Inspection on 25/07/05 for Harleith

This inspection was carried out on 25th July 2005.

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

Harleith 17/07/06

Harleith 18/03/06

Harleith 22/02/05

Harleith 05/10/04

Harleith 15/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Harleith 42 Grand Avenue Southbourne Bournemouth Dorset BH6 3TA Lead Inspector Stephanie Omosevwerha Unannounced 25 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Harleith Address 42 Grand Avenue Southbourne Bournemouth Dorset BH6 3TA 01202 426544 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Stable Family Home Trust CRH PC - Care Home Only 8 Category(ies) of LD Learning disability (8) registration, with number of places Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 22 February 2005 Brief Description of the Service: The registered service provider is the Stables Family Home Trust [S.F.H.T] a charity that provides residential care, a day service and related services for adults with learning disabilities. The day and residential services are interdependent with support from specialist staff at the day service being available to the staff and service users in residential care. The day service staff provide training, guidance and help with among other things matters such as employment; risk assessments and personal relationships. The home is located in a residential street in the Southbourne area of Bournemouth, within easy walking distance of local amenities that include, cliff top walks, a beach, shops, cafes, restaurants, post office and places of worship. Public transport is readily available and Bournemouth town centre a ten-minute bus ride away. The accommodation provides for up to eight people in a large detached threestory house converted for use as a residential care home. Service users bedrooms are located on the first and second floors of the premises. The home is centrally heated and all residents have single rooms, and the use of a shared lounge, dining room, kitchen and laundry facilities. To the rear of the property there is a garden with a paved patio area, a brick built barbeque and garden seats. At the front there is a large parking area and some flowerbeds. It is not obvious from the exterior that the premises are used as a care home, which ensures the integration of the service into the local community. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place during the evening between 16.45 and 21.45. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. As the inspection took place during the evening all of the service users were present except one service user who was away visiting relatives. The inspector had the opportunity to talk to all seven service users both individually and in a group and the inspector was also invited to attend the residents’ meeting that was held during the evening. The service users at Harleith are articulate and confident about expressing their views and therefore, able to fully participate and greatly contribute to the inspection process. The responsible individual was present for part of the inspection and the proposed manager was available during the entire inspection. There were a further 2 members of staff on duty although one member of staff had to go off shift sick and was replaced by a bank staff worker. There was limited time available to talk to staff during the inspection, as they were busy supporting the service users. The inspector received one letter from relatives who said they were “pleased with the service and care provided by staff”. During the inspection all communal areas of the home were viewed and a sample of 2 service users’ bedrooms. Records and documentation were sampled including medication records and staffing records. After the inspection the inspector was also provided with additional information including draft copies of the Statement of Purpose, the Service Users Guide and service user contracts. A comprehensive complaints policy and procedure was also received along with an accessible format designed specifically for service users called “Making it Better”. What the service does well: Residents at Harleith are enabled to fully participate and contribute to the life of the home. There are many examples of good practice where service users are encouraged to make choices and have control over their own lives. These included service users self-medicating, service users choosing and preparing their own evening meals, 2 service users having their own food budget, service users chairing residents meetings and being included on interview panels for the selection of staff. These practices also help service users to develop their independent living skills and reach their full potential in all areas of their lives. Service users benefit from an ethos that is open and inclusive and feel Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 6 confident about raising issues and that these will be listened to and acted upon. Service users have good relationships with the majority of staff that are based on mutual respect and treating people equally. There are excellent opportunities for social and educational opportunities and good links with the local community. The home has a very welcoming atmosphere and service users express a great deal of satisfaction and enjoyment about the service they receive. What has improved since the last inspection? What they could do better: The finishing touches need to be put into place now so that the information, which has been produced in draft format, can be sent out to its intended audience e.g. statement of purpose and service user guide. There are still some outstanding policies and procedures, however, it is appreciated that these are being prioritised and produced as quickly as possible. There is an outstanding requirement to repair a shower rail in the top bathroom; although the proposed manager told the inspector there are plans Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 7 to refurbish all the homes’ bathrooms in the near future so this will be remedied then. The home is still not staffed during the day between the hours of 9.00 am to 5.00pm (Mondays to Fridays) and whilst this is clearly specified in service users’ contracts it does restrict service users choice and access to the home during these periods. The organisation may wish to review their staffing levels/fee structure in the future to facilitate working in a person centred way promoting peoples’ choices of what they do during the day. The home has not had a registered manager for several months now and it is important that the proposed manager submits a valid application and fee to the CSCI as a matter of priority. 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. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5. Much better information about the organisation and the range of services offered has now been produced in draft format. Once these have been implemented service users and their representatives will have a comprehensive guide enabling them to make an informed decision about admission to the home. Residents living in the home have been encouraged to make a significant contribution to the guide meaning this is based on service users actual experiences of the home. New contracts have now been devised and these need to be distributed to service users so they are fully aware of the terms of residency. EVIDENCE: The inspector saw a copy of the draft Statement of Purpose. This was comprehensive and included all the information required by regulation. The Statement of Purpose has been designed corporately so all the information is consistent between all the care home owned by SFHT. This now needs to be fully personalised to include the details specific to each home e.g. number of rooms, ensuite facilities and staffing details and qualifications. Once this has been implemented the standard will have been fully met. The proposed manager told the inspector that a management meeting is held every fortnight, which facilitates consistency enabling things to be produced on a corporate level e.g. induction of new staff and risk assessments. A draft Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 10 Service User Guide has also been produced. This is written in simple language providing a useful guide about living in the home. When it is finished it will also contain pictures enhancing its accessibility. Service Users told the inspector they had been consulted about the service users guide and had come up with alternative ideas. They were hoping to produce it in video and tape format and were working in 2 groups supported by staff to come up with ideas. Some of the quotes they wished to appear included “it is a nice place”, “nice people around to talk to”, “quiet and relaxing” and “you can choose where to go on holiday”. Once work on this has been completed it is anticipated that the Service User guide will exceed the minimum standards required by regulation. A contract has been set up that specifies the terms and conditions of residency in straightforward language. It clearly sets out both parties’ responsibilities. It is recommended that the contract includes details of the fees charged and who they are payable by, particularly the amount the service user contributes to their fees. This now needs to be implemented and signed by service users with support if appropriate to fully meet the standard. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. Service users were encouraged to make a whole range of decisions giving them a real sense of control and choice over their daily lives. The inspector was impressed with the way service users were enabled to participate in all aspects of running the home, empowering them to feel able to fully contribute to the service. Information in the home is handled appropriately although service users are not entirely sure about who has access to this and would benefit from clarification in an accessible/simplified format. EVIDENCE: Observation throughout the evening evidenced many good examples of how service users are supported to make their own decisions e.g. they could choose their own meals, be supported to prepare them and choose when and where to eat them, service users could choose where to go on holiday and 3 service users had been supported to access college courses starting in September. There was evidence that staff helped service users to access advocacy support and take part in local self-advocacy groups if they wished to. All service users are supported to manage their own finances and have their own bank accounts. Service users confirmed they were enabled to manage their own Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 12 finances and 2 service users said they had their own budgets for food further promoting their independence by enabling them to purchase and prepare their own meals. Observation during the inspection further demonstrated service users control and choices over their finances as 2 service users decided to go to the bank to access their money supported by a member of staff. Service users are encouraged to participate in all aspects of the life of the home. Again many examples of good practice were seen such as residents chairing their own meetings, residents being involved in the production of the Service User Guide, residents being involved on interview panels for the selection of staff, and residents being involved in the redecoration of the home. Service users had a real sense of ‘ownership’ of the home and told the inspector how they been involved in the spring-cleaning of the home and taken the responsibility to decide what should be kept or thrown away. They also said they were looking forward to helping with the painting when the home was re-decorated. The home was working at developing alternative formats and had consulted the residents about preferred methods e.g. service users had chosen to work on producing the Service User guide in video and tape formats. There was evidence that information was kept securely in the office and in accordance with the Data Protection act. There is an outstanding recommendation, however, to make the policy on confidentiality more accessible to service users and discussion with service users during the inspection indicated they were still not entirely certain who could have access to their personal information. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 17. The home has adopted a more person centred approach to provision of daytime activities offering service users the chance to experience other environments other than the SFHT’s own day service. Links with the local community are good and support and enrich service users’ social and educational opportunities. The home offers maximum choice and flexibility over meal times promoting service user’s individuality and independence. EVIDENCE: All service users were engaged in daytime activities. The SFHT has its own integrated day service that provides a variety of courses such as art & craft, pottery, woodwork, personal relationships, current affairs and horticulture. Under the new director, the SFHT are taking a more person centred approach to service users care and this means individuals choices are being promoted. Discussion with the service users during the inspection showed they were now attending a range of different services during the day including college courses and work placements. There was evidence that service users accessed the community on a regular basis. Service users confirmed they utilised a whole range of amenities including shops, banks, post offices and leisure facilities. Some residents were assessed as being able to access the local community Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 14 independently and 2 residents told the inspector they had been learning how to catch the bus to college. Another resident regularly caught the bus to his work placement in the nearby town of Christchurch. The home also has its own transport, which is available to take residents on outings and trips. Observation during the inspection confirmed residents could access the community as two residents went out during the evening to the bank supported by a member of staff. Service users attending the SFHT day service are provided with a cooked lunch. Arrangements during the evening for food preparation are flexible with all residents being encouraged to make their own meals or snacks. This means that service users are able to choose exactly what they want and on the evening of the inspection some residents had a cooked meal they had helped prepare with staff and others had snacks such as a toasted sandwich. Two service users have their own food budgets and purchase their own food. They have kitchenettes in their bedrooms so are able to make their meals entirely independently. Meal times are flexible and service users choose when they want to prepare their meal, in fact a couple of service users were so involved in the inspection that they had only just began to prepare their meals as the inspector left! Residents can also choose where to eat and some ate in the dining room, some in the lounge and some in their rooms. Service users told the inspector that they all sit down to Sunday lunch in the dining room as they thought it was important to share one meal a week together. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. The systems for administration of medication are good with clear and comprehensive arrangements in place to ensure service users medication needs are met including promoting service users’ abilities to self medicate. EVIDENCE: A comprehensive policy and procedure is in place that gives detailed advice to members of staff about the administration of medication. The home uses a NOMAD system of medication and records were checked and these were found to be up-to-date and accurate. All service users current medication is listed as well as information about the medication including any contraindications so staff have easy reference to this. The proposed manager has also complied a list of agreed homely remedies for each service user, which is signed by their G.P. to confirm his agreement to them being taken if necessary. The proposed manager also carries out a weekly audit of all medication and disposal of medication is recorded and signed for by the chemist. 2 residents are currently administering their own medication and appropriate risk assessments for this were seen. One resident showed the inspection a locked medicine cupboard in his room and was able to explain how he takes his medication to the inspector. Staff complete external courses in Medicine Management that are arranged through the SFHT. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22. There is an ethos of openness throughout the organisation in which service users are encouraged to raise any issues/concerns and feel confident that their views will be listened to and acted on. EVIDENCE: The SFHT have now up-dated their complaints policy and procedure, in order to ensure consistency throughout the organisation. The policy is clear offering comprehensive guidance to staff about dealing with minor complaints and more serious ones. There is a clear line of accountability throughout the organisation and information is given about other agencies that can be approached including CSCI. An accessible format has been developed for service users called “Making things better”. This includes a simple written format and symbols to explain the procedure and a form that the service user can complete with appropriate support if necessary e.g. an advocate. Service users told the inspector they were fully aware of the procedure and this was discussed at the residents meeting when some of the service users felt they wanted to make a complaint about issues concerning a member of staff. Both the Director and the proposed manager were present at the meeting and they were quick to reassure service users about their rights to complain and agreed to come back to them with a proposed course of action. The inspector was also informed of the outcome of the service users complaint after the inspection and it had been resolved in a professional manner and in a way that satisfied the service users living in the home. It was noticeable that the organisation encourages an ethos of openness and “welcome complaints as they can bring something wrong with the service to our attention and enable us to improve what we do”. The home has a separate complaints procedure for anyone other than service users. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24. The home provides service users with a comfortable, homely environment offering full participation in all future plans to re-decorate which gives service users a real sense of ownership of the home. EVIDENCE: The lounge, dining room, kitchen and office were viewed as part of the inspection. 2 residents also showed the inspector their bedrooms. The home was seen to be bright, comfortably furnished and welcoming. Service users told the inspector they had recently been involved in spring cleaning and had all taken responsibility for various areas in the home, including making decisions about what to throw out e.g. they said they had got rid of an old hi-fi that no longer worked. The proposed manager said there were plans to improve the environment including re-decorating the hall and dining room and up-dating all the bathrooms. Service users told the inspector they were excited about the re-decoration and were going to be fully involved from choosing the colours to helping to paint the walls. There is an outstanding requirement to fix a shower rail in the top floor bathroom but the manager assured the inspector this would be resolved when the bathroom was refurbished. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34. There are sufficient staff on duty to meet service users individual and collective needs, however, the current residential fee does not include staffing support between the hours of 9.00 am and 5.00 pm. Robust procedures are in place for vetting and recruiting staff to ensure the protection of service users. Service users are given excellent support and training to fully participate in the selection of new members of staff. EVIDENCE: The home has employed 2 new staff since the previous inspection, meaning there are current 5 permanent members of staff working in the home. In addition bank staff are available that are employed by SFHT. The current rota provides one member of staff from 7.00 am to 9.00 am and two members of staff from 5.00 pm to 10.00 (Mondays to Fridays) and two members of staff from 7.00 am to 10.00 pm at the weekends. This means the home is not staff during the day apart from some management hours. The service users’ contract specifies “the money (residential fees) does not pay for the support you have during the daytime” so most of the service users attend the SFHT day service that is funded separately. However, the SFHT has been Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 19 working towards offering people more choice and extra funding can be agreed to provide support at home during the day if appropriate. One service user currently receives 10 hours one-to-one support during the week at the home. Although the staffing hours provided are less than those recommended by the Department of Health guidance, observation during the inspection demonstrated that sufficient staff were available to meet service users’ needs. This was further evident as one member of staff had to go off shift sick. The manager was able to replace the member of staff with a bank worker and the service users were still able to carry out tasks with the support they needed during the evening such as preparing their meals with and going out to the bank. During the inspection, one member of staff’s file was viewed. Records were up-to-date and the necessary documentation was held to ensure robust recruitment procedures were followed e.g. obtaining satisfactory references, and CRB checks. All staff received terms and conditions and a corporate induction has now been introduced into the organisation. An employee handbook is also available, which contains amongst other things information on the SFHT’s grievance and disciplinary procedures. Staff are employed subject to a six month probationary period and a form completed to record the outcome of this was observed during the inspection. The proposed manager told the inspector that service users are now included on the interview panels for staff recruitment and service users are given training in how to carry out interviews. Several service users confirmed this in discussion with the inspector. They also said they had been given the opportunity to be paid for delivering flyers to the local area advertising for bank staff for the organisation. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38. The proposed manager needs to submit an application to ascertain her ‘fitness’ for this post to the CSCI to fulfil the legal requirements of having a registered manager in post. The style of management in the home created an open environment where service users were encouraged to speak up and make a real contribution to the life of the home. EVIDENCE: The proposed manager has now been in post for several months. It is important that an application to establish her ‘fitness’ for this post is submitted to the CSCI in order to fulfil the legal requirement of having a registered manager in post. Observation throughout the inspection showed that service users were empowered to make decisions and contribute to the running and development of the services. Examples included resident’s chairing their own meetings, Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 21 openly discussing their concerns about a member of staff with the proposed manager, being included on interview panels for staff selection and deciding how the home should be decorated. The inspector was invited to attend the residents meeting and service users clearly felt confident about putting their views forward. Further written evidence received after the inspection set out an action plan in response to issues raised by service users, which demonstrated their views had been listened to and acted upon. Harleith D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 4 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 4 x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x 4 Standard No 31 32 33 34 35 36 Score x x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Harleith Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 1 3 x x x x x D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 23 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 1 Regulation 4 Requirement A draft corporate Statement of Purpose has now been produced. This needs to be personalised to include specific details related to Harleith. A draft Service User Guide has now been produced. The homes details and pictures now need to be included to produce a final version that can be given out to service users. The registered person must repair the shower rails in the bathroom on the top floor. The proposed manager must submit a valid application and fee for registration with Commission. Timescale for action 1 December 2005 1 December 2005 2. 1 5 3. 4. 27 37 23 9 1 January 2006 30 September 2005 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. Refer to Standard 5 Good Practice Recommendations It is recommended that the draft contract includes details of service users contributions to their fees and that the contract is distributed to service users so they are clear D55 S3945 Harleith V239040 250705 Stage 4.doc Version 1.40 Page 24 Harleith 2. 10 3. 33 4. 39 5. 40 about the terms and conditions of their residency. It is recommended that information about client access to records and sharing information is made available in a more accessible format and this is explained by staff to ensure service users understand the policy. It is recommended that the registered provider review staffing levels/fee structure to facilitate more service users spending time in the home during the day whether this is necessary because of illness or through personal choice. It is recommended that a corporate policy regarding quality assurance still needs to be developed especially to establish consistency amongst the three homes in the locality. This recommendation was not assessed on this occasion but was carried forward from the previous report and will be addressed at the next inspection of the home. It is recommended that the registered provider should produce written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition) and these should be produced in relevant formats for service users where appropriate. 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