Inspection on 17/01/08 for Havelock House

This inspection was carried out on 17th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Havelock House 01/09/09

Havelock House 18/12/08

Havelock House 26/04/07

Havelock House 03/05/06

Havelock House 04/10/05

Havelock House 19/04/05

Havelock House 21/12/04

Havelock House 06/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Havelock House 57 - 59 Victoria Road Polegate East Sussex BN26 6BY Lead Inspector Rebecca Shewan Unannounced Inspection 17th January 2008 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 Havelock House DS0000013997.V353236.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. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havelock House Address 57 - 59 Victoria Road Polegate East Sussex BN26 6BY 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) 01323-482291 01323 482622 jules48k@hotmail.co.uk Mr Bhardwaj Dhunnoo Mrs Tarramattee Dhunnnoo Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty seven (27). The service can provide up to twenty-six (26) nursing place and one (1) social care place. Service users must be aged sixty-five (65) years of age or over on admission. 26th April 2007 Date of last inspection Brief Description of the Service: Havelock House is registered to provide nursing care for up to 26 older people and personal support for one. Situated in a residential area of Polegate, it is within walking distance of the high street and the railway station, with the library, GP and dental surgeries being easily accessible. The home is on two floors with a shaft lift and stair lift giving residents access to all parts of the home. There are 21 single rooms and 3 double rooms with no en-suite facilities, although there are two assisted bathrooms, an assisted shower and a number of assisted toilets. There is a separate dining room and a large lounge, looking out to the rear garden that is accessible to wheelchair users and is used by all service users when weather permits. Potential new service users can obtain information relating to the home via CSCI Inspection Reports, Care Managers, Placing Authorities, the internet, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) were £400 - £607 per week, with additional charges made for hairdressing and chiropody. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place during the morning and afternoon of the 17th January 2008. Incident reports, previous inspection reports and the home’s Annual Quality Assurance Assessment (AQAA), held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six and three quarter hours. Records such as care plans, staff files and medication records were also viewed. Twenty three residents were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Appointed Manager, four staff, three service users (known as residents) and one relative was spoken with. The CSCI also conducted Service User, Relatives and staff surveys. Of which one relatives survey was returned. What the service does well: The home ensures that pre- admission assessments are carried out on all new and potential residents with only those whose needs can be met, being admitted to the home. The health needs of residents are met with the support of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. There is an efficient complaints procedure in place and the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. Staff training is on going and is appropriate to the level of needs of current residents. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is a need for the home to ensure that: Residents risk assessments must be implemented for those who require the use of bedside rails, in order to reduce the risk of harm. This remains outstanding from three previous inspections. Urgent action is taken to address errors made in the recording of medication administration, this will reduce the associated risks of harm to residents. Daily activities that are published must be made available in order to provide stimulation and variety to the lives of residents. Commodes throughout the home need to be thoroughly cleaned to prevent the risk of infection. Quality monitoring and quality assurance systems are to be expanded, in order that all residents, staff and other interested parties can give and receive feedback about the service that they experience. This remains outstanding from three previous inspections. Suitable risk assessments are to be put in place to reduce the risk of harm associated with the building works being completed and for residents who use the designated smoking area. Havelock House DS0000013997.V353236.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. Havelock House DS0000013997.V353236.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 Havelock House DS0000013997.V353236.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&6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has processes in place for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home’s Appointed Manager carries out pre- admission assessments. Copies of care management assessments from a placing authority, where this exists, are also obtained. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. The Appointed Manager confirmed that any potential resident whose needs could not be met, would be declined the services of this home. Residents spoken with said that they had been involved in the assessment process and had felt included in their admission to the home. Intermediate care is not provided by the home. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 10 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. All care is administered in way that protects residents privacy and dignity. Bedside rail risk assessments are insufficient in detail, leaving residents at risk of harm. Daily care entries are brief in content and are not reflective of the care administered to residents, making it difficult to determine whether residents individual care needs are met. Medication administration recording errors leave residents at risk of being over or under medicated. EVIDENCE: Following the inspection of April 2007 the home has made improvements to ensure that elements of the Statutory Requirements that the care plans are to reflect the assessed needs of residents, to include all risk assessments including falls and continence, and the use of bed barriers to enable staff to provide appropriate care and that training for staff to be provided have been met. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 11 Staff spoken with and training records viewed provided evidence that staff have received training in Care Planning Processes, since the previous inspection. Care plans sampled were comprehensive, detailed in content and covered all aspects of resident’s needs and are written to allow the assessor to gain a good overview of individuals medical, social and personal care needs. Residents informed the inspector that care plans were devised with their involvement. Monthly care plans reviews were evident. Details of any specialist interventions required e.g. for the management of nutrition, pressure area sores and wounds are specified and recorded in residents care plans. Risk assessments are in place. Of those sampled it was noted that residents care files had a ‘use of cot sides’ disclaimer in place, yet there were no detailed risk assessments, which informs staff of the risks associated with their use. Therefore this element of the previous inspection Statutory Requirement has not been met in full. The home has access to specialist pressure relieving equipment and utilises the resources of the Tissue Viability Nurse, as required. Daily care records were maintained. It was observed that these did not reflect the individual residents needs/care and were not written in line with care plans. Entries stated ‘comfortable day’, ‘washed in bed’ and ‘eating and drinking ok’. Staff recording entries also wrote ‘Nocte’ for night care and day care was written as the days date only. There were no separate entries for morning, afternoon and evening care. Staff initials were noted on each entry and there were no printed names or job designation recorded. In line with the Nursing and Midwifery Councils (NMC) guidance on ‘Report Writing and Record Keeping’, staff must date, time and sign each entry and include their printed name and designation. Therefore a recommendation has been made. The health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. Residents are registered with one GP from one of the two local surgeries. Resident’s are encouraged to attend the GP surgery where able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist, Dietician and Audiologist are made via the GP or the hospital. Direct access to a domiciliary dentist is available. A visiting Chiropodist attends residents six weekly, with additional appointments being arranged if necessary. A domiciliary optician attends the home annually. The home has good, clear procedures in place for the monitoring and recording of all drugs entering and leaving the home. Staff training in medication has been conducted since the previous inspection and all staff that administer medications have been certificated as safe to do so. A monitored dose box system is in place for many medications prescribed. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Administration Record (MAR) sheets were viewed for all residents and twenty incidents of missed entries were evidenced. Missed entries had occurred on various dates from the 7th – 15th January 2008. It was also noted that Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 12 unexplained, undated and unsigned handwritten entries for medications had been made on some MAR sheets. Therefore Immediate Requirements were made. The controlled drug register was audited with controlled medications maintained by the home. At the time of the inspection there were forty two Temazepam unaccounted for. This incident was investigated at the time of the inspection and it was found that the unaccounted for tablets had not been transferred from the old register to the new one. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Residents spoken with said that care staff are ‘kind and helpful’. Havelock House DS0000013997.V353236.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Social contact with friends and relatives is positively encouraged and in accordance with residents wishes. The home does not provide a daily wide range of social, cultural and recreational facilities on a daily basis, meaning that residents are unable to enjoy a full and stimulating lifestyle. Dietary and nutritional needs are met, with resident’s choice and wishes relating to diet and food being respected. EVIDENCE: The Activity Co-ordinator works at the home two days of the week. On these days activities are arranged in accordance with residents choice. The remainder of the week, activities are arranged by care staff who have full access to activity equipment. Though activities are only arranged if care staff are ‘not too busy’. As a result there is no published list of activities for residents to refer to. This is acknowledged by the home and is recorded in the AQAA that the management hope to provide a wider range of activities in the next twelve months. Records found in care files sampled had recorded when Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 14 residents had entertained a visitor and did not detail specific activities. Therefore a requirement has been made. Activities conducted are quizzes, bingo, reminiscence, inflatable dice board games and movement. Special activities are arranged for birthdays and festive occasions such as Christmas, Easter and other seasonal holidays. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion if they wish. Discussions with the Appointed Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents are treated with respect and there is a good rapport between staff of the home and residents. Residents spoken with and the survey received highlighted that there can sometimes be communication difficulties between staff and residents. Residents spoken with said that they sometimes felt that this was a combination of staff’s poor command of the English language and hearing problems experienced by residents. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and residents guests are also welcome to have meals at the home. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Residents spoken with reported that ‘the food is good here’, ‘pureed food doesn’t look nice but it is enjoyed and always eaten’, ‘food is often cold’ and ‘there are no alternatives offered.’ Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: There is an established complaints procedure in place. The appointed Manager reported that two complaints had been received in the previous twelve months. These complaints related to care practices and laundry services. The appointed Manager stated that these complaints have been resolved to all parties satisfaction. Evidence of complaint records could not be viewed at the time of the inspection, as the Appointed Manager could not locate the file. Residents were asked whether they knew about the homes complaint procedure and all responded that knew who to complain to, other comments received stated that ‘that there is not a lot of action – promises are made but nothing happens’ and ‘I have never had cause to complain’. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. There is currently one Safeguarding Alert being investigated under the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Staff have attended training in the Protection of Vulnerable adults, this was evident from the staff files that were viewed. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 16 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, 25 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides accommodation for residents that is appropriate and odour free. Redecoration of the home and replacement of furniture is underway, in order to improve the quality of the residents environment. Infection control procedures are in place but are not adhered to at all times, individual residents commodes need to be thoroughly cleaned in order to reduce the risk of infection. EVIDENCE: The location and layout of the home are suitable for its stated purpose. Since the inspection of April 2007 improvements have been made to ensure that the Statutory Requirement (outstanding from two previous inspections), that an ongoing maintenance programme to be developed and introduced to ensure the safety of residents, has been met. There is now an ongoing plan of Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 17 refurbishment in place. It was evident that the recent redecoration of some bedrooms, the dining area and kitchen had been completed. The Appointed Manager provided evidence that quotes had been obtained for the purposes of fitting new carpets throughout the home. New flooring was evident in both the kitchen and dining areas. It is acknowledged by the Appointed Manager that although redecoration has commenced, there is still much to do to bring the home in line with current standards expected by residents. Following the inspection of April 2007 improvements have been made to ensure that the Statutory Requirement that the management of the home consult with Health and Safety Executive and take suitable advice concerning protecting residents from the risk of hot surface temperatures from radiators has been met. All radiators observed during the tour of the premises were noted to have appropriate radiator covers in place. Two radiators that were not covered, due to having the new dining room flooring installed had been obstructed with heavy objects in order to reduce the risk of harm to residents and staff. Since the inspection of April 2007 improvements have been made to ensure that the Statutory Requirement that furniture is to be audited and replaced or bought as required, to ensure infection control is effective and there is a sufficient number of tables for all residents use has been met. The Appointed Manager provided evidence that quotes had been obtained for the purposes of purchasing new beds, bedside cabinets, wardrobes and chest of drawers for each residents room. It was evident that a new table had been purchased for each resident. The home was odour free throughout. There is a daily cleaning schedule in place. There is an infection control policy in place and staff have received recent training in infection control procedures. This was evidenced from staff training files viewed and staff spoken with. Staff were observed adhering to infection control procedures, particularly at meal times. During the tour of the premises it was noted that some individual residents commodes were unclean. Those observed were covered in a thick dust layer and required cleaning underneath the seat. Therefore a requirement has been made. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. Staff are recruited in an effective manner, in order that residents are safeguarded from the risk of harm. Staff receive appropriate training to conduct their jobs effectively. EVIDENCE: Following the inspection of April 2007 improvements have been made to ensure that the Statutory Requirement that staffing numbers and deployment of staff to be reviewed, in line with the assessed needs of residents has been met. There is a staff rota in place, which details staff designations and hours of working. The Appointed Manager reported that there is currently one full time care worker vacancy at the home, which an individual had been appointed to and was currently awaiting CRB clearance before commencing employment. Staff spoken with stated that the staffing levels had improved and that working at the home ‘was much better’. Other comments received stated that ‘staff often seem to lack motivation, say they are poorly paid and staffing levels often appear erratic’ and ‘there seems to be no difference from weekdays to weekends as far as staff numbers are concerned.’ Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 19 The home has a permanent staff team of six Registered Nurses (RN’s), eleven carers, three cooks, one Activity Coordinator, one laundry person, two cleaners, five kitchen staff and a maintenance person. A National Vocational Qualification (NVQ) Assessor who determined that five staff were NVQ level 2/3 in care, equivalent, has recently assessed all care staff. These staff are either trained nurses or other health care professionals in their country of origin. Additionally five care staff have been signed up to undertake NVQ level 3 in care training, which will commence in February 2008. Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. Appropriate NMC Personal Identification Numbers checks were noted in RN’s staff files. Many of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Since the inspection of April 2007 improvements have been made to ensure that the Statutory Requirement that staff training in infection control to be reviewed and updated to ensure staff follow the homes policies to protect residents has been met. A sample of individual staff training files were viewed and it was evident that staff had received training in Induction, Moving and Handling, Fire Safety, Food Hygiene, pressure area sore prevention, infection control and Medication. RN’s also receive training in wound care, continence, and customer care. Staff training certificates are not reflective of the training attended by staff. The Appointed Manager is currently in the process of updating training files in line with the reintroduction of formal supervision. Staff spoken with gave a mixed response to the training provided. Some said that the level of training received was appropriate to enable them to conduct their roles efficiently, whilst some said they would like more training. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Appropriate Quality Assurance monitoring systems are currently not in place, meaning that the success of the home in meeting it aims and objectives is not measured effectively. The health, safety and welfare of both staff and residents are not met on a consistent basis, leaving staff and residents at risk of harm. EVIDENCE: The Appointed Manager is a qualified RN and has worked in the elder care home environment for the past ten years. Residents and staff spoken with said that the Manager was friendly and approachable. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 21 Following the inspection of April 2007 some improvements have been made to ensure that the Statutory Requirement that an effective quality assurance and monitoring system to be implemented has been partially met. The Appointed Manager reported that the Registered Provider has purchased a new software package that will enable an effective Quality Assurance system to be introduced. This software package requires another computer to be purchased so that all staff may have access to records that require auditing and/or monitoring for Quality Assurance purposes. In the interim the Appointed Manager conducts themed questionnaires every six months. The last questionnaire to be conducted related to food, meals and menus. Previous questionnaires have related to laundry and care. Questionnaires are not sent to other interested parties. Results of questionnaires are also not published. Staff meetings are held three monthly, minutes of which are maintained. Residents meetings are held periodically throughout the year and at times agreed by residents. Minutes of the last two meetings held were viewed and these detailed actions taken by the staff team to address any issues raised. The home does not take any responsibility for any of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. Since the inspection of April 2007 some improvements have been made to ensure that the Statutory Requirement that a programme of formal supervision to be developed and introduced to ensure that all staff are aware of their roles and responsibilities has been met. Staff receive individual formal supervision with the Appointed Manager, records of which are maintained. Plans have been devised to inform staff of their planned supervision dates throughout the year. Staff spoken with confirmed that they received supervision and could request more supervision then those planned, should an issue arise that they wish to discuss sooner. The previous inspection Statutory Requirement that relating to hot surface temperatures from radiators, furniture being audited and replaced and there are sufficient number of tables for all residents to use, has been addressed in the Environment outcome group. From the tour of the premises it was evident that the staff room has been designated as the smoking area. This room is clearly signed in accordance with the new fire regulations regarding smoking on premises. Residents who wish to smoke are escorted by a staff member to this room. The Appointed Manager confirmed that this room is also currently utilised as the store for building equipment. Suitable risk assessments were not in place to support any building work being conducted or for residents wishing to you the designated smoking area. Therefore requirements have been made. The AQAA provided by the management of the home confirmed that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out within the last twelve months. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 22 The homes annual policy reviews are due to be conducted within the next few months. Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 2 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 2 3 X 2 Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The care plans to include risk assessments for the use of bedside rails. Previous timescale of 01/06/06 and 04/07/06 not met. All medications must be signed for once administered. This is an Immediate Statutory Requirement. All handwritten entries onto MAR sheets must be signed by two staff and an explanation for the handwritten entry entered onto the back of the MAR sheet. This is an Immediate Statutory Requirement. A daily programme of activities to be provided for service users must be implemented. All commodes must be clean thoroughly in order to reduce the risk of infection. An effective quality assurance and monitoring system to be implemented. Previous timescales of 06/03/06, 06/07/06 and 04/06/07 not met. Timescale for action 17/02/08 2. OP9 13 (2) 17/01/08 3. OP9 13 (2) 17/01/08 4. 5. 6. OP12 OP26 16 (2) (n) 13 (3) & 16 (2) (j) 24 & 26 17/03/08 19/01/08 17/03/08 OP33 Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 25 7. OP38 8. OP38 12 (1) (a) (b) & 13 (4) (a) (b) (c) 12 (1) (a) (b) & 13 (4) (a) (b) (c) Ensure that suitable risk assessments are in place for all building work being undertaken. Ensure that suitable risk assessments are in place for service users who utilise the designated smoking area. 19/01/08 19/01/08 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 OP7 Good Practice Recommendations Daily care record entries must be written in accordance with the NMC guidance on ‘Report Writing and Record Keeping’ Havelock House DS0000013997.V353236.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Havelock House DS0000013997.V353236.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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