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Inspection on 06/11/07 for Haven Lodge Residential Home

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

This inspection was carried out on 6th November 2007.

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

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

What the care home does well

The pre admission arrangements are satisfactory to ensure people`s needs can be fully met. People are generally satisfied with the care provided and the standard of care planning is good. Relatives`/representatives` views varied about the staff, however they were generally positive. Comments made were "excellent", " a senior carer is very good and caring", "staff are very professional, "it depends who is on duty". The meal was taken at the visit and was cooked and served to a good standard, people spoken with said the meals are good. The standard of cleanliness and decor throughout the home is of a good standard.

What has improved since the last inspection?

This was the first visit since the new company was registered. However, there is the same registered manager who is supernumerary to the care roster recommended at the last visit. This enables her more time for management duties. Staff are delegated areas of responsibility on a shift basis to ensure people`s needs are better met. A new emergency call system has been fitted to ensure calls made can be heard wherever staff are located. Some carpets and dining chairs have been purchased to provide a comfortable and pleasant environment for people to live in. The dining arrangements have improved, smaller dining tables have been provided in one room making for better interactions between the people living at the home, and people sitting in the lounges have access to the emergency call cords. People are able to access their personal allowances when needed to make purchases and pay for hairdressing and chiropody.

What the care home could do better:

Fire system and water temperature checks must be completed so that risks and system failures can be identified immediately and appropriate action taken. Staffing levels must be provided in numbers that ensure people living at the home are supervised at all times, particularly when two staff are needed to assist individual people to bed and get up in the morning. Two satisfactory references must be obtained before potential staff start work at the home to ensure people are fully protected. People`s daily events logs need to be completed and kept up to date to ensure people`s needs are being fully met. Daily activities should be provided that are appropriate to meet the needs, abilities and preferences of all people living at the home. Handwritten entries on the medication records should be signed and checked and countersigned by staff to ensure they are accurate. The dates of opening should be written on all eye drop containers to ensure they are always administered within the recommended timescale from the date of opening. A record should be kept when food supplements and other supplements to assist people to eat are administered to ensure they are being given as prescribed. Complaints made to the home, the action taken to investigate the complaints and the outcome, should be recorded to confirm that they have been dealt with appropriately.Staff should wear protective gloves, where needed, to prevent the risk of cross infection occurring. The registered person should ensure that people have sufficient funds made available for them should they wish to make purchases or pay for hairdressing etc. In the event of people not being able to manage their own finances, particularly those who lack mental capacity, the registered person should ensure that satisfactory advocacy arrangements are in place.

CARE HOMES FOR OLDER PEOPLE Haven Lodge Residential Home Haven Lodge Wakefield Road Normanton Wakefield W Yorks WF6 1BP Lead Inspector Susan Vardaxi Key Unannounced Inspection 09:15 6th November 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 Residential Home DS0000069576.V349268.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 Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven Lodge Residential Home Address Haven Lodge Wakefield Road Normanton Wakefield W Yorks WF6 1BP 01924 220013 01924 895464 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) Carestream Limited Mrs Tracy Bedworth Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the following gender: Either, whose primary needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 32 First inspection under new ownership. 2. Date of last inspection Brief Description of the Service: Haven Lodge is situated in Normanton on the main road between Wakefield and Castleford and is on a bus route. Set in its own grounds, there is parking provided to the front and side of the home and a large walled garden area at the back, accessible to people living at the home. The home is registered to Carestream Limited and provides a service for up to thirty-two older people. In relation to the accommodation, there are two main lounges and a good size dining area. In addition, there is a large conservatory at the back of the home which people can use at their leisure. All the bedrooms are single and there are good toilet, bathing and washing facilities. There is a pleasant reception area. Outside, there is good access to the home at the front and back. Ramps are in place. Inside, there is access to the first floor by means of two stair lifts. The home is generally spacious. The provider makes information about the service available to enquirers when initial enquiries are made, and a copy of the Service User Guide, on admission to the home, which includes the Commission for Social Care Inspection contact details. The weekly fees in November 2007 are £380. Hairdressing and chiropody are charged extra to these fees. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key visit to the home on 6 November 2007 over 8.5 hours commencing at 9:15 am. There has been a change to the ownership of Haven Lodge since the last inspection. The home is currently registered to Carestream Limited; the name of the home and the registered manager remain unchanged. The inspection process included a walk round the building, talking with some people who live at the home and checking some of the records kept. Twelve surveys were sent people living at the home; 11 to relatives and 4 to health providers. Information provided on the six surveys returned from people living at the home, 6 from relatives and 2 from GPs was considered with information provided by the manager prior to the visit occurring. A concern about the service raised prior to the visit was discussed with the manager and the issues have been included in the body of the report. What the service does well: What has improved since the last inspection? This was the first visit since the new company was registered. However, there is the same registered manager who is supernumerary to the care roster recommended at the last visit. This enables her more time for management duties. Staff are delegated areas of responsibility on a shift basis to ensure people’s needs are better met. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 6 A new emergency call system has been fitted to ensure calls made can be heard wherever staff are located. Some carpets and dining chairs have been purchased to provide a comfortable and pleasant environment for people to live in. The dining arrangements have improved, smaller dining tables have been provided in one room making for better interactions between the people living at the home, and people sitting in the lounges have access to the emergency call cords. People are able to access their personal allowances when needed to make purchases and pay for hairdressing and chiropody. What they could do better: Fire system and water temperature checks must be completed so that risks and system failures can be identified immediately and appropriate action taken. Staffing levels must be provided in numbers that ensure people living at the home are supervised at all times, particularly when two staff are needed to assist individual people to bed and get up in the morning. Two satisfactory references must be obtained before potential staff start work at the home to ensure people are fully protected. People’s daily events logs need to be completed and kept up to date to ensure people’s needs are being fully met. Daily activities should be provided that are appropriate to meet the needs, abilities and preferences of all people living at the home. Handwritten entries on the medication records should be signed and checked and countersigned by staff to ensure they are accurate. The dates of opening should be written on all eye drop containers to ensure they are always administered within the recommended timescale from the date of opening. A record should be kept when food supplements and other supplements to assist people to eat are administered to ensure they are being given as prescribed. Complaints made to the home, the action taken to investigate the complaints and the outcome, should be recorded to confirm that they have been dealt with appropriately. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 7 Staff should wear protective gloves, where needed, to prevent the risk of cross infection occurring. The registered person should ensure that people have sufficient funds made available for them should they wish to make purchases or pay for hairdressing etc. In the event of people not being able to manage their own finances, particularly those who lack mental capacity, the registered person should ensure that satisfactory advocacy arrangements are in place. 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 Residential Home DS0000069576.V349268.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 Haven Lodge Residential Home DS0000069576.V349268.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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The pre- admission arrangements ensure the home can meet people’s needs appropriately. EVIDENCE: Information provided by the manager prior to the visit showed that pre admission assessments are completed by the home and, where applicable, social workers. Records checked confirmed this. Six surveys were received from people who use the service and 6 from their relatives. Of these, nine considered they had been given enough information about the service. The manager said intermediate care is not provided at the home. Haven Lodge Residential Home DS0000069576.V349268.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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Whilst healthcare needs are met, individuals’ daily event records need to be more detailed to fully confirm that people are getting the care planned. EVIDENCE: Care plans looked at detailed the action needed by staff to ensure people are assisted appropriately, although individual records sometimes need expansion to confirm that this occurs, eg. one person’s record of bathing could not be found although the manager reported bathing had occurred. Required risk assessments were in place and staff ensure fluid intake and pressure care charts are maintained. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 11 District nurses confirmed staff follow advice and maintain charts although there was discussion with the manager about gaps in night staff recording, which she said would be discussed with staff. The survey forms received from GPs indicated that they were satisfied with the service and that they had not received any complaints. Three of the 6 surveys received from people living at the home considered medical support was provided when needed. Three people’s surveys considered the home supports them, included staff are “excellent”. A relative’s survey form stated, “staff are very professional.” A visitor said “staff are excellent” and their “relative is being well looked after”. A district nurse said “it depends who is on duty as to how care is delivered”; she said a senior carer is very good and caring. These comments have been discussed with the manager who said she would monitor this. The medication cupboard was clean, tidy and well ventilated. The medication records seen had been generally well maintained, and the medication in stock and records checked balanced. The following areas for improvement were observed: • Handwritten entries on the medication records had not been countersigned by staff necessary to double check the dose and directions are accurate. • A Thick and Easy Rapid Thickener prescribed for a person with swallowing difficulties had not been recorded to confirm that it has been given as prescribed by the GP. • The date that one person’s eye drops had been opened had not been recorded on the container necessary to ensure the drops are not used out of the expiry date. Staff were observed assisting people with their needs respectfully and people looked relaxed when support was given. Haven Lodge Residential Home DS0000069576.V349268.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): 12,13,14,15 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are satisfied with the meals provided, however there are not enough daily opportunities provided for people’s social and recreational needs to be met. EVIDENCE: The manager said she is in the process of recruiting an activities person. She said the post has been vacant for some time and the provision of activities has not always been sufficient to stimulate people. Some people spoken with in the lounge said entertainers visit sometimes. One person said they would “like to work with wood”, the manager said she would look into this for them. Surveys received showed that people are not satisfied with the current provision of activities, some staff spoken with said they only have time to sit Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 13 and speak with people occasionally as they are very busy, therefore not always able to provide activities daily. Relatives spoken with, and comments on survey forms completed, confirmed they are able to visit at any time and made welcome and kept informed of relatives’ needs. People were joined in the dining room for lunch. The meal was cooked and presented to a good standard. People spoken with, and comments made on survey forms, showed that people are satisfied with the meals. Staff said the people sitting at the table had really benefited from the interaction with staff throughout the meal. A member of staff said they don’t always have time to sit with people at mealtimes. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 14 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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home and their relatives/representatives are aware of the home’s complaints procedure. However, the records do not always evidence complaints have been made, dealt with and satisfactorily resolved. EVIDENCE: Some concerns about the service were received prior to the visit regarding the chair lift not being in working order, there being too much equipment in the conservatory, and not having blinds fitted to the windows in the conservatory. The people raising the concerns were satisfied that the issues would be checked at this visit. The manager confirmed that these issues had been brought to her attention, which the home was dealing with, however these complaints had not been recorded in the complaints records. The survey forms received showed that people living at the home, and their relatives, know how to make a complaint if needed. Four complaints made to the home had been progressed through the home’s complaints procedure, however the records did not confirm if the complainant Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 15 was satisfied with the outcomes. This was discussed with the manager who said she would record outcomes of complaints in the future. The manager said safeguarding training had been provided for some staff and arrangements are being made for other staff to attend training. Four staff were spoken with, one had attended safeguarding training. They were all aware of the action to take if they observed abuse or were informed that abuse had occurred. Haven Lodge Residential Home DS0000069576.V349268.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): 19,22,23,24,25,26 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a clean and pleasant environment for people to live in. However, people could be at risk when action is not taken to ensure fire and water system checks are completed. EVIDENCE: It was observed during a walk round the building and grounds that the home was clean, tidy and well decorated. Some new carpets had been fitted and some dining chairs replaced. Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 17 The emergency call system has been replaced since the last visit to ensure staff can hear calls from wherever they are working in the building. The sluice room is currently located in the boiler room; it was observed that this room was being used to store cleaning items and materials. The manager arranged for these to be relocated during the visit. The manager said quotes had been obtained for work to be carried out to move the sluice facility from this room to another location and evidence of this was provided. Some chairs in the lounges were worn and some were not clean. A large screen TV was mounted on the wall in the lounge, the manager said a loop system had also been fitted in the lounge and in a bedroom to help people who have diminished hearing. The stair lift located on the right side of the building was reported out of action prior to the visit, the manager demonstrated that the lift was working at the visit. People’s bedrooms seen were clean and tidy and personalised. The kitchen was clean and tidy, the manager said an environmental health inspection was carried out in July 2007, one recommendation for probe wipes had been made and the home had been awarded four stars. The manager said the home had not had a maintenance person for some weeks, however he was due to start work again later that week. The fire system and running hot water temperature checks had not been completed for six weeks. The manager checked the fire alarm points during the visit. She informed that Commission the day after the visit that all hot running water temperatures had been checked and no problems had been observed. The laundry facilities were not seen at this visit. The manager had notified the Commission prior to the visit that some people at the home had been affected by sickness and diarrhoea which was reported to environmental health services and was clear at the time of the visit. It was observed that procedures to prevent cross infection were in place at the time of the visit. However, a district nurse has since told the Commission that “sometimes staff do not always follow good hygiene procedures” and gave an example of “not always wearing protective gloves”. Also that they had observed staff manually lifting people out of chairs, which has been brought to the manager’s attention and she said she would make sure staff followed the home’s procedures at all times. Haven Lodge Residential Home DS0000069576.V349268.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): People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staffing arrangements at night and some recruitment procedures do not always ensure people are safe. EVIDENCE: Staff rosters seen showed that there are three carers and a senior carer on duty during the waking hours and two carers on duty at night. Staff spoken with said there are times at night and in the mornings when the people are left unsupervised in the lounges, when people require two staff to assist them to go to bed and get up in the mornings. Some people are unable to use the emergency call system due to their mental frailty therefore require staff’s presence to ensure they are safe. Staff said they do not always have time to spend talking to people and are only able to assist them with activities, eg bingo, occasionally. Some surveys received from people living at the home, and their relatives, indicated that staff were not always available to help people. Four staff spoken with said mandatory training, fire, manual handling, infection control, food hygiene, first aid, health and safety and safeguarding training Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 19 were being provided and updates are being arranged. A training matrix displayed in the office confirmed this. Another senior carer said they are currently doing NVQ level 3 training, a carer said they have NVQ level 2 and is currently working towards achieving NVQ level 4. It was noted that dementia care training had not been provided, necessary to help staff to identify and meet people’s needs should they become mentally frail. This was discussed with the manager who said she would look at the availability and arrange as soon as possible. Two files were checked for people recruited to the home since the last visit, it was observed that only one reference had been received for one person, the manager contacted the second referee at the time of the visit and a satisfactory verbal reference was given. The manager said she had contacted the referee in respect of a negative comment on a reference seen and said she was satisfied with the outcome. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults from Abuse (POVA) first checks had been completed. The manager said new staff are always supervised by trained staff on receipt of POVA first checks if they commence employment prior to CRB checks being received. Haven Lodge Residential Home DS0000069576.V349268.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): 31,33,35,38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The service needs to be monitored regularly to ensure people’s needs are always met and that they live in a safe environment. EVIDENCE: The registered manager has worked to make some improvements to the service since the last visit. She said she is now supernumerary to the roster, which gives her more time for her management duties. She said meetings are arranged with staff and people who live at the home although the minutes were not requested at the visit. A relative spoken with Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 21 prior to the visit said they wanted the owners to be more involved in meetings to give people the opportunity to discuss any issues with them. The manager said she is putting systems in place to monitor the service on an ongoing basis. Records of people and their relatives’/representatives’ views of the service were not requested at this visit. Some records of people’s monies held on behalf of people living at the home were checked and balanced to date. Only one signature was recorded for transactions made. It was observed from a person’s records that they were always in credit, the manager said letters are sent to people’s advocates to make funds available when this occurs. There were no health and safety concerns observed on the day other than those mentioned in standards 19-26 and the manager has informed the Commission since the visit that action has been taken to deal with the issues. Haven Lodge Residential Home DS0000069576.V349268.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 17 X 18 3 1 X X 3 N/A 3 1 2 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Haven Lodge Residential Home DS0000069576.V349268.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 OP19 OP25 Regulation 23(4)(a) 13(4) Requirement The registered person must ensure that there are arrangements in place for completing fire system and running hot water temperature check in the absence of the person designated to do them to ensure people are safe. The registered person must ensure that there are enough staff on duty at night to meet people’s needs appropriately and that they are adequately supervised. The registered person must ensure that two satisfactory references are obtained before people start work at the home. Timescale for action 30/11/07 2 OP27 18(1)(a) 30/11/07 3 OP29 19(1)(c) 30/11/07 Haven Lodge Residential Home DS0000069576.V349268.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 Refer to Standard OP8 OP9 Good Practice Recommendations The daily events log should be kept up to date to ensure people’sneeds are being met appropriately. • Handwritten entries on the medication records should be signed and checked and countersigned by staff to ensure they are accurate. • The dates of opening should be written on all eye drop containers to ensure they are always administered within the recommended timescale from the date of opening. • A record should be kept when food supplements and other supplements, when needed to assist people to eat, are administered to ensure they are being given as prescribed. Daily activities should be provided to meet the needs, abilities and preferences of all people living at the home. All complaints made to the home, the action taken to investigate the complaints and the outcome, should be recorded. The registered person should ensure that all staff wear protective gloves, where needed, to prevent the risk of cross infection occurring. The registered person should ensure that people have sufficient funds made available for them. In the event of people not being able to manage their own finances, particularly those who lack mental capacity, the registered person should ensure that satisfactory advocacy arrangements are in place. 3 4 5 6 OP12 OP16 OP26 OP35 Haven Lodge Residential Home DS0000069576.V349268.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Residential Home DS0000069576.V349268.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!