Inspection on 07/08/06 for Haven Lodge Nursing Home

This inspection was carried out on 7th August 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

Haven Lodge Nursing Home 05/07/07

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 Lysette Butler Final Unannounced Inspection 09:00 7th August 2006 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.V306992.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.V306992.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.V306992.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 24th January 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 service users. 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 service users over the age of 60 who require nursing care for a physical illness or disability and includes up to 3 service users over the age of 55 who require general palliative care. Mayflower, the ground floor unit, cares for up to 24 service users over 60 who require care for a progressive mental disorder. Current fees are between £575 and £700. Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection started on 1st April 2006. The inspection process included: a site visit on 4th August 2006, which lasted 7 hours; review of evidence supplied by the proprietor, residents, visitors to the service or the staff; resident, visitor, healthcare professionals and staff surveys; discussions with the registered manager, senior carers, care staff, ancillary staff, residents and relatives. During the site visit the premises were inspected, including inspection of the grounds. Samples of records and residents care plans were also reviewed. The home was clean and well maintained. The overall care and well being of the residents was the focus of the inspection. Staff and residents were welcoming and happy to speak to the inspector at the site visit. This inspection covered all twenty-one key standards and three of the remaining standards. The manager and her staff approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: What has improved since the last inspection? What they could do better: Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 6 Care plans need to be consistent throughout the whole home using all of the assessments and information contained in a satin unit that is available to the staff. There needs to be consideration given to the medications rooms to ensure that all medications are kept below 25°C and that double locked metal cabinets are supplied on both floors. Staff need to ensure there is no chance of cross contamination of medications when administering liquids or tablets. When the administrator is not in her office, the security of the front entrance of the home needs to be improved to ensure the safety of the residents. Quality assurance that the home must be individual to the needs of the current residents. 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. Haven Lodge Nursing Home DS0000015324.V306992.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.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. All staff were clear on the conditions of registration of this home, ensuing that prospective residents and their relatives were given information that enabled them to choose the right home. EVIDENCE: The welcome pack contains a summary of the statement of purpose and the service users guide. It is given to all new residents on admission. The administrator takes time going through the information contained within, so that she is assured that the resident and their relatives have up-to-date information about all aspects of the home. She has found that there are far less problems regarding day-to-day financial issues and residents/relatives understanding of the running of the home. There are up-to-date copies of the statement of purpose and service users guide kept on file at the local office of the Commission for Social Care Inspection. Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 9 The manager and/or the senior nurse on each of the units carry out preadmission assessments of prospective new residents. Assessments are also received from the social services and some residents are admitted to the home on the strength of the social service assessment, especially on Speedwell unit, (elderly frail), as the turnover of residents is quite high. However if there was any question about the suitability of the resident from the social services assessment it would be backed up by a visit from personnel at the home. The nurse spoken to on Speedwell unit stated that the liaison between the local PCT and social services is good and they have therefore not admitted anybody who was unsuitable into the home. All preadmission assessments are on paper, the information is then transferred to the computerised Saturn system and paper documentation is archived. The assessment paperwork used was Care UK documentation. Intermediate care is not offered at this home, however the inspector and registered manager discussed PCT contracts, which include provision for interim care within the home. The manager was clear on what intermediate care meant and that the home would have to comply with the national minimum standards if they decided to admit residents who needed intermediate care. Haven Lodge Nursing Home DS0000015324.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is adequate; this judgement has been made from evidence gathered both during and before the visit to this service. Health and personal care is well supported for all the residents in this home. Residents looked well cared for, clean and dressed appropriately. EVIDENCE: All resident care plans and personal file information is contained on the homes computerised Saturn system. Saturn is a wide-ranging system that offers easy to complete risk assessments and dependency assessments, covering all elements required to cover all aspects of the residents care. However a total five care plans were reviewed during the site visit and there was a distinct difference between the two units, in how much of the information on the system was actually used. Mayflower unit (dementia care,) use all available assessments to assess the care needed by residents and the quality all of information in the care plans and daily records was very good. Speedwell unit do not use all available assessments and some important assessments were not present on the care plans reviewed during the site visit. (E.g. manual Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 11 handling assessments were not completed.) The only drawback with Saturn as highlighted by the registered nurses was that it had slowed down considerably over the last few months as more homes had come online and were using it. Following the site visit the inspector discussed this problem with one of the clinical directors and was told that the firm were fully aware of the problem and were in the process of trying to solve it. When the system was not available for whatever reason, paper daily records were kept. Some were transferred to the system when it was back up and running, but mainly these were filed with the archived notes, which sometimes made it difficult to follow the progress of the individual resident progress. The use of Saturn has highlighted a considerable overall improvement in quality of information kept about the resident; it also provides a good audit trial when investigating concerns or complaints. Care plans are reviewed regularly and the system highlights any care plans that are overdue for evaluation. The provision of health care in the home was good. There is at least one registered nurse on each floor 24 hours a day. District nurses did not need to attend the home, however specialist nurse professionals were consulted as needed and attended the home if required. Two GPs visited the home during the site visit and one told the inspector that the home and the staff were good at keeping them informed about the progress and needs of the residents, and that they only calls the surgery if it really necessary. The GP also stated that the general care in the home was good. Since the last inspection the manager has instigated formal reviews for all residents on a rotational basis; there is a meeting on each floor every week, which includes a consultant and appropriate professionals, where they review all of the residents, their health care, medication and progress. This group also occasionally agrees new admissions if they are known to the professionals at the meeting. The manager stated that she felt that these meetings had reduced hospital admissions and had helped more residents to be discharged to their own home with care packages. Other allied professionals attended the home regularly including a chiropodist, a masseur, optician’s and dentist’s. This home uses ‘blister’ packaging for all medications. The senior nurse on Mayflower unit, to accommodate local and national changes to medication administration policies, had recently updated the local medications policies and procedures. Changes had been made to the policies relating to medication administration through enteral feeding systems; the monthly audit procedures; procedures to be followed if a drug error occurs; the handling of medications brought in by residents who are at the home for respite care; and medication waste disposal procedures. All medication administration records were Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 12 checked and found to be correct. Stock levels in the home were generally quite high at the time of the site visit, because it was the beginning of the ‘medication month’. Both medications rooms were tidy and all cupboards were appropriately labelled. There was a new drugs fridge on each floor, which enabled staff to separate medications for individual resident. The drugs fridge and room temperatures are documented on a daily basis, however this demonstrated that the medications room on Speedwell unit consistently registered a temperature above 25°C, which is the recommended temperature to store medicines at. Controlled drugs were kept in a locked metal cupboard, bolted to the wall of the medications room and the medications room were always locked when not in use. Controlled drug records were checked and are found to be correct. Both floors used syringes to measure liquid medications, which were not individually labelled. Staff had removed the syringes before the end of the site visit and stated that they would be replaced with labelled syringes before the evening medications round. Tablet cutters on both floors were in need of more regular cleaning to insure tablet residue was not transferred to different medications. There was sunscreen present in both medication rooms and staff stated that this had been used on all residents who sat outside during the recent heat wave. There was evidence that regular medication reviews were being undertaken and that residents were being maintained on the most appropriate medications for their conditions. During the site visit of the inspector observed all staff treating residents with respect and maintaining their privacy in various ways, including knocking on their doors before entering rooms and calling the residents by their preferred name. This included laundry, housekeeping and administration staff, as well as care staff. Residents and visitors spoken to at the site visit said that staff were polite, but always jovial. One relative said “they always have a smile and treat mum as an individual, not as if she is stupid, which happened in her previous home. Mum has blossomed at Haven Lodge.” Haven Lodge Nursing Home DS0000015324.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Resident activities were varied and appropriate to their levels of dependency. Food offered was very good and meets the nutritional needs of the residents. EVIDENCE: Activities in this home are varied and activities programs were seen throughout the home. There are two part-time coordinators who worked on both floors, however neither of them were on duty on the day of the site visit. The coordinators tried to balance activities undertaken to include activities within the home, ‘bought-in’ entertainment and trips out for those residents that were able. They also had a programme of one-to-one time that included all residents. Community input to the home had been improving and the manager made an effort to include relatives, visitors and local neighbours in events at the home. There had been a recent fate that raised money for the residents’ activities fund, which had been well attended and relatives of the homes residents had ‘manned’ the majority of the stalls. All residents were on the electoral register. Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 14 Sample menus had been supplied with the PIQ and demonstrated that a varied balanced diet was offered. The chef and kitchen assistants were all happy to speak to the inspector and they demonstrated a commitment to resident choice. The residents were happy with the quality and quantity of the food offered and one told the inspector that they can have what they want “ we only have to ask.” the last Environmental Health Office visit had been in January 2006 and there had been no issues highlighted. During the recent hot weather the kitchen and care staff ensured that the residents were given drinks on a regular basis, jugs of water and squash were kept chilled and they had increased their order of fruit juices squash etc. They also decreased the amount of food offered as they had found that the residents were eating less during this time. The chef is not restricted in what she can order or the type of food she can offer the residents. One relative said that they were regularly asked if they wanted a meal, which they enjoyed with the resident. Care staff were observed helping residents during both breakfast and lunch time, their help was appropriate and communication was good during this time. Haven Lodge Nursing Home DS0000015324.V306992.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The residents in this home are protected by the policies & procedures the service operates, being followed at all times by the staff. EVIDENCE: There had been one complaint to the home, which was forwarded to the Commission for Social Care Inspection, since the last inspection. Although the complaint was ongoing the manager and proprietors had followed their own policies and procedures well and were keeping the commission informed of the outcome. The complaint policies and procedures were reviewed regularly and were clear about the staff responsibilities. There had been no Protection of Vulnerable Adults issues since the last inspection and staff training was up-to-date. Haven Lodge Nursing Home DS0000015324.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The environment of this home was clean, a tidy and well maintained, however some security issues need to be reassessed. EVIDENCE: A complete tour of the home was undertaken during the site visit. There had been no change to the fabric of the building since last inspection. Mayflower unit on the ground floor had been redecorated since the last inspection; colours were more muted and calming for the residents. Some carpets had been replaced and the whole area looked brighter. Speedwell unit on the first floor would benefit from a redecoration of all paintwork, however all rooms were redecorated when a resident left the home and before the new resident was admitted. The home was clean and tidy throughout and there was no malodour throughout, all storage areas were locked and sluices were tidy. All CoSHH products were locked away. This home has three conservatories, which were cool on the day of the site visit, however the manager and staff reported that they had not been used during the recent hot spell as they could not keep them cool enough, but the manager was assessing their usefulness on a Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 17 continuing basis. Staff were welcoming and visibly helping with breakfast at the beginning of the site visit, however the inspector had been able to enter the home and wander around unimpeded for about the first three or four minutes. Security first thing in the morning and in the evening when the administrator is not in the front entrance of the home must be improved to ensure the safety of the residents. The laundry was well laid out, tidy and nicely maintained. All machinery complied with requirements. The laundry person had worked at the home for over 10 years and she was very clear about her responsibilities, she discussed the problem of unnamed clothing. She is happy to label the clothes of new residents whenever needed, if the staff let her know that it needs to be done. Haven Lodge Nursing Home DS0000015324.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Staffing numbers and training ensures that the residents in this home are looked after safely and appropriately. EVIDENCE: Staff rosters were supplied with the pre-inspection questionnaire and the roster for the week of the site visit was supplied at the time. Staffing levels on each floor were appropriate for the dependencies of the current residents and the skill mix was good. Staff turnover was very low and staff spoken to during the site visit said that they liked working at the home. The only staff to leave the home since the last inspection had moved from the area. Over 50 of the care staff had achieved National Vocational Qualifications at level 2 or above. At the time of the site visit a further six staff were on National Vocational Qualification courses, two were waiting to start level 2 and two were about to start level 3. The manager demonstrated a commitment to National Vocational Qualification training for the care staff and training to assist maintenance of their registration for the trained nurses. Five personnel files were reviewed during the site visit. The paper copies were initially reviewed, but the majority of information is also available on the Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 19 Saturn system. In the front of the paper files a sheet printed from Saturn gives all the basic information needed for reference. All folders were very neat and easy to follow. Criminal Records Bureau declaration’s were up to date and staff did not work unsupervised in the home until they had a current declaration. The training matrix and copies of training records were supplied to the inspector, they demonstrated a commitment to statutory training by the home and that all staff were up-to-date with their training, or booked on courses in the near future. Training information is also kept on the Saturn system and is therefore easy to report upon. Haven Lodge Nursing Home DS0000015324.V306992.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Management and administration of this service is good and quality assurance procedures are followed, the information obtained is used to improve the service offered. EVIDENCE: The registered manager at this home has been in post for over three years and is well qualified for the post. Staff spoken to said that she was approachable and were happy with the management structure. The unit manager for Speedwell had recently left the home due to her husbands job moving from Colchester and staff spoken to felt that she was lost to the unit. The unit manager on Mayflower had recently been working on a number of the local policies and procedures, updating them in line with local and national policy. Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 21 A copy of the last audit report carried out by the proprietors was supplied to the inspector; it showed compliance at all levels. There was regular staff, resident and relative meetings throughout the year. The inspector is planning to attend the next relative forum and trained staff meetings in September. The inspector left Commission for Social Care Inspection survey forms for all residents and their relatives at the time of the site visit. Six resident personal monies were reviewed and were found to be correct. The recording system is excellent and procedures had not changed from the last inspection. One resident looks after her own finances and neither the manager nor the administrator are appointee for any of the residents. Maintenance records were detailed and up-to-date for all areas of the home. All certificates and servicing contracts seen at the site visit were up-to-date and appropriate for the equipment used within the home. The maintenance person coordinated all service contracts and visits by the appropriate personnel. All insurances were valid at the time of the site visit. Haven Lodge Nursing Home DS0000015324.V306992.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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 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 3 13 3 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 3 X 2 X 3 X X 3 Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 23 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, 13(4b-c), Schedule 3(1b) 13(2), 17(1a), Schedule 3(3i) 13(4), 23(1-2a) Requirement The registered manager must ensure that all care plans are complete and contain all appropriate risk assessments. (This specifically refers to Speedwell unit.) The registered manager must ensure that all medications are stored at 25°C or less. (This specifically refers to Speedwell unit.) The registered manager must ensure that the front entrance of the home is secure at all times, to protect the safety of the residents. The registered manager must ensure that an effective quality assurance system is in place and that the annual development plan for the home reflects the aims and outcomes for residents of this home specifically. (Timescale of 30/06/06 not met.) Timescale for action 30/09/06 2. OP9 30/09/06 3. OP19 30/09/06 4. OP33 24(1)(a) (b)(2)(3) 31/12/06 Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 24 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. 2. 3. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The registered manager should consider having a double, locked metal cabinet in both medication rooms. The registered manager should ensure that tablet cutters are regularly cleaned to prevent cross contamination of medications. The registered manager should ensure that syringes used for medication measurements are individually labelled. Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haven Lodge Nursing Home DS0000015324.V306992.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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