Inspection on 25/10/06 for Hatherley Care Home

This inspection was carried out on 25th October 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.

Other inspections for this house

Hatherley Care Home 28/09/07

Hatherley Care Home 21/12/05

Hatherley Care Home 25/04/05

Hatherley Care Home 07/03/05

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 Hatherley Care Home Chaters Hill Saffron Walden Essex CB10 2AB Lead Inspector Sharon Thomas Key Unannounced Inspection 25th October 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 Hatherley Care Home DS0000062235.V317547.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. Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hatherley Care Home Address Chaters Hill Saffron Walden Essex CB10 2AB 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) 01799 508080 01799 508081 sabita@hatherleycare.wanadoo.co.uk Hatherley Care Home Ltd Lorna Margaret Law Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 24 persons) 21st December 2005 Date of last inspection Brief Description of the Service: Hatherley is a large period building; it has three storeys with lift access for residents. The accommodation for residents is situated on the ground and first floors. The home provides care to meet the physical, social, and emotional needs of residents. The home has been adapted to meet the needs of residents with limited mobility. The manager and staff work hard to create a homely atmosphere, where choices are valued, and rights preserved. The home was well decorated and well furnished throughout. The home provided pleasant communal lounges and a large dining room. The grounds are attractive, well maintained and provided adequate parking space for visitors and staff. The home has recently refurbished space to increase the number of available bedrooms by three. The home’s current charges are £440.72 per week per bed. Hatherley Care Home DS0000062235.V317547.R01.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 25 October 2006, and took 5 hours to complete. Twenty-one of the thirty-eight National Minimum Standards were inspected: nineteen were met and two were nearly met. For the purpose of this report the individuals 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 5 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 for residents to live in. The care at Hatherley has never been of any concern, and the atmosphere in the home on this visit was calm and residents appeared happy and content. 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 admission process used in the home ensures that appropriate and safe admissions are made. The care plans used in the home are comprehensive and well maintained, giving clear direction to staff to enable them to deliver appropriate care. The medication systems used in the home ensure the safety of the residents. Through the care practice of staff residents privacy and dignity are maintained. The menu in the home provides a well-balanced and varied diet for residents. The kitchen is well stocked, clean and well maintained. The home serves home cooked meals and cakes that the residents enjoy. The religious and cultural needs of residents are addressed through the menu. Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 6 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 including chair games to promote physical exercise and interaction with 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 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 meets the National Minimum Standards. What has improved since the last inspection? What they could do better: Staffing levels must be maintained to ensure the safety of the residents. The recruitment system used in the home must be tightened up to ensure that appropriate staff are employed. The issues identified above are important as the lack of sufficient staffing numbers in the home may ultimately impact on the quality and standard of care that service users receive. The lack of any of the required preemployment documentation for staff may impact on the safety of residents. This report contains two requirements linked to the above issues and may be found at the end of this report. Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hatherley Care Home DS0000062235.V317547.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 Hatherley Care Home DS0000062235.V317547.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): 3: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough pre admission process is in place to ensure the home is able to meet the individual’s entire assessed needs. EVIDENCE: The manager assesses the needs of the prospective resident to establish the needs of the individual and decide whether the home can meet the need. Two of the four care plans examined were two of the newest admissions into the home. These residents were funded by the local social service department and their files contained the social service assessment and the home’s preadmission assessment. The home had used its own pre-admission assessment, which has been developed and is comprehensive and contained an appropriate assessment of need. This information was then used as the basis for the individual care plan. There was evidence that the resident and their family are involved in the care planning process. One resident spoken with confirmed that Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 10 prior to their admission, both they and their family had been fully involved with all decision-making plans and that the home had provided them with useful information that had helped them make a clear decision. One recent admission into the home made the following comment “the move in here was made easier by the staff” and “the staff made me feel so welcome and at home”. Hatherley does not provide intermediate care. Hatherley Care Home DS0000062235.V317547.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, & 10: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system used in the home is comprehensive and thorough and provides staff with appropriate information. Health care needs are well met within the home, and as before care plans adequately set out residents’ health, personal and social care needs. The medication procedures and systems used in the home help protect the residents. Staff treat residents with dignity and respected their privacy. EVIDENCE: The four resident files examined contained a clear and detailed care plan, which gave precise information for care staff on how to meet personal, social emotional and psychological needs, ensuring consistent and structured support. They also provided evidence of the resident’s choices and preferences with regard to their personal care needs. Individual night care programmes were in place for residents detailing individual preferences such as time, Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 12 pillows, warmth and hot drinks and how needs were to be met to promote a good night sleep. The care plans contained information on the resident’s need, the action for staff to address the need and the aim of the care being provided. The care plans paint a clear picture of the individual, and give staff in-depth information regarding the needs, wishes and strengths of the resident. One care plan contained up to date information regarding the needs of a resident who leaves the home on a regular basis. Local road works in the town had been identified as increasing the risk to this particular resident and a comprehensive risk assessment had been carried out to enable the resident to continue with their daily routine. 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 detailed. Routine health checks offered such as optician, dentist, and podiatrist were documented. The home provided residents with access to aids and equipment to address their health needs and issues. The care plans contained detailed and relevant risk assessments along with manual handling and pressure sore assessments. The deputy manager confirmed that the home is well supported by the local primary healthcare team. Two residents stated that they were confidant that staff would “phone for the GP if they were ill” and “the staff look after me all of the time”. Healthcare issues are picked up speedily and dealt with in a preventative manner. The system of medication used in the home remains well maintained. The medication administration records, disposal records, and controlled drug records were all well maintained. Observation of care staff during the inspection showed that they were friendly and respectful towards residents, and understood and recognised residents’ rights to privacy and to be treated with dignity. Residents spoken with reported that staff were patient and kind, they enabled residents to preserve their dignity and assisted them with their personal needs in a professional and sensitive manner. One resident said that they had decided who they wanted to assist them with their personal care needs. One resident stated that their relatives were always welcomed into the home and “sometimes eat Sunday lunch with me”. Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 13 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, & 15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the residents with variety and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are well met. The residents are provided with a well balanced nutritional diet, where special dietary needs are addressed. EVIDENCE: The home’s activity programme continues to provide a variety of social activity that was appropriate to the needs of the residents. The care plans sampled detailed some of the social and leisure needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. Residents confirmed that they were consulted regarding the entertainment brought in from the outside and that they were consulted prior to any changes being made. Residents spoken with confirmed that the home provided a variety of activities in line with their preferences. Three residents confirmed that “there was always something to do” and one resident Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 14 stated that, ”I do some of the activities” and “I don’t like to take part in the activities I prefer to spend time with my friends, having a chat”. Residents 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. Residents commented that there “were no restrictions on them”. Resident choice is observed throughout the day and the staff support 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 care is provided with respect, and carried out professionally. The staff are pleasant, polite and professional with 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 deputy 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 possessions are available. The care plans examined indicated some personal preferences in terms of clothes, times for rising and going to bed, personal care preferences and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. One resident commented that they felt that “I pretty well do as I please” and “staff respect the choices I make and they do not question me” “ I suit myself as to what I do, except at meal times”. Comment cards from three relatives confirmed they were kept informed of important matters affecting their relative and were consulted about their care. The home displayed details of an independent advocacy service that is available to residents. The five weekly rota’d menu examined reflected that the home provided residents with a variety of well-balanced, nutritional and high quality meals. The menu was displayed throughout the home and residents spoken with were aware of the choices available on the day. 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 residents stated that the quality of food in the home was “very good”. Residents confirmed that the meals provided in the home were “more than enough” and “well cooked”. Fresh fruit, snacks and drinks 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 special dietary needs are catered for. The cook and her assistant have received over and above the required training including the protection of Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 15 Vulnerable Adults. The chef was proud of the food that she prepares and was committed to providing the residents with tasty and appealing meals. Hatherley Care Home DS0000062235.V317547.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 & 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had an effective complaint procedure that enabled residents and relatives to make a complaint. The home operates appropriate practices and procedures to protect vulnerable adults. The manager and staff promote awareness of adult protection issues through the written policies. EVIDENCE: The home has a Complaint Procedure that is both clear and concise. 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 written in plain language and was understandable. The home’s newly developed complaint log contained one new complaint and this was well recorded and dealt with in a timely and appropriate manner. The complaint log was well maintained, and up to date. The home has developed a new adult abuse policy and procedure since the previous inspection. The policy and procedure is an excellent document that provides guidance for staff on how to safeguard adults in their care. It describes the types of abuse, how to recognise abuse and what to do if you do witness abuse. The document is clear and well written. The staff training records indicated that all but one member of staff had received training with Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 17 regard to this issue. Staff spoken with were confident that they would respond appropriately if an allegation of abuse were made. The deputy manager has a comprehensive knowledge with regard to protecting the residents who live in the home. Hatherley Care Home DS0000062235.V317547.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 & 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a homely, warm and welcoming environment. The accommodation was of a comfortable and safe standard with good levels of hygiene. Specialist equipment and aids are available to promote optimum independence and well-being. EVIDENCE: The home is clean, bright and airy and has a homely feel. A running redecoration and maintenance programme to maintain and improve the environment is in place. On the day of inspection the foyer area where residents sit was cold and a resident made a complaint to the inspector. The issue was taken up with the deputy manager and it was explained that the boiler servicing the area had broken down and was being repaired on the day. As previously reported the home is increasing its room numbers by three. On Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 19 the day of the inspection it was not possible to view the bedrooms as major works were still being undertaken. The rooms will be reviewed prior to registration to ensure that they meet the standards. It is planned that the rooms will be registered as accommodation in November 2006. Hatherley has good levels of hygiene. The home employs appropriate numbers of domestic staff to ensure that hygiene levels are maintained. The laundry and kitchen areas are well maintained and staff wear appropriate protective clothing. The home smelled fresh and clean and there were no offensive odours present. The communal areas and individual bedrooms are clean, tidy and domestic in nature. Bedrooms were personalised by the pictures, ornaments and furniture brought into the home by residents and their relatives. Hatherley Care Home DS0000062235.V317547.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, & 30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home provides appropriate numbers of staff to meet the needs of the residents. The staff in the home are provided with appropriate levels of training. The recruitment procedure in the home was not robust and did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The staff rota examined on the day reflected that the home was providing the agreed levels of staff in the previous week. However, on the day of the inspection the staff team was one member of staff down. The deputy manager stated that she had attempted to cover the absence with someone from the permanent team and bank staff, yet she had been unsuccessful. The home does not use agency staff, this issue was discussed on the day and it was agreed that agency staff are to be used to cover absence if all other options have been exhausted. The staff rota’s indicated that the home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. Records confirmed that of the 29 staff currently employed at Hatherley 21 members of staff in the home had achieved the NVQ Level 2 qualification. The Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 21 manager provided evidence that the home is securing places with the provider on the NVQ Level 2 for the remaining 7 staff. The staff personnel files of the two newest recruits to the home were examined on the day. These both contained some of the information needed to ensure the safety of residents through the recruitment process. They both contained a POVA first/Criminal Records Bureau check. Both files contained only one of the required two references, one of the references had been written by the current manager of the home. Therefore one of the files did not contain an independent reference. Both files contained a photograph of the member of staff and only one contained the required personal ID. Both members of staff had received a contract of employment and a copy of the General Social Care Council Code of Conduct for staff. Training records and discussions with staff indicated that the staff working in Hatherley receive an appropriate level of training. The staff confirmed that they had been provided with training appropriate to their job. They also confirmed that their training needs were discussed in supervision sessions. Hatherley Care Home DS0000062235.V317547.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, & 38: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hatherley 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 are comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: The manager of the home is 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 manager’s skills, trust her and find her “approachable and honest” and Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 23 “easy to talk to”. The manager has gained the trust of the care team who view her leadership as a positive enhancement for the home. The manager is undertaking the NVQ4 Registered Managers Award, however the building works have taken priority in her workload and the timescale to complete the qualification has been extended. She now hopes to complete the course in 2007. The home has developed a quality assurance system that has been implemented. The residents, representatives, staff and external agencies have been surveyed and the information gathered from those surveys has been used to enhance residents’ lifestyles within the home. The proprietor has analysed the results and published a report a copy of which must be sent to the C.S.C.I. The home holds minimal amounts of personal allowance for residents. The financial needs of the residents are handled by relatives and representatives. The monies of 4 residents were examined and found to be accurate and the records of expenditure were well maintained. 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. Hatherley Care Home DS0000062235.V317547.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 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 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hatherley Care Home DS0000062235.V317547.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 (1) (a) 19 Requirement The registered person must ensure that the home has the appropriate numbers of staff on duty on all shifts. A contingency plan for cover is to be created by the manager and used when absence occurs. The registered person must ensure that the recruitment system is robust and that all checks and documentation is in place prior to the employment of newly recruited staff. Timescale for action 30/11/06 2 OP29 7, 9, 19 Schedule 2 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, 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 Hatherley Care Home DS0000062235.V317547.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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