Inspection on 13/07/07 for Harewood House

This inspection was carried out on 13th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Harewood House 10/08/06

Harewood House 14/02/06

Harewood House 30/08/05

Harewood House 17/11/04

Harewood House 26/05/04

Harewood House 02/12/03

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

CARE HOMES FOR OLDER PEOPLE Harewood House 66 Plymouth Road Tavistock Devon PL19 8BU Lead Inspector Andy Towse Unannounced Inspection 13th 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 Harewood House DS0000032457.V340449.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. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harewood House Address 66 Plymouth Road Tavistock Devon PL19 8BU 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) 01822 613130 http/www.devon.gov.uk/adoption.htm Devon County Council Brian Burley Care Home 28 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (20), of places Physical disability (8), Physical disability over 65 years of age (14) Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home can accommodate no more than 14 people with a physical disability at any one time. Anyone with a Physical Disability must be 50 years of age or over. The Home can accommodate no more than 8 people with dementia at any one time. Any one with dementia must be 55 years or over. 10th August 2006 Date of last inspection Brief Description of the Service: Harewood House is arranged on three floors. The ground floor comprises a day centre, offices, laundry and kitchen facilities. The Kitchen provides for the day centre and meals on wheels service as well as the care home. Food is distributed to the home in heated trolleys. The first and second floors which comprise the care home are divided into four units, each offering a service. On the first floor there are two units. Edgecombe provides long term care for 6 people whose main needs relate to frailty due to their age. There are 6 large bedrooms, a lounge and a kitchen/diner. In addition there are 2 toilets (one with disabled access), a bathroom with a floor based hoist, and a sluice room. Reablement provides for 6 people who need to restore their skills and confidence following an operation, accident or period of ill health. This service is run in conjunction with the Health Service. Intensive support from Occupational Therapists and Physiotherapists is available. On the second floor Drake is a service for 8 people who have a diagnosis of dementia. There are 8 large bedrooms, a lounge and a kitchen/diner. In addition there are 2 toilets (one disabled access), a bathroom with a high/low bath, a small laundry and a sluice room. Treetops is a service for 8 people and whose main needs relate to frailty due to their age and who are staying at the home for a period of respite care. There are 8 bedrooms, 2 of which are suitable for the use of people with a physical disability and are situated on the first floor; 2 toilets (one with disabled access); a walk in shower; a kitchen diner and a lounge. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over a period of nine and a half hours. The information contained in this report came from a variety of sources. One was an assessment which was completed by the registered manager prior to the inspection and the inspection itself which comprised a site visit, a tour of the premises and discussions with five staff and five residents, an agency worker working in a senior capacity and the registered manager. Surveys were forwarded for both staff and residents prior to the inspection but there was no response to these. What the service does well: What has improved since the last inspection? The parallel bars, requested by the physiotherapist and referred to in the previous inspection have now been purchased and await installation. The privacy of residents is respected with staff referring each other to relevant residents’ files rather than putting in personal details in the communications book. The home has produced an ‘Alerter’s Flowchart’ which will clarify the procedure for reporting any abuse should this occur. The bathroom on the Edgecombe Unit has been refurbished, giving residents access to another specially designed bath to meet their needs. We were given sight of an environmental assessment of the home, compiled by a qualified person, which overall gave a positive description of the home. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. The admissions process ensures that prospective residents can be confident that their needs will be met. However, it would be useful if visits to prospective residents by the manager were recorded. Residents using intermediate care were positive about how they were being encouraged to maximise their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 9 From records and discussion with the registered manager and a senior staff member it was established that there had been no people admitted to the home to live there, in a permanent capacity, since before the last inspection. The files of four residents were examined. All were seen to contain assessments. These had been completed by various relevant healthcare or social services personnel. Examples of these were a ‘Rapid Assessment’ completed by a discharge sister which was full of medical information, another contained a Hospital Referral Form and another an assessment completed by a care manager. In discussion it was said that several residents had received respite care before becoming permanent residents of the home, and that the periods of respite care allowed staff to know the needs of the residents prior to their becoming permanently resident at the home. The registered manger said that it was the practice of the home for him to visit prospective residents before they were admitted to the home. Whilst there were no records of these visits, the registered manager said that they were used to confirm information contained on assessments compiled by other professionals. He also said that residents and/or their relatives were ‘always invited’ to look around the home as part of the admissions process. This was confirmed by a resident who said his /her relatives had looked around the home on his/her behalf. Harewood House offers intermediate care in the ‘Reablement Unit’ which accommodates up to six people. This unit is run in conjunction with the Health Service which offers physiotherapy and Occupational Therapy support. As in the last inspection this unit was seen to contain aids and adaptations to promote the skills required for daily living. The parallel bars, which had been requested by the physiotherapist and were referred to in the previous report have now been purchased, however there is ongoing discussion about where best they should be installed. The rota for the Reablement Unit was discussed with the manager. There was a also a discussion with a senior carer and a resident about the following of a programme of exercises drawn up by a physiotherapist. The discussion and records showed that exercises were being carried out in accordance with the instructions of the physiotherapist. The resident spoken to was complimentary about the support he/she received from the staff and health care professionals. Two other residents in the Reablement Unit spoke about assessment visits to their homes and another was aware of a forthcoming assessment. This showed that they were involved in their rehabilitation programme and were kept aware of its development. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 10 Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents benefit from well maintained care files and care plans which are regularly reviewed. Residents’ healthcare needs are generally well met. Residents benefit from being cared for by a staff group who respect their right to privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of four residents were examined. All contained care plans. All also contained detailed and well written personal profiles. These were written by key workers. Key workers have specific responsibility for designated residents. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 12 The personal profiles contained information about residents’ life history, achievements and events of importance all of which are relevant in understanding the needs of individual residents. Residents’ files showed separation between assessments and care plans. The ‘Needs assessment’ which is completed by the home is subdivided into relevant and easily understood sections. Examples of these were, ‘Personal Care and Physical wellbeing’, Communication, Mobility and Dexterity, Medical History, Dental and Foot care, Diet, Daily Living skills, and Religious beliefs. Examination of records showed that care plans were reviewed regularly. The residents’ files which were case tracked showed that the residents had regular contact with health care professionals. Entries confirmed visits by district nurses, general practitioners and allied professionals such as chiropodists. Discussion with a resident and staff member in the Reablement Unit, coupled with examination of a case file showed that the advice of professionals such as occupational therapists and physiotherapists is sought. Further discussion with a member of staff and a resident and examination of records showed that the home implemented this advice. The home also has specialist equipment such as mattresses for use by people who have pressure sores. Staff confirmed that additional aids and assistance would be sought from the health services if any resident required them. The home allows residents who have the ability the right to administer their own medication. When this occurs, risk assessments are used to safeguard the residents and ensure that they have the capability to manage this responsibility. Medication was seen to be stored appropriately. There is a correct procedure for the storage and recording of controlled drugs. There was appropriate recording for the receipt and return of medicines. Whilst there is a list of homely medicines, these have yet to be approved by a general practitioner. We did observe at one mealtime, that whilst staff had given medication to two residents, the staff did not observe the residents taking this medication, although it was recorded as having been taken in the record book. This was discussed with a senior staff member who considered that this was not the usual practice and was aware of the need for staff to witness medication being consumed before signing to confirm it had been taken. In the previous inspection there was reference to personal information being recorded in the communications book. An assistant manager had put Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 13 comments into the communications book instructing staff that this was not appropriate. An examination of the communication book showed that the privacy of residents was respected with entries in the book referring staff to designated resident’s files rather than anything personal regarding residents being written in the book. Staff were asked about how they ensured that residents were treated with respect and their privacy and dignity ensured. Staff responded by giving examples of the way they delivered personal care in a manner which would be as dignified as it was possible to be. They were also seen to knock on bedroom doors before entering and talk to residents in a courteous and dignified manner. A senior staff member showed a respect of residents’ right to privacy referring to residents not having personal questions being put to them when in communal areas or over meal times, when others might be privy to what was being said. Harewood House DS0000032457.V340449.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents pursue lifestyles of their choice and maintain contact with family and friends. Residents enjoy a varied menu which reflects their preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff offer residents various activities. These take place in one of the units with residents having the choice of whether or not to participate. Residents were seen in different lounges watching television, reading or just relaxing. Staff were seen interacting with residents, both in general conversation and encouraging them in table top activities. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 15 Reference was made on residents’ files to their spiritual needs and other interests. Visiting residents in their rooms confirmed that they were encouraged to bring with them items of sentimental value, as rooms contained personal pictures and ornaments belonging to their occupants. Two residents spoken to confirmed that they could receive visitors when they wanted to and that they were made welcome. This was confirmed when we also spoke to a visitor. This is in accordance with the home’s Statement of Purpose which says that visitors are welcome although suggests that they do not come at meal times. We ate a meal in the respite unit. Both the residents enjoyed a different main course and the cook had obviously taken time to make the sweet look both unusual and appetising. Both residents said that they enjoyed their meal. In the afternoon a staff member was seen discussing and recording what individual residents wanted for meals for the following day, including breakfast. Residents ate the meal at a pace dictated by their needs. A staff member was in the dining room, but remained unobtrusive as he/she took away plates or asked if residents wanted assistance or a drink. In accordance with infection control the staff member wore a white overall when assisting with catering. Harewood House DS0000032457.V340449.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents are protected by the home’s complaints procedure however, to fully protect residents staff must be more aware of what action to take if they need to report abuse and also the protection afforded them by the Whistle Blowing Policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaints procedure. Residents and their relatives are made aware of it as it is included in the Service User’s Guide which is made available to both residents and their relatives. It is also included in the letter which is forwarded to prospective residents prior to their admission to the home. Records are kept of complaints made and the last recorded complaint was made prior to the last inspection. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 17 In discussion three staff were asked about what they considered constituted abuse. All were able to give appropriate answers about what constituted abuse. There was some discrepancy about how abuse would be reported when questions were asked regarding abuse being committed by people in different positions in the hierarchy of the home. They were unfamiliar with the existence of a Whistle Blowing Policy which serves to protect anyone who reports perceived instances of abuse or poor practice, in good faith. One staff member spoken to had yet to attend a Protection of Vulnerable Adults training course, although in discussion he/she was able to give examples of what constituted abuse. In the previous inspection mention was made of ‘confusion at managerial level concerning the procedures for investigating and reporting such incidents’. This was discussed with the registered manager at this inspection. In response he produced an ‘Alerter’s Flowchart’ which gave instruction as to the process of reporting an incident , which would he anticipated reduce the possibility of confusion in the event of another incident being reported. In discussion the registered manager showed that he was aware of the Protection of Vulnerable Adults (POVA) Register and the expectation that he would refer anyone considered unsuitable to work with vulnerable adults, for possible inclusion on it. Harewood House DS0000032457.V340449.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): 19 and 26 Quality in this outcome area is good. Residents are accommodated in a clean environment which meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Harewood House is situated within easy access to the centre of Tavistock. The home is situated on two floors above a Local Authority run day centre. Whilst the home does have a CCTV this is only for the entrance to the combined day and residential service and serves to protect residents rather than impinge on their privacy. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 19 The residential area of the building can be accessed by residents through either the use of a passenger lift or stairs. Harewood House is divided into four discrete units. These are as follows: Edgecombe, which provides long term care for six elderly people. Reablement, which offers accommodation to six people who stay for a limited period of time during which they receive support to relearn life skills and develop confidence and independence before returning to the community. Drake, which accommodates eight people with dementia, and finally Treetops, which offers a respite facility. All the units have separate dining and lounge areas complete with bathing and toilet facilities. The Reablement Unit was seen to have appropriate equipment for assisting people in gaining their independence. The unit was domestic in size and décor. All units had appropriate aids and adaptations, such as raised toilet seats, grab rails, bath hoists and electronically raising beds which met the various needs of residents. All residents were accommodated in single occupancy rooms. These were seen to be of a good size and, where they had long stay occupants were seen to have been personalised with the addition of pictures and ornaments of value to the resident. The registered manager produced a very thorough report which had been compiled by a Senior Occupational Therapist. This related specifically to the National Minimum Standards, 19-22, concerning the home’s environment. This report in general draws favourable conclusions about the physical environment of the home and makes some recommendations about how the environment could be improved for the benefit of residents. Since the last inspection the refurbishment of the bathroom on the Edgecombe unit has been completed and a new specially adapted bath has been installed. We walked around the premises unaccompanied at the start of the inspection. There was a good standard of hygiene and cleanliness throughout. The home has appropriate infection control practices and the laundry areas were seen to have impermeable flooring and cleanable walls. Harewood House DS0000032457.V340449.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. The home is adequately staffed to meet the needs of those who reside there. Residents benefit from a staff group which receive appropriate training. Whilst the manager is aware of the legal requirements of having stated documentation on each member of staff, this was not found to be the case on the day of the inspection. This judgement has been made using available evidence including a site visit. EVIDENCE: Discussion with staff, observation and examination of rotas showed that the level of staffing, as commented on in the previous inspection, appeared adequate to fulfil the functions of the home, including offering appropriate care and support to residents. As in the last report, records showed that the home still relies to a substantial degree, upon agency staff. In discussion it was shown that wherever possible the same agency staff are used in order that a consistency of care delivery can be achieved. The manager explained that the use of agency staff was due to Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 21 the vacancies being often on the same day and there not being enough hours to constitute a full post Examination of staff records showed that staff received training in mandatory subjects such as the Protection of Vulnerable Adults, First aid, Moving and Handling and Infection Control and the manager confirmed that there was a commitment having staff achieve NVQ 2 qualifications. The home appears to have a stable core staff group. Discussion with staff showed that the ‘full induction programme compatible with national training standards’ referred to in the previous inspection has yet to be implemented in this home. The manager is aware that no staff should be allowed to commence work until a check had been made to see that their name(s) had not been placed on the Protection of Vulnerable Adults (POVA) register. Since the last inspection only one new member of staff had commenced work at the home. This person had previously worked for social services and the home had not got, on the premises, the information required of her by the regulations. Harewood House DS0000032457.V340449.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): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. The quality of the service offered at Harewood House is not sufficiently well monitored. Whilst staff receive supervision, this is not carried out at the frequency agreed in the supervision contract. Whilst most health and safety issues appear to be met, the absence of confirmation of the safety of the electrical installation and records which do not confirm that all staff have received fire safety training means that the health and safety of residents could be compromised. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 23 This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has over five years experience of running Harewood House. He has several qualifications including one in management, however he has yet to qualify and obtain the Registered Manager’s Award. In the previous inspection reference was made to the development of a county wide quality assurance system which would obtain the views of stakeholders such as care managers and healthcare professionals. This has yet to be formulated. The manager however did refer to the reviewing of care plans as being a form of quality assurance and did say that on occasion a quality assurance system devised by the NHS was used. Fire safety records were inspected. These showed that there was regular testing of the fire alarm system, which records said was done each week when all the alarm points were tested. The extinguishers had also been serviced and the emergency lighting was checked. In addition to the records showing that the fire safety equipment was appropriately tested and serviced, the records relating to staff receiving instruction relating to fire safety were also inspected. A designated senior staff member carries out fire safety training, however records could not confirm that all staff had received fire safety training. Staff files contained contracts relating to supervision. These were signed by the staff member concerned and the staff member offering the supervision. Whilst some supervision had taken place, none of it was carried out with the regularity agreed in the signed contract. In the previous inspection it was recommended that personal electrical appliances should be tested at regular intervals. Records, together with a discussion with the registered manager showed that a member of staff had been trained to check these electrical appliances. This testing had commenced in August 2006 but although the majority of appliances had been tested, some still needed testing. Examination of other records showed that the residents’ safety and welfare was being protected by the appropriate servicing and maintenance of equipment. Examples of this being the testing of the gas boiler, call bell system, the servicing of lifts and hoists, the testing of the fire alarm system and other items relating to fire safety and the safety testing of the water system relating to Legionella. . The manager was however unable to show evidence that the electrical installation in the home had been safety tested. Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 24 Harewood House DS0000032457.V340449.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 tfrtrghwCHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 1 Harewood House DS0000032457.V340449.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 OP29 Regulation 17 (2) Requirement The registered person shall maintain in the care home records as specified in Schedule 4 All staff members must receive regular instruction in fire safety procedures. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (This refers to the home not having certification to confirm the safety of electrical installation within the home.) Timescale for action 31/08/07 2. 3 OP38 OP38 23 13 (4((a) 30/09/07 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. Refer to Standard Good Practice Recommendations Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 27 1 2 OP9 OP30 A list of homely remedies approved by an appropriately qualified person should be obtained. The home should provide induction and foundation training that meets the National Training Organisations specifications. The registered manger should attain qualifications as recommended in the National Minimum Standards The home should expand its quality assurance monitoring to all of the service users, their families and friends and stakeholders in the community. The home should provide an Annual Development Plan based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users. Supervision should be offered at the frequency agreed in the signed contract. 3 4 OP31 OP33 5. OP36 6 OP38 All personal electrical appliances should be tested at regular intervals Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 28 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 © 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 Harewood House DS0000032457.V340449.R01.S.doc Version 5.2 Page 29 - 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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