in writing a policy statement on how the home will address the requirements of the Disabilities Discrimination Act 1995. Harefield House DS0000025622.V301524.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 Harefield House DS0000025622.V301524.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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