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Inspection on 27/09/06 for Hatfield Haven Residential Care Home

Also see our care home review for Hatfield Haven Residential Care Home for more information

This inspection was carried out on 27th September 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that the resident and relatives spoke about. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. The home serves home cooked foods and cakes that the residents enjoy. The religious and cultural needs of residents are addressed through the menu.Hatfield Haven has a strong caring staff team with a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic, well trained and skilled. The resident spoken with reported that relatives and visitors are welcomed into the home at all times. Some of the activities provided in the home are specifically designed to provide stimulation for residents with dementia including chair games to promote physical exercise and interaction with the other residents and staff. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. The information held in the home (care plans) are well maintained and provide staff with detailed information regarding the care needs of the residents. The proprietor of the home has taken up the concerns of the CSCI and has invested both time and finances to ensure that the service has improved and in some areas exceeds the National Minimum Standards.

What has improved since the last inspection?

The manager has developed the individual care plans that now contain an up to date risk assessment that identifies all elements of risk and action to address these needs. The home has developed the care plans to ensure that these contain detailed information relating to the resident`s health care issues. The information has been updated to reflect when a change in need has occurred. The home has implemented an appropriate activity programme that meets the needs of the residents.

What the care home could do better:

The menu is to be developed to include the alternative choice that is offered on a daily basis.

CARE HOMES FOR OLDER PEOPLE Hatfield Haven Stortford Road Hatfield Heath Bishops Stortford Essex CM22 7DL Lead Inspector Sharon Thomas Final Key Unannounced Inspection 27th September 2006 09:30 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.V314305.R02.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.V314305.R02.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 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.V314305.R02.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 8th May 2006 Date of last inspection Brief Description of the Service: Hatfield Haven is a large detached house. The home is located on the edge of the village of Hatfield Heath that provides access to public transport and shopping facilities. The home has a manager who has successfully registered with the Commission for Social Care Inspection. The home is registered to provide residential accommodation for 18 older people (over the age of 65, with dementia), with low to high dependency needs. Hatfield Haven aims to provide individually tailored care and to meet the physical, social and emotional needs of the individuals who live there in a warm and homely environment. The home has bedrooms located on both the ground and first floor of the premises; 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 service users with limited mobility. The home benefits from a well-trained and sensitive staff group who had a sound knowledge of the service users and their needs. The home currently charges £550.00 per week. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 27 September 2006, and took 5.5 hours to complete. The home had had a previous unannounced random visit in May 2006, where some of the information for the key inspection was gathered. Twenty-one of the thirty-eight National Minimum Standards were inspected: and all of these were met. For the purpose of this report the individual living in the home and spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with one resident, the manager, three members of staff including the cook, and two relatives. The tour of the premises included observation of two bedrooms, all of the bathrooms and toilets, the communal areas and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection covered the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home had 4 requirements from the previous inspection report. The manager and the staff team are to be commended on the positive changes made in the home and the commitment to making the home a safer place to live in. The care at Hatfield Haven has never been of any great concern, and the atmosphere in the home on this visit was calmer and residents appeared happier. The home was warm and comfortable with good furnishings and a good level of decoration. The residents were cared for by a team of well-trained, skilled and caring staff. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that the resident and relatives spoke about. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. The home serves home cooked foods and cakes that the residents enjoy. The religious and cultural needs of residents are addressed through the menu. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 6 Hatfield Haven has a strong caring staff team with a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic, well trained and skilled. The resident spoken with reported that relatives and visitors are welcomed into the home at all times. Some of the activities provided in the home are specifically designed to provide stimulation for residents with dementia including chair games to promote physical exercise and interaction with the other residents and staff. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. The information held in the home (care plans) are well maintained and provide staff with detailed information regarding the care needs of the residents. The proprietor of the home has taken up the concerns of the CSCI and has invested both time and finances to ensure that the service has improved and in some areas exceeds the National Minimum Standards. What has improved since the last inspection? What they could do better: The menu is to be developed to include the alternative choice that is offered on a daily basis. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hatfield Haven DS0000017843.V314305.R02.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.V314305.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a random and key visit to the service since April 2006. The home has a thorough pre-admission system in operation that ensures that the needs of prospective residents are fully assessed and can be met. EVIDENCE: Two of the three care plans examined was that of the newest admissions into the home. One resident was funded by the local social service department and their file contained the social service assessment and the home’s preadmission assessment. The other was the care plan of an individual who was self funding, the care plan contained a copy of the home’s pre-admission assessment that was complete and detailed. There was evidence that the residents and their families are involved in the care planning process. The home had used its own pre-admission assessments, which were comprehensive and contained an appropriate assessment of need. One relative spoken with confirmed that prior to their admission, both they and their family Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 10 had been fully involved with all decision-making plans. One recent admission into the home made the following comment “the move in here for Mum was as easy as possible” and “the staff made Mum feel so welcome and at home”. Hatfield Haven DS0000017843.V314305.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a random and key visit to the service since April 2006. Health, personal care, social and emotional needs are set out in individual care plans, and satisfactorily cover all key needs and provide sufficient details of the action required by staff. Health care needs are well met within the home, and care plans adequately set out residents’ health, personal and social care needs. The medication procedures and systems used in the home ensured the protection of the residents. Staff treated residents with dignity and respected their privacy. EVIDENCE: Three care files were examined on the day. All contained detailed information regarding the resident’s need, the action to address this need, and the longterm outcome of the care given. The care plans covered all aspects of a Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 12 resident’s physical, mental and social needs, and were fully reviewed on a monthly basis. Where the resident has a dementing illness the care plans reflected this issue. The care plans are comprehensive and detailed, the level of information is excellent, well written, informative and directive to staff. All of the care plans contained a detailed risk assessment that enabled staff to identify and manage the risk. The manager and staff were commended on the day for the excellent improvement in the documentation. There was evidence that residents and relatives signed care plans and were involved in the planning process. Relatives spoken with confirmed that the staff in the home provided their family member with a good level of support and assistance. They commented “I trust the staff to give my Mum with what she needs” and that staff “do a great deal to look after her even though she is hard to manage”. Staff were observed treating residents with care and sensitivity, addressing residents appropriately and demonstrating a genuine level of care. The care plans that were examined all contained clear and detailed instructions for the delivery of personal care for residents. Oral and foot care were fully detailed. Routine health checks offered such as optician, dentist, and podiatrist were well documented. The manager confirmed that the home provided residents with access to aids and equipment to address their healthcare needs and issues. The manager confirmed that the home is well supported by the local primary healthcare team including GP’s and District and psychiatric nurses. The relatives and one resident spoken with stated that they were confidant that staff would “phone for the GP if Mum is ill and then contact me” and that “the staff are good at spotting if I am ill”. The care plans confirmed that healthcare issues are picked up speedily and dealt with in an appropriate manner. The medication used in the home is securely locked and stored. The records of the administration, receipt, and disposal of medication are accurate and well maintained as are the records of controlled medication. The staff spoken with that are responsible for giving medication confirmed that they had received appropriate training and support, and they are confident that they ensure the safety of the residents when administering medication. The manager has developed the system to secure controlled drugs used in the home. At the time of the visit no one in the home was able to administer their own medication, and no one in the home was in receipt of controlled drugs. Through discussion with staff it was clear that they were knowledgeable regarding side effects of medication, the policies and procedures and the importance of accurate recording. The manager reported that they had a good working relationship with the pharmacist, and is able to contact the pharmacy to seek advice if required. All of the relatives and the resident spoken with commended the staff with regard to the treatment they received in Hatfied Haven. The relatives stated that their family members privacy and dignity was maintained in a variety of ways, including the way staff provided personal care, toileting issues, respect Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 13 for visitors, and the provision of private areas in the home that enabled residents to see visitors in private. Observation of staff during the inspection indicated that staff are friendly, considerate and respectful toward residents. The resident and relatives commented that the “staff are wonderful” and “respect Mum as a person” and “treat her with respect at all times”. The resident and relatives confirmed that the home’s routines were relaxed and that this made them “feel even more at home”. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a random and key visit to the service since April 2006. The home provides an environment that meets the social and recreational preferences of the residents. There is a full range of activities to meet the residents’ varying needs. The home provides the residents with flexibility and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are well met. Residents are provided with a wholesome, nutritional and appetising diet. The residents are enabled to exercise choice over what they eat and the issue of equality and diversity is addressed in this standard. EVIDENCE: The home’s activity programme now offers a wide variety of social activity that is appropriate to the needs of the residents. The home has employed a dedicated activity co-ordinator who provides 3 hours a day Monday to Friday. The activities provided in the home include reminiscence, exercise to music, Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 15 board games and other dementia related activities. The co-ordinator has joined organisations that provide advice and specific activities for homes accommodating residents with dementia. The care plans sampled detailed the social and recreational needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. The resident confirmed that they were consulted regarding the entertainment brought in from the outside and that they were consulted prior to any changes being made. The relatives spoken with confirmed that the home provided a variety of activities in line with their preferences. The manager and staff involved in the improvement of this issue are to be commended for their hard work and commitment. The relatives and resident spoken to confirmed that they felt that they had choices in their daily lives (e.g. where and how to spend their day, what to eat, when to go to bed, etc.). On the day of the inspection, residents spent time in various parts of the home undertaking different activities both formal and informal. The resident spoken with commented that there “were no restrictions on them”. Resident choice is observed throughout the day and the staff are supporting choices made by residents rather than making choices for individuals. Staff are very clear regarding this issue and stated that the policy of the home is that the care is resident led. The staff are pleasant, polite and professional in their dealings with the residents and provide care in a discreet and quiet manner. The atmosphere in the home is calm and soothing and is suitable to the residents needs. The manager confirmed that the home does not act as appointee for any of the residents living there. Arrangements for residents to bring in possessions are discussed prior to admission, and records of the inventory of possessions are available. The care plans examined indicated some personal preferences in terms of food, clothes and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. The 4 weekly rota’d menu examined reflected that the home provided residents with a variety of well- balanced, nutritional and high quality meals. The home’s menu did not provide a formal choice of meals on a daily basis, but staff, relatives and the manager confirmed that the home provided an alternative to the meal on offer on a daily basis. The kitchen was well organised, and the food stocks were high and of good quality. Meals are freshly prepared and cooked by the chef who has a great deal of experience. The chef was knowledgeable and skilled and was committed to providing good wholesome meals to the residents. The meal presented on the day was appealing and was served with refreshments. The relatives stated that the quality of food in the home was “excellent” and “I often have lunch here and the food is very good”. The residents confirmed that the meals provided in the home were “good, appetising and more than enough”. Fresh fruit and snacks are available throughout the day, and residents confirmed that they could have a drink or snack at any time. When required, meals are served ‘softened’ and Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 16 special dietary needs are catered for. The religious needs of one resident who had specific issues regarding meals on Friday were addressed and evidence of this need is recorded in the individual care plan. In addressing this particular need the home have practically implemented the issues of equality and diversity within the service. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a random and key visit to this service since April 2006. The home has appropriate systems for responding to complaints, and that ensures that residents and relatives are enabled to make complaints. The home promotes the protection of service users through its policies and procedures and through staff training. EVIDENCE: Hatfield Haven has a Complaint procedure that is displayed in the foyer of the home. The document directed the individual on how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was a user-friendly document and was easy to read and understand. The resident and relatives confirmed that they were aware of the existence of the Complaint procedure, and they were able to confirm that they knew who to complain to, and felt confident that their concerns would be dealt with immediately. The home’s complaint log was well maintained and confirmed that no new complaints had been received since the previous inspection. Evidence indicated that the complaints were well recorded and dealt with in a professional manner. The Protection of Vulnerable Adult abuse policy and procedure examined over the course of the two site visits and was suitable for the purpose of protecting residents. The document had detail regarding the signs or types of abuse and Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 18 contained clear and detailed information for staff. The home has a whistle blowing policy and procedure available to staff, that ensures their protection should they report bad practice. The training records for staff were not available on the day and the manager confirmed that all staff except the one new member of staff had received adult abuse training. However, discussion with staff confirmed that indeed all staff in the home had received training and were able to describe what abuse was and were confident in the reporting of such matters. The manager reported that the home had not had any reported allegations of abuse since the previous inspection. The manager has dealt with an allegation of abuse in the past and the inspector is confident that the manager dealt with this in an appropriate and effective manner. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a random and key visit to the service since April 2006. The home provides a safe, well-maintained environment, which on the day of the site visit was clean and hygienic. Residents have access to safe and comfortable indoor and outdoor communal facilities. Bedrooms viewed were clean and well maintained, with suitable furniture and furnishings. EVIDENCE: The home continued to appear safe, clean and in a satisfactory state of decoration and repair. Records of decoration and refurbishment were not inspected on this occasion: monthly reports on the home sent into the CSCI by the registered provider over the course of the last year showed regular maintenance of the home taking place. The manager oversees the maintenance and safety of the premises and has access to maintenance Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 20 services when required. Communal lounges are homely. The home has a secure garden area, which is well maintained and laid out. Two bedrooms were viewed: these were similarly clean and tidy, with furniture and furnishings appropriate to the needs of residents, and well personalised. One relative stated that a key factor in them choosing this home was the homeliness of the rooms. The home’s laundry is sited inside the main building and away from areas where food is stored or prepared. Washing machines had the facility to carry out sluice and wash cycles suitable for infection control purposes when washing soiled linen, and the laundry person was aware of which cycles to use, and of the importance of wearing protective clothing when handling laundry. Infection control policies and procedures were not reviewed on this inspection; protective clothing was seen to be available to care staff. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including random and key a visit to the service since April 2006. Staffing levels (number and competence) are sufficient to meet the needs of current residents. There is a stable and loyal staff team, which ensures consisitency in the delivery of care. The recruitment procedure in the home is robust and ensures the safety and protection of the residents. Residents benefit from a well trained staff team. EVIDENCE: The staff rota examined reflected that the home was providing the agreed level of staffing. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. The home does not use agency staff to cover absence as it will use a member of the permanent staff team or a member of the bank staff ready to work on stand by, this results with the consistency of staff available to residents. Hatfield Haven provides staff with a full and appropriate annual training programme. Of the twelve members of staff, three have achieved their NVQ Level 2 or above, three carers have almost completed the course and there are plans to have the remaining staff enrol for the course in January 2007. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 22 The staff training and development programme provided in the home was not available for inspection on the day the manager confirmed that this will be sent to the commission from head office. The home provides a thorough and comprehensive induction programme for staff, which uses the Skills for Care induction standards; all staff are fully inducted within twelve weeks of their appointment. Staff have a range of refresher and specialist training available to them and are obliged to undertake refresher training when identified. Discussion with staff confirmed that they are receiving the full range of training available in the home. The staff spoken with and staff personnel records of the newest member of staff confirmed that all pre-recruitment checks are completed prior to employment. The staff file contained references, application forms, Criminal reference Bureau checks, personal identification, photograph and contract of terms and conditions for staff. The file of the newly recruited employee confirmed that she will receive a full induction programme, and will shadow a senior care worker until she was assessed as fit to work alone. The manager is fully aware of all the checks that are needed prior to the employment of staff. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a random and key visit to the service since April 2006. Hatfield Haven is well run by a competent and skilled manager. The home has an effective system in place to ensure that the quality of the service is reviewed and monitored and has systems in place that safeguards the residents’ financial issues. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 24 EVIDENCE: The manager of the home has been registered with the Commission for Social Care Inspection. The manager has a wealth of experience in the social care industry and is knowledgeable and skilled. The staff report that they are confident in the managers skills, trust her and find her “fair but firm” and “willing to listen”. The manager has gained the trust of the care team who view her leadership as a positive enhancement for the home. The home has developed a quality assurance system that has been implemented. The residents and representatives are involved in the user surveys and the information gathered from those surveys has been used to enhance residents’ lifestyles within the home. The home plans to survey the staff working in the home. The home does not hold any personal allowance for residents. The financial needs of the residents are handled by relatives and representatives. The home provides staff with appropriate Health and Safety training. Risk assessments of the premises are undertaken and regular Health and Safety checks of facilities and equipment are completed. The manager is aware of relevant Health and Safety legislation and is committed to the welfare of both the residents and staff group. Hot water, fire alarm and equipment checks were accurate and up to date. The staff spoken with are aware of the policies and procedures regarding Health & Safety issues. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP15 Good Practice Recommendations The registered person should ensure that the choice provided at meal times is formally recorded on the menu. Hatfield Haven DS0000017843.V314305.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hatfield Haven DS0000017843.V314305.R02.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. 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