Inspection on 10/10/07 for Hatfield Haven Residential Care Home

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hatfield Haven Residential Care... 30/09/09

Hatfield Haven Residential Care... 27/09/06

Hatfield Haven Residential Care... 18/10/05

Hatfield Haven Residential Care... 13/04/05

Hatfield Haven Residential Care... 22/10/04

Hatfield Haven Residential Care... 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hatfield Haven Stortford Road Hatfield Heath Bishops Stortford Essex CM22 7DL Lead Inspector Mr Trevor Davey Unannounced Inspection 10th October 2007 10:45 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 Hatfield Haven DS0000017843.V353050.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. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatfield Haven Address Stortford Road Hatfield Heath Bishops Stortford Essex CM22 7DL 01279 730043 01279 730043 hatfieldhaven@hotmail.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hatfield Haven Limited Mrs Donna Marie Turner Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 18 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 18 persons) The total number of service users accommodated in the home must not exceed 18 persons Service users must not be admitted to the home under the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 27th September 2006 Date of last inspection Brief Description of the Service: Hatfield Haven is registered to provide personal care and accommodation for 18 older people over the age of 65 years of age with dementia. The home is a large detached house located on the edge of the village of Hatfield Heath that provides access to public transport and shopping facilities. The home has bedrooms with ensuite facilities located on both the ground and first floors of the premises as well as three communal bathrooms. The upper floor is accessible through the passenger lift. The homes grounds are accessible to both the service users and their visitors. The home is well equipped to meet the needs of the current service user group and provides aids and adaptations to assist residents with limited mobility. Residents are encouraged to be involved in various types of social activities, which reflect individual needs and interests. The home benefits from a welltrained and sensitive staff group who have a sound knowledge of the residents and their needs. The current rates of fees are between £595 and £650 per week. Additional charges are made for hairdressing, chiropody, toiletries, papers and magazines. Information about the home is made available to prospective residents in the Statement of Purpose and Service User’s Guide. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit covered a period of 7.50 hours and covered all key standards. The manager, staff, residents and some relatives were available during the site visit and were spoken with. Their comments and contributions received were helpful in assisting the Inspector to prepare the report. In addition, comments included in survey forms issued by the Commission for Social Care Inspection were taken into account as well as feedback in response to the home’s own questionnaire as part of their quality assurance system. As part of the site visit, a tour of the premises took place, personal care records and other official records within the home were also assessed. The information included in the annual quality assurance assessment form (AQAA) which had been submitted to the Commission for Social Care Inspection, was also used in compiling the inspection report. This form gives homes the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as future plans for improving the service. Matters relating to the outcome of this inspection were discussed with the manager. Full opportunity was given for discussion and/or clarification both during and at the end of the site visit. At the time of writing the report, there is an adult protection matters that is being investigated by Social Services. The outcome of the investigation will be reflected in the next inspection report. What the service does well: The Registered Provider together with the manager, are committed in promoting high quality care and ongoing improvements have taken place in the home since the last inspection. There is a warm and homely atmosphere with the staff team who are committed in providing personalised care to meet the needs, choices and aspirations of residents. The home has introduced its own quality assurance system and some of the positive comments in survey questionnaires completed by relatives stated , residents appear always clean and tidy, people are well cared for and happy, staff are approachable and helpful, rooms are in very nice condition. Positive comments were also made about the good atmosphere in the home. Wherever possible, residents are stimulated and encouraged to be Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 6 involved in daily routines such as folding napkins and clearing tables. The home has demonstrated that it is good at listening to people who use the service and introducing improvements as a result of comments made. The manager has an open door policy to encourage residents and visitors to discuss issues on a regular basis. Opportunities are also made for relatives to attend meetings to discuss the service provided and future development of the home. The manager is also good at being involved with the staff team and interacting with residents within the daily life of the home. As part of the monitoring process, the Registered Provider visits the home during the week and is in regular contact with the manager so that issues can be discussed. The home also enjoys a good professional working relationship with other health care professionals who visit the home on a regular basis. There is very little staff turnover and appropriate training is provided including dementia care, diabetes awareness and infection control. The home is also actively looking at ways to update and define a clear staff induction and training programme. What has improved since the last inspection? As a result of listening to comments made by users of the service, improvements have been made in the provision and variety of social activities in the home. A social activities co-ordinator who is part of the staff team, continues to give this aspect of the service a high profile, which has provided improved benefit for the daily living experiences of residents. Fresh fruit has been made available to residents as an alternative desert. Religious services take place on a regular basis in the home meeting specific spiritual needs. As part of the homes quality assurance system, questionnaires are distributed to relatives twice a year to give them an opportunity of providing their comments about the service. In order to assist staff to be able to interact better with residents, letters have recently been sent to families with questionnaires with a view to building up personal fact files of information. This includes details of early background information, family history, interests and hobbies. Other questions relating to emotional needs have also been included. It is intended that information gathered will form an important part of the care plan for staff to follow. New lounge and dining room furniture has been purchased for the home as well as replacement carpets, kitchen equipment and many areas have been redecorated. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 7 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. Hatfield Haven DS0000017843.V353050.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 Hatfield Haven DS0000017843.V353050.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (standard 6 is not applicable in this home) People who use the service experience excellent quality outcomes in this area. Residents can expect to have their care needs assessed by the home to ensure that the proposed placement is suitable. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Information about the home is available in the Statement of purpose and Service User’s Guide. Copies of the Service User’s Guide had been given to residents and were available in their rooms. These documents had clear information and details about the service provided. When next updated, more information should be provided in the Statement of Purpose to show how the specific needs of residents requiring dementia care are met and provided for by the home. The home already has plans to improve the resident’s ‘welcome pack’, which will include a new brochure available in different formats. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 10 From the sample checks made, personal care records included a detailed client profile together with photograph and pre-admission assessment. Information regarding personal and family details as well as medical conditions had been recorded. The pre-admission assessment took into account the holistic needs of potential residents including dietary preferences, history of falls, continence and medication as well as social interests and hobbies. Reference was also made to religious and cultural needs as well as the carer and family involvement. There was also a mental health and nursing needs assessment, which had been prepared by the Social Services Department. In one case, a tissue viability assessment had been carried out which was accompanied by a plan and wound management record. This had been reviewed and updated since the resident had been admitted to the home. As part of the preadmission process, the manager visits potential residents in their own homes or hospital. One of the relatives spoken to during the inspection was complimentary about the skills of staff who support and care for residents. The relative said the manager was approachable and if there were any concerns, staff always kept them informed. Other positive comments were made about the location of the home and that it was in an area and surroundings, which were familiar to the resident. Comments included in survey questionnaires completed by relatives, felt the home was a ‘real’ home rather than an institution and visitors were made to feel welcome as well as staff being respectful. In the Annual Quality Assurance Assessment (AQAA) completed by the home, mention is made that details are made available to relatives regarding the Alzheimers Association should they wish to make contact for more information. Relatives are also encouraged to personalise bedrooms with possessions prior to admission of residents in order to assist the settling in process. Hatfield Haven DS0000017843.V353050.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 People who use the service experienced good quality outcomes in this area. Residents can expect to have a plan of care drawn up by the home that details their assessed needs and to receive the services of health care professions. Residents can expect the home to manage the administration of medication in accordance with accepted good practice guidelines. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Time was spent in the lounge/dining area and staff were observed to be interacting positively with residents with a clear understanding of their needs and being able to communicate effectively. A sample of personal care records were inspected which included care plans, risk assessments, reviews and daily record sheets. Daily entries had been recorded with regular entries, which included details of care and support provided. Intervention by the visiting community nurse was also noted and cross-referenced with other records. Care plans had details of the key worker involved and examples of care plans Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 12 drawn up included personal care and physical well-being, diet and dietary preferences, communication, sight and hearing, moving and handling. Where appropriate, risk assessments had been included detailing how to respond and deal with potential issues. From the sample check made, specific action had also been recorded for staff to follow. In some of the records examined, some dates were incomplete with the day in the months recorded but not the year. The separate sheet recorded the visits and treatment provided by local doctors and community nurses. In discussions with the manager, care plans are reviewed monthly and changes are recorded if appropriate. There was no clear evidence, however, that reviews had been carried out to indicate that changes might not have been necessary. There should be some documentary record to show that named staff have carried out reviews of care plans and risk assessments to evidence that reviews have not been overlooked. Where residents and relatives have been consulted, this information should also be recorded. The Inspector was advised that although expected, staff do not always have time to read care plans because of shortages of staff and the pressure of care duties. The home have acknowledged in their AQAA self-assessment form that they need to review and update care planning and in particular, to include the principles of the Mental Capacity Act 2005. They also recognised that the weight record of residents needs to be monitored more effectively. The home plans to introduce these improvements in the next twelve months. Sample checks were made of the medication administrative arrangements in the home. Medication administrative records (M.A.R.) had been properly completed, initialled and dated in accordance with prescription instructions. A record of discontinued drugs had been maintained showing when these had been returned to the pharmacist. The manager was advised that local doctors must be requested to verify and give written confirmation of changes in medication. Medication administrative records can be signed by the local doctor concerned or there must be two staff signatures where transcribing of medication details are recorded, in accordance with the guidance issued by the Royal Pharmaceutical Society. It is understood that the home is planning to go over to the monitored dose system (blister pack system) in November 2007. Local doctors visit as required and regular intervention is provided by other health care professionals. Responses received from survey questionnaires completed by health care professionals confirmed that communication and staff action has improved in the last few months. Comments were also made that they would like to see training improved in the areas of pressure care, first aid, nutrition and moving in handling. Plans for additional training in these areas has been made by the home. The home also recognises that in consultation with community nurses, there is a need to update the clinical procedures policy. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 13 Some comments from survey questionnaires completed by relatives were positive in that staff were unfailingly kind and were well trained. Residents were said to be well cared for and happy; staff were said to be very caring and attentive. Hatfield Haven DS0000017843.V353050.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 People who use the service experience excellent quality outcomes in this area. Residents can expect to receive a balanced diet and assisted in maintaining family/friend/community contact. Residents can be assured of a meaningful activity/recreational programme that meets their needs and interests. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has continued to give high priority in providing a variety of social and leisure activities to take account of different interests and aspirations. A record was available showing the residents who had been involved and the type of activities in which they had participated. These included musical bingo, card making, icing and decorating cakes. The activities co-ordinator, who is a trained occupational therapist, has a key role in promoting this part of the service. Other initiatives include musical therapy, dancing and some of the residents are able to take part in playing indoor skittles and bowls. A variety of videos on royalty and appropriate music/songs were also available. Some of the staff were successfully engaging and interacting with residents during the Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 15 afternoon in a sing-along session. Outside entertainers also come to the home on a regular basis. The activities organiser also takes different residents to the local village shops as an opportunity of pointing out places of interest. A vehicle is also hired for outings and relatives are also sometimes involved. Activities are available to meet the needs of all residents including specific social stimulation for those people requiring dementia care. A reminiscence box had recently been hired from the local library which contains objects of interest which residents are able to identify with dating back to the 1940’s. Some of the residents spoken with were able to talk about their childhood memories, interests and how they enjoyed visits from their family. Other residents seen in their rooms were positive about being able to choose how they spend their day with the opportunity of joining in some group activities or watching favourite television programmes. Visitors are welcome and some come to the home on a daily basis to be with members of their family. Comments from relatives were generally positive and suggestions had been made to provide more exercise and an activity plan for each resident. It was also acknowledged that these concerns had been discussed with the manager and acted upon. The home is actively seeking to enhance the choice of individual residents on a one-to-one basis in order to respond to individual wishes and suggestions. Some families have also prepared family photograph albums for residents as an aid for stimulation and reminiscence. In their AQAA assessment form, the home acknowledged that the well-being of residents has improved as result of appointing a social activities co-ordinators post. Details of meals provided to individual residents were recorded including dietary preferences where these were appropriate. Comments from relatives confirmed that the standard of food was good, well cooked and where suggestions had been made to increase the variety, such as fresh fruit to be available as an alternative to cooked puddings, these had been implemented. Religious services take place in the home on a regular basis and visiting clergy attend to individual spiritual needs as required. Hatfield Haven DS0000017843.V353050.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 People who use the service experience good quality outcomes in this area. Residents can expect to have their complaints taken seriously and be assured that they will be protected by the home’s ‘safeguarding adults from harm’ procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The complaints procedure is set out in the Service Users Guide and a copy of this document is displayed in the entrance hall. Two complaints were recorded since the last inspection and these were investigated with successful outcomes. Improvements were introduced to the service as a result and a better relationship has been established with relatives. Responses from survey questionnaires completed, show that when concerns are raised, the management are good at responding and dealing with the issues. Relatives spoken to during the inspection also confirmed that they were confident in being able to approach the manager where issues needed to be raised. A number of positive comments have also been made about the home and the service provided. Policies and procedures on’ safeguarding adults from harm’ were in place and the home is in the process of reviewing and updating these. The Inspector advised the manager of the updated telephone contact at Essex Social Services Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 17 when issues of this nature need to be reported. The home has had some experience of using the safeguarding adults procedures. At the time of writing the report, there is an adult protection matter, which is being investigated by Social Services. The outcome of the investigation will be reflected in the next inspection report. Hatfield Haven DS0000017843.V353050.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): 19,22,25 and 26 People who use the service experience good quality outcomes in this area. Residents can expect to live in a clean and comfortable environment This judgement has been made using available evidence including a visit to the service. EVIDENCE: A number of improvements have taken place in the home since the last inspection including the provision of new carpets in the corridors and some bedrooms. Hallways have been redecorated and the furniture in the lounge has been upgraded. The kitchen equipment has also been renewed and new exterior fencing and improved security lighting has been provided. A tour of the building included looking at some of the bedrooms, which were personalised with photographs, pictures and fresh flowers and included some furniture, which belonged to residents. Call bells were in place in bedrooms, bathrooms and toilets with the exception of one bedroom, which did not Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 19 appear to have a call bell facility to enable the resident to call for assistance if required. The corridor area with steps leading down to the lower level of the home was poorly lit which could pose a hazard to residents. Given that a number of the residents in the home require dementia care, appropriate signage, symbols and colour schemes should be incorporated in the premises to assist residents in being familiar with their surroundings. These matters were drawn to the attention of the manager who agreed to take any necessary action. It is understood that the home is already considering making available clearer recognition symbols in areas of the home to assist residents with dementia or who have a sensory impairment. Sample checks of hot water temperature were taken which was safe and not hot to the touch. A full-time member of staff is employed to carry out maintenance and a message book is kept to record any repairs or breakdowns, which need to be dealt with. A record had been kept in the kitchen of refrigerator and freezer temperatures and appropriate food hygiene regulations were being followed in the storage and dating of food. The cook confirmed that she had completed a food hygiene course. Responses from survey questionnaires indicated that the home is kept clean and tidy. Carpets are cleaned regularly and a clear continence management programme is in place. There were no unpleasant odours in the home at the time of inspection. The home also uses battery operated air fresheners to maintain a pleasant smell throughout the home. Protective gloves were readily available and the staff team was following infection control procedures. Hatfield Haven DS0000017843.V353050.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 People who use the service experience adequate quality outcomes in this area. Residents cannot always be expected to be cared for by sufficient numbers of staff at certain times of the day. Residents can be assured that records will be able to demonstrate that the home has followed robust recruitment and employment procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Apart from the manager, the normal provision of rostered staff includes one senior care assistant plus three carers for the early shift and one senior care assistant plus two carers for the late shift. In addition, an activities coordinator is available for three hours per day for five days per week. Night cover includes two care workers on awake duty. Other staff provided includes one cleaner in the mornings, a cook and kitchen staff, an administrator and a maintenance person. From observation, conversations with staff and responses included in survey questionnaires, there are concerns that there are times during the day when existing care staff are under pressure particularly in the morning and evening periods. At the time the home’s AQAA self-assessment form was completed, Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 21 eighteen of the residents were identified as needing help with dressing, undressing, washing/bathing and assistance to the toilet. Seven of the residents require dementia care and a number are singularly or doubly incontinent. Another resident is bedfast. Given that some residents require two carers to provide safe assistance and others are likely to wander and need constant supervision, staffing levels must be reviewed to ensure that suitable numbers of experienced staff are available at all times to give the care and support required. At the time of inspection, there were two vacancies and relatives have commented that this poses a burden on the existing staff team. Health care professionals have commented that there have been staff shortages day and night with existing staff having to do double shifts. Positive comments have been made regarding how staff are welcoming and respectful but that staffing levels need to be remedied. Other comments have been made to say that activities are not provided if there are shortages of staff. Staff spoken to, confirmed that there was good communication with each other and that senior staff have a meeting every two months. Also general staff meetings take place and minutes were available. Although sometimes under pressure, staff get on well together. Staff confirmed that ongoing training is available and that senior care assistants had completed medication training recently and this is to be followed up when changing to the new medication system. Training records were available for inspection, which showed staff who had attended courses, which included dementia awareness, advanced medication training, infection control, tissue viability and health and safety. It is recommended that further training be arranged for staff to include care planning and risk assessments as well as Parkinsons awareness. Some staff have commented that further hoist and equipment training would be welcome as well as safeguarding of adults from harm. Other courses had been planned for first aid, moving and handling, empathy training and continence care. The home has been successful in enabling over 50 of the staff team to achieve National Vocational Qualification level 2 or 3. The home has also identified that a primary focus needs to be placed on improving the induction programme for new staff. A sample check was made of the home’s recruitment records, which included Criminal Record Bureau checks, references and proof of identification. Where final clearance is awaited for CRB checks, the home ensures that staff concerned work under constant supervision. Hatfield Haven DS0000017843.V353050.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 and 38 People who use the service experience good quality outcomes in this area. Residents can expect to live in a home where the management and administration of the service is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Registered Manager has considerable experience in residential care, is competent and skilled in overseeing and promoting the service. The manager has obtained the Registered Manager’s Award and National Vocational Qualification Level 4. Practices and procedures are in place which are regularly reviewed and updated to improve the delivery of care and to bring greater fulfilment to residents in their daily living experiences. An important part of Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 23 this process is the quality assurance systems, which are in place which includes obtaining feedback from people who use the service. As well as using questionnaires, talking to residents and their relatives, it is recommended that other health care professionals should also be included in this process. Regular monitoring visits take place on behalf of the Registered provider and reports were available for inspection. The Registered provider is also very much involved in the home, visits regularly and is in constant touch with the manager. Servicing certificates were available and included electrical wiring, electrical portable appliance testing, gas safety and the maintenance of hoists and equipment. Fire risk assessments had been carried out for the premises and details were available of safe environment work place assessments The home does not hold any personal allowances for residents. Relatives and representatives handle the financial needs of the residents. Staff spoken to, had an awareness of policies and procedures and were positive in the support which exists for one another. A comment was made that the home is more like a family. The manager makes herself available, is involved and positively interacts with staff and residents. Staff spoken with confirmed that supervision on a one-to-one basis takes place every six months. The manager covers this for senior care assistants and the administrator for care staff. Supervision covers training, work and relationships as well as ensuring staff have an awareness of policy and procedures. From survey questionnaires completed, a comment was made that not all staff have one-to-one supervision and training is not always available. Although a regular training programme is in place, all staff groups (day and night) should be given the opportunity for training, supervision and further development. The Registered Provider and manager are constantly looking for ways to improve the quality of the service and fulfilment for residents. They intend to continue reviewing policies and procedures in the home and as part of this process, to use the structure of the AQAA self-assessment form as a quality tool to audit all areas, assess performance, reflect and learn from experiences and to plan. This demonstrates that the home is forward-looking and prepared to set objectives for genuine improvements in the service and care provided to residents. Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 24 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 3 x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 x x 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP27 Regulation 18 Requirement The Registered Person shall, having regard to the size of the care home, the Statement of Purpose and the number and needs of service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This is to ensure that residents can be supported at all times safely by adequate levels of suitably trained staff and individual needs are met. Timescale for action 01/01/08 Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The Statement of Purpose should include more details of how the home provides for the specific needs of people who require dementia care and any special facilities available for this purpose. To improve the practices for safe administration of medicines, arrangements should be made for local doctors to provide confirmation of changes in medication. Facilities, including communication aids, improved lighting and signage should be provided to assist the needs of residents with dementia and who may have sensory impairments. Training should be provided to give staff a greater awareness of the value of completing care plans/risk assessments as a means for providing continuity of care. Training should be provided to give staff an awareness of care needs associated with Parkinsons disease. To obtain a broader view of the service provided by the care home, health care professionals should be included when survey questionnaires are distributed as part of the home’s quality assurance exercise. 2. 3. OP9 OP22 4. 5. 6. OP30 OP30 OP33 Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Hatfield Haven DS0000017843.V353050.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!