Inspection on 05/07/07 for Haven Lodge Nursing Home

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Haven Lodge Nursing Home 07/08/06

Haven Lodge Nursing Home 24/01/06

Haven Lodge Nursing Home 27/06/05

Haven Lodge Nursing Home 07/12/04

Haven Lodge Nursing Home 16/06/04

Haven Lodge Nursing Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Haven Lodge Nursing Home Reckitts Close Holland Road Clacton on Sea Essex CO15 6PG Lead Inspector Francesca Halliday Unannounced Inspection 5th - 10th July 2007 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 Haven Lodge Nursing Home DS0000015324.V345251.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. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven Lodge Nursing Home Address Reckitts Close Holland Road Clacton on Sea Essex CO15 6PG 01255 435777 01255 475680 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) Lanemile Limited Mrs Pauline Teresa Goh Care Home 50 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Physical disability (26), Physical disability of places over 65 years of age (26), Terminally ill (3) Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical illness (not to exceed 26 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 26 persons) Persons of either sex, aged 60 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 24 persons) Persons of either sex, aged 55 years and over, who require general palliative care (not to exceed 3 persons) One person, under the age of 60 years, who requires care by reason of dementia, whose name was made known to the Commission in April 2003 The total number of service users accommodated in the home must not exceed 50 persons 7th August 2006 Date of last inspection Brief Description of the Service: Haven Lodge is a purpose built, two-storey nursing home set in its own grounds. It provides care for up to 50 residents. The home is divided into two distinct units. Lanemile Ltd owns Haven Lodge and is part of the national company Care UK. The home is situated in a quiet residential cul-de-sac, approximately a mile and a half from Clacton town centre. The local bus services pass at the end of the drive and the railway station is half a mile away. The sea front is a short walk from the home. Speedwell, the first floor unit, cares for up to 26 residents over the age of 60 who require nursing care for a physical illness or disability or for palliative care. Mayflower, the ground floor unit, cares for up to 24 residents over 60 who require care for a progressive mental disorder. The fees at the time of inspection in July 2007 were between £550 and £693. Additional charges were made for private chiropody, hairdressing, the tuck shop and toiletries. For the most up to date information on fees please contact the home directly. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on 5th July 2007 and was completed on 10th July 2007. The term resident is used throughout this report to refer to people who live in the home. The registered manager was present for part of the day on 5th July and on 10th July. Seven residents were spoken with during the inspection, although advanced dementia made it difficult to communicate with some residents on Mayflower. Nine staff were spoken with during the inspection. Six relatives were spoken with during the inspection. Two surveys were received from residents, five from relatives and five from staff. Parts of the premises and a sample of records were inspected. What the service does well: What has improved since the last inspection? The hours for activity co-ordinators had been increased and residents were being given the opportunity to go out more. Links with the community had been developed extremely well. The manager had made herself more available to relatives out of hours and at weekends. Links with the Primary Care Trust and the hospice had been developed further. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 7 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 Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 8 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): Standard 3 (standard 6 not applicable) Quality in this outcome area is good. Prospective residents can expect to have an assessment and assurances that their needs can be met prior to entering the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessments seen were generally informative. The information was usually supplemented by assessments from the primary care team. The manager said that the home very occasionally accepted residents without an assessment in an emergency, usually for people with palliative care needs. However, she confirmed that in these instances the home would always have discussions with the primary healthcare team and be in receipt of a nursing needs assessment prior to a decision being made to admit. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 9 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): Standards 7, 8, 9, 10 Quality in this outcome area is good. Residents’ healthcare needs are met and they are treated with dignity and respect. Medicines management is being reviewed in order to improve the safety for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives said that they were very happy with the standards of care in the home. They confirmed that staff were caring and respectful and upheld residents’ privacy and dignity. The community liaison nurse spoken with said that they were very happy with the standards of care and had extremely good communication with staff at the home. One resident said “The staff really look after you. It’s lovely here”. A relative said “The nursing care is excellent, they monitor health needs very well”. Another relative said “It’s wonderful care here”. Relatives spoken with said that staff communication with them about health concerns was very good. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 10 There was evidence from discussions with residents and relatives that staff tried as far as possible to provide person centred care. Staff spoken with were knowledgeable about individual resident’s needs and problems but some of the care plans seen did not fully reflect this. All the residents’ care documentation was computerised on the Saturn system. Residents had a range of care plans and risk assessments. However, many of residents, including those with dementia and palliative care needs, did not have a care plan for their psychological and emotional health. A discussion was held about developing the care documentation to reflect more of residents’ preferences, abilities, rehabilitation needs and the preservation of their life skills (where appropriate) as well as their mental and physical health and care needs. Residents and relatives described how a number of residents had been rehabilitated and enabled to regain their independence and mobility. There was evidence that a number of residents had been admitted for rehabilitation and had successfully returned home. The home had links with the falls prevention service and referred residents who had suffered falls or who had problems with their balance and were at increased risk of falls. Staff said that the home had good support from local GPs and community nurses. The home had extremely good links with the local hospice and staff described them as very supportive. Residents were referred to hospital for consultations and treatment where appropriate. There was evidence that staff acted as advocates on behalf of residents. Some residents had private chiropody but residents with diabetes had treatment from the community chiropodist. The manager said that the home was developing links with a local physiotherapy practice and were considering developing a post-operative service for people recovering from operations and needing rehabilitation prior to returning home. Medicines management needed some improvements. It was not always possible to audit some medicines accurately as balances from the previous month had not always been recorded on the Medicine Administration Record (MAR). In order to provide clarity staff were advised to record the brought forward balance and to circle the start of the new supply on the MAR in a red pen. The codes used on the MAR occasionally needed an explanation on the reverse of the MAR. The Controlled Drugs (CD) cupboards were being replaced by the home’s new dispensing pharmacist, as there was concern that they did not meet the requirements for a CD cupboard. The administration of two Schedule 3 CDs had not been recorded in the CD register in line with the home’s policy, however, they were stored appropriately and had been recorded on the MAR. The temperature of the clinical rooms and drugs fridges was being monitored, but staff were advised to record the room temperature at the hottest time of the day. Staff were also advised to take action if the fridge temperatures fell outside the safe range of 2-8c. The manager said that the dispensing Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 11 pharmacist had been asked to label the actual medicine container as well as, or instead of, the outer carton in order to improve safety of administration. The stock balances of some homely remedies were not correct. The manager said that the recording of medicines would be discussed at the next staff meeting and that medicine audits would be increased to every week. Staff administering medicines had received an assessment of competence. The manager said that their new dispensing pharmacy would be providing further training. The manager said that she asked the pharmacist to carry out three audits in the home each year. The home had a contract for the disposal of waste medication. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14, 15 Quality in this outcome area is good. Residents benefit from a range of activities and from good links to the local community. The nutritional needs of residents are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence that all members of staff in the home provided some time to chat to residents individually. For example the administrator sat and read letters to residents who were not able to do this for themselves. One relative particularly commented on the fact that the resident they visited was included in activities even though they were bed bound. Another said that the activity co-ordinator on Speedwell stimulated residents and helped them to keep up with their interests. At the time of inspection there was a vacancy for the post of activity co-ordinator for Mayflower and staff said that care and nursing staff had not been able to provide 1:1 sessions and activities due to the reduced staffing levels. However, staffing levels were increased following the inspection and an activity co-ordinator had been appointed to work with the residents on Mayflower. The new member of staff had experience in activities for older people with dementia. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 13 The manager said that when staff organised activities they tried to establish residents’ interests prior to their illness, and their previous occupation if relevant, and tried to match their interests where possible. Some residents had been planting up the planters in the garden and others enjoyed cookery sessions. The manager said that they tried to help residents retain or regain their independence as far as possible and both residents and relatives spoken with confirmed this. There was evidence that residents were able to make choices about what they did and how they spent their day, and that staff tried to respond flexibly to their needs. The home had very good links to the local community. An aromatherapist visited the home periodically and residents said that they enjoyed the massages. The hospice chaplain visited the home to provide support for residents who requested it. The manager said that the home tried to establish links with local clergy of all denominations in order that residents’ spiritual needs could be met. There was evidence that they had tried to meet residents’ very diverse spiritual needs. There was a church service in the home every two weeks. Entertainments were held in the home periodically. Some relatives of previous residents visited the home and provided support to current residents. The Navy brass band from Harwich played at the home and provided support to residents who had been employed by the military services. Members of the local rotary club also visited. The home was also hoping to establish contact with local schools. The home had links with the Tendring Advocacy services, the local stroke club and the Alzheimer’s society. The manager said that the home was hoping to establish links with advocates for all residents who had no relatives. Relatives spoken with said that they were made to feel very welcome at the home whenever they visited. The manager said that twenty relatives had attended Christmas dinner at the home. The manager said that staff had frequent informal meetings with relatives and also incorporated a relatives meeting into a recent garden party, which was very successful. A regular hairdresser visited the home and some residents had visits from their personal hairdresser. The home had purchased a large pagoda and staff said that some residents had meals outside in fine weather. Occasional outings were also arranged to places of local interest. Residents spoken with and surveyed were generally happy with the standard of food and the choices available. Staff were observed assisting residents with their meals in an unhurried manner. Relatives described the food as “lovely” and “excellent”. Staff used the framework of Essence of Care to review the nutrition, diets and menus in the home both for individuals and for residents as a whole. This had resulted in an increase in finger foods and other snacks being made available for some residents with dementia, who found it difficult to sit down for meals for any length of time. Residents’ weights were generally monitored on a monthly basis and supplements were requested from their GPs when necessary. The kitchen looked clean and well organised and there was a cleaning schedule in place. There was a delivery of fresh fruit and vegetables Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 14 twice a week and food was appropriately labelled. The menu had choices and there was evidence that alternatives were available. Haven Lodge Nursing Home DS0000015324.V345251.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): Standards 16, 18 Quality in this outcome area is good. Residents have concerns addressed very promptly and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure, a copy of which was available in all residents’ rooms. The manager said that the home had received no recent complaints. Residents spoken with said that staff dealt with any concerns very promptly. One resident said “I’ve got no complaints about anything”. A relative said “We haven’t had one cause for concern in a year”. The home had numerous letters of compliments displayed on a notice board. One allegation of potential abuse was investigated and reported appropriately but the allegation was not substantiated. Staff had all received Protection of Vulnerable Adult (POVA) training. The Essex County Council POVA guidance was given to both staff and relatives. Haven Lodge Nursing Home DS0000015324.V345251.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): Standard 19, 26 Quality in this outcome area is adequate. Residents live in a clean and wellmaintained environment, but residents on Mayflower have a limited choice of safe communal space. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that a number of areas in the home were being redecorated and refurbished and that new furniture and flooring was being ordered. New kitchenettes were also due to be installed on each floor. Mayflower had two conservatory areas. However, the temperature in the main conservatory was recorded as 30.8c on the day of inspection, on a relatively cool summer day. It was therefore not possible to use this space safely for residents with dementia, as they would not be able to judge the temperature. This resulted in a considerable reduction in available and useable space for residents and therefore did not meet the standards for communal space. The garden Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 17 attached to Mayflower was due to be re-laid with new pathways and seating and with a covered area to encourage more regular use of the garden. Security of the home had recently been reviewed and staff had been reminded to keep the front door locked at all times and to use the keypad access. Mayflower, the dementia unit on the ground floor, had an additional security devise on the door. The home had laundry staff for six hours on seven days a week. The laundry assistant spoken with confirmed that staff used appropriate procedures to minimise the risk of infection when handling soiled linen. Residents and relatives spoken with praised the laundry service and the cleanliness of the home. A relative said “The home is always clean and there are no unpleasant odours”. Haven Lodge Nursing Home DS0000015324.V345251.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): Standards 27, 28, 29, 30 Quality in this outcome area is good. Residents’ needs are met by competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection the staffing levels had recently been reduced as the home was not at full occupancy. There was evidence that staff had tried hard to compensate for this and not let it impact too greatly on standards of care. However, on Speedwell the dependencies of residents was extremely high, with a number of them having end stage palliative care needs. Staff were also concerned that they would not be able to continue the good standard of rehabilitation with reduced staffing levels. On Mayflower one relative noted that the reduced levels had resulted in less supervision for residents with dementia. Staff considered that some recent falls and accidents had been as a result of this reduced supervision. Staff also expressed concerns about their ability to assist and supervise the residents with dementia at mealtimes. Following discussions with the manager about the dependencies and standards of care in the home the original levels were reinstated. Both residents and relatives were full of praise for the staff. One relative said “The staff are brilliant. They’re all friendly. The staff are happy and this reflects on the home”. The manager reported that staff retention was good. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 19 Appropriate checks were carried out on all staff as part of the recruitment process. The checks included Criminal Records Bureau (CRB) and Protection of Vulnerable Adults list checks. Nurses’ registration was checked with the Nursing and Midwifery Council. Seven staff on Mayflower had completed a twelve week dementia care course at level 1 and three staff had enrolled for level 2. Four staff attended a training day at the local hospice in palliative care for people with dementia. The staff were also undertaking the Alzheimer’s disease course and this was being facilitated by senior staff within the home. Eight training sessions had been set up for staff with the Palliative Community Nurse. One nurse was in the process of completed a palliative care degree. There were three training sessions on loss and bereavement each year. Over 50 of care staff had completed National Vocational Training (NVQ) at level 2 and a number were working towards NVQ level 2 and NVQ level 3. The manager said that the home had good liaison with the NVQ assessor about the training needs of individual carers. Some of the training carried out in the home was done via self-assessment on the home’s laptop computer, with additional practical sessions when necessary. There were regular practical sessions for training such as fire safety, infection control and moving and handling. However, there was only one practical session for POVA each year. There were good systems in place to monitor and ensure that all staff completed the necessary training. Haven Lodge Nursing Home DS0000015324.V345251.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): Standards 31, 33, 35, 38 Quality in this outcome area is good. The management and administration of the home is very good and the home is run in the best interests of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was an experienced registered nurse with a number of years management experience. The manager was due to complete the Registered Manager Award shortly after the inspection. She had a commitment to providing high quality person centred care. A number of relatives considered that the home was very well run and said that the manager was very approachable. One relative said, “The manager has transformed the place, it’s extremely well run”. One member of staff surveyed said the manager’s “door is always open, she is willing to sit and listen whenever I need her to”. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 21 Another member of staff said “The manager is very supportive and approachable”. The manager said that she gave her mobile number out to relatives and let them know that they could contact her at any time if they had any concerns, even out of hours and at weekends. The manager was very well supported by two unit managers, one of whom was the clinical lead for the home, and by an experienced administrator. The home had a quality assurance programme. Residents and their relatives were regularly surveyed and there were two suggestion boxes in the home. The home carried out monthly audits of accidents, falls and pressure sores. The operations manager carried out audits within the home every 3-4 months and an action plan was then developed to address the issues raised. The Annual Quality Assurance Audit (AQAA) had been well completed and demonstrated that the manager had a good understanding of quality assurance. The company carried out regular Regulation 26 visits to assess the quality of the services and care in the home. The majority of residents had small amounts of money deposited with the home by relatives or advocates, to enable them to pay for chiropody, hairdressing, toiletries and items from the tuck shop. One resident was supported to be independent and to manage their own money with assistance from the administrator. There was evidence of receipts for all items purchased and balances checked were correct. There was evidence that the manager acted as an advocate for a resident to try and ensure that they received the money that they were entitled to. The home had appropriate systems in place for servicing and maintenance of equipment. All staff received training in safe working practices and there were systems in place to ensure that staff all received the appropriate training. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 22 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 Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 4 X 3 X 4 X X 3 Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement Staff must ensure that there is a clear audit trail for each individual medicine in the home so that a check can be made that residents have received their prescribed medicines. Residents on Mayflower must have access to an adequate amount safe communal space that does not put them at potential risk. Timescale for action 14/08/07 2. OP19 23(e) 01/12/07 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 The care documentation should more fully reflect residents’ preferences, abilities, needs for rehabilitation and the preservation of their life skills (where appropriate) as well as their mental and physical health and care needs. Haven Lodge Nursing Home DS0000015324.V345251.R01.S.doc Version 5.2 Page 25 2. OP30 Practical sessions for Protection of Vulnerable Adults training should be offered regularly to ensure that staff have fully understood the theory and their role in protecting vulnerable residents. Haven Lodge Nursing Home DS0000015324.V345251.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 Haven Lodge Nursing Home DS0000015324.V345251.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. 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