Inspection on 24/07/08 for Havenmere

This inspection was carried out on 24th July 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOME ADULTS 18-65 Havenmere 191 Pelham Road Immingham NE Lincolnshire DN40 1JP Lead Inspector Theresa Bryson Key Unannounced Inspection 24th July 2008 09:00 Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 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 Havenmere DS0000071588.V368801.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 Adults 18-65. 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. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havenmere Address 191 Pelham Road Immingham NE Lincolnshire DN40 1JP 01469 557340 01469577042 havenmere@exemplarhc.com 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) Havenmere Manager post vacant Care Home 40 Category(ies) of Dementia (40), Mental disorder, excluding registration, with number learning disability or dementia (40), Physical of places disability (40) Havenmere DS0000071588.V368801.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 with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE, Mental Disorder, excluding learning disability or dementia - Code MD, Physical disability - Code PD. The maximum number of service users who can be accommodated is: 40 New Service 2. Date of last inspection Brief Description of the Service: Havenmere is a new build purpose built home set in the small town of Immingham. It is close to the larger fishing port of Grimsby and the seaside resort of Cleethorpes. All with good transport links to Immingham. Each room has en-suite facilities and there is also a wide range of nursing equipment to meet all types of needs of people using the service. The home is split into 4 10-bedded units each with a range of sitting rooms and a separate dining room. There is sensory equipment in some bathrooms and also a sensory room in the building. All garden areas are accessible by wheelchair and there is ample car parking space. The Statement of Purpose and Service Users Guide is on display in the large reception area and given to each prospective person wanting to use the home. Fees are negotiated on an individual basis and the Company is happy to accept people who are privately, local authority and Primary Care Trust funded. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that the people who use this service experience good quality outcomes. The site visit for this inspection took place over one day in July 2008. Prior to the visit the home sent us a copy of their Annual Quality Assurance Assessment (AQAA). This told us how the home obtains views from service users, how the Company runs the home, any barriers to improvement and whether they feel they give value for money. It also gives us a lot of statistical data gathered by the home since it opened. We also sent surveys out to people who use the service and staff, of which 3 were returned by people using the service and 4 by staff. We spoke on the telephone to some health professionals before visiting the home. During the site visit we spoke to a number of people resident in the home, some relatives and staff. We also toured the home and looked at a number of records and documents. The Acting Manager was not present during the course of the site visit, but we were assisted by the Area Manager for the Company and staff. What the service does well: Staff in the home are very friendly and appeared knowledgeable about the people they look after. Adequate checks had been made on them prior to commencing employment and since then they have received a lot of training to help them do their jobs. The assessment of each person before they are admitted is very thorough to enable them and the home to decide whether this is the right place to look after them. Care is taken to ensure that people are consulted to enable them to make decisions about their daily routines and major events in their lives. All events Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 6 are well documented to ensure all parties can keep up to date with peoples’ current needs and requests. Progress is being made to source local educational and leisure opportunities for this new service to use, should the need arise for any individual. It was well documented in the care notes contacts already made with local health care professionals who have supported people currently resident in the home. The Company has spent a lot of time ensuring that the environment is a safe and comfortable place in which to live. This has involved ensuring a wide range of equipment such as special beds, sensory equipment and decoration meets the needs of the people who are likely to use the home. The 4 10-bedded units are self-contained and have ample communal space and large bathroom and toilet areas. People spoken to commended the home in allowing them to help make choices on how their personal bed room space should be laid out, colour choices in the rooms and felt more settled as they could bring items from their previous home’s with them. The Company also ensures that continual auditing is completed on all aspects of running the home, to ensure peoples’ views are taken into consideration and improvements or requests actioned quickly. This process is carried out by local staff and a more arms length approach by head office staff. What has improved since the last inspection? What they could do better: The Company must ensure that the supervision of staff is carried out on a more regular basis to ensure they can do their jobs and people are not put at risk. This must include all areas as detailed in the National Minimum Standards and reflect a balance of discussion and observational supervision to test staff abilities to do their jobs. Progress must also be made with the application to The Commission for the Registered Manager’s position to ensure that the day to day operations of the Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 7 home run smoothly and people using the service have someone they can identify with if they should need to voice concerns or ask questions. 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. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 1,2,3,4,5 were checked. Adequate information is given to each person to enable them to make informed choices about using the services in the home. EVIDENCE: The information about the service is on display in the main reception area of the home and is given to each prospective person wishing to use the home. Copies were seen and the information pack given to us on the site visit day. It contains all the information to enable people to make informed decisions about the home and whether they feel it can meet their needs. Prior to admission each person is assessed by the manager and some times another trained nurse. An introductory visit is offered and all services used by the person on that day are free of charge. The needs assessment looks at each person in a holistic manner to see if the services on offer can meet that person’s needs. If it is suitable and the person is admitted a contract is put in place. Of those seen it covered all aspects of a person’s stay. And also had fees detailed so each person could see what they are charged for and can check this against Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 10 monthly invoices. The home is happy to take people who are privately funded, or funded by the local authority or Primary Care Trust. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 6,7,8,9 and 10 were checked. Documented evidence shows people can make major life decisions as well as every day choices to suit their individual needs. EVIDENCE: During the course of the site visit 2 people who use the service were able to speak to us as well as 2 relatives. 2 care plans were also looked at in depth. Prior to the visit 3 people using the service and 4 staff returned surveys sent to them. There were only 4 people resident at the time of the site visit although the admissions register did show various numbers had been in the home in the last few weeks on respite admission. Most people spoken to made very positive comments about the home. Commenting on “how they have turned my life around and helped me move forward” as well as saying staff “are ace, they are my friends”. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 12 People spoken to were able to detail the type of care they were receiving and this was compared to the care notes tracked and also in conversation with staff. The care plans were in 15 sections and all had been evaluated on a regular basis and showed how and when people had been capable or assisted in making decisions on a daily basis as well as more major decisions, such as use of a wheelchair. The records also showed involvement with other health care professionals and visits to hospitals and GP units. The care plan documentation seen was well written, legible and clear, following the plan of care and detailing all events in each person’s life. Records seen also showed how each person was able to attend meetings about their lives in the home, not only about their own needs, but how the people in the home were coming together more as a family unit to discuss, for example joint outside visits and how and when main communal meals should take place. There was well-documented evidence on the risks that had been assessed for each person. For example the ability of a person to walk rather than use a wheelchair for getting around. And another risk of whether someone needed to smoke their cigarettes under supervision or could be left alone. The risk assessments seen showed how people could be allowed to take risks to maintain their independence but if this went wrong what mechanisms were put in place to help them establishment a new outcome. For example the drinking of alcohol, if access was reached and medication could not be taken how a person could overcome the alcohol dependency to achieve a better quality of life and not harm their physical well being. During the course of the day staff were observed assisting people with personal care needs and meals, as well as generally socialising with each person both in communal areas and on a one to one basis. This they did in a calm, quiet manner showing dignity and respect to each person and using phrases suitable to each person’s needs and abilities. Staff spoken to stated what training they had received whilst working in the home on such topics as head injury, dealing with aggression and personal care. When spoken to they stated that training by the Company had been very thorough when they started employment and covered a broad spectrum of topics, which as one person stated, “ has really helped me do my job”. Another stated they felt “ supported by other staff who have more knowledge in some areas, but we work as a team so people living here are happy”. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 11,12,13,14,15,16 and 17 were checked. People in the home can maintain appropriate and fulfilling lifestyles in and outside the home, which meet their personal expectations. EVIDENCE: During the course of the site visit we were able to speak to several people in the home and some relatives. They were able to explain how their daily expectations are met and how their lifestyles may have changed since being resident in the home. For example one person was very excited about attending an adult further education centre, which they had been encouraged to look at to help further Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 14 their educational needs, which they said, “ I never thought this would happen and the choice there is so good, I don’t know where to start”. The surveys returned also reflected people’s personal needs such as being able to practise their own religion and be supported to attend events if they want to outside the home. The documented evidence in each care file detailed how by attending meetings, using local taxis to go out and making small decisions for example of what clothes to wear each day, staff were assisting people in making personal decisions about their lives. The home was starting to make links with the local community and ensuring information was available for people in the home on local activities and resources. The Company financial budget allows for lifeskills events to be paid for so people do not have to use their own personal money for some events. The staffing budget also allows for a lifeskills coordinator to be employed to facility and take part in events with people living in the home. This person also coordinates with other staff on daily task choices for people. This still needs to be developed to ensure that all parties are aware that information should be shared to ensure peoples needs and expectations are recognised and documented. For example information of peoples choices of foods and snacks need to be passed to care staff as well as kitchen staff to ensure people are not offered foods they don’t like and be frustrated if they feel this information has previously been shared. Relatives spoken to and who returned surveys stated they feel welcomed by staff and are often asked if they would like to be actively involved in a person’s daily routine. One person stated “ we feel it is something tangible we can do daily, like taking washing home or sit and assist at meal times”. A tour of the kitchen took place in the presence of one of the cooks. They were able to give a good account of the running of the kitchen, the processes and procedures in place to ensure it is a safe environment and people are receiving what meals they would like. There is currently a 4 week cycle of menus in place but due to low occupancy this is reviewed daily and often very individual choices given. The people spoken to and other staff confirmed this. The daily menu is displayed in the dining area and a staff member responsible for reading this to those who cannot see or understand the written word. Some people stated they like for example Chinese takeaway meals and pizzas and staff have ensured that local shops menus are in the home and people enabled to telephone through or go to collect their own menu choices. The kitchen area was very clean and all records for health and safety were up to date and open for our inspection. The last environmental health officer’s visit in February 2008 gave the kitchen a 5 star rating. The certificate as on display for everyone to see. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 18,19,20 and 21 were checked. Evidence supports that people receive appropriate personal and healthcare support to meet their needs. EVIDENCE: There was good documented evidence in the 2 care plans tracked that peoples personal and healthcare needs are being met on a daily basis. The evidence showed that people are offered alternatives for example bathing and this can also take place in a sensory bathroom, which additionally offers relaxation as well as meeting a basic need. One person commented in a survey that they are given the opportunity to do as much for themselves as they can, but know “I can have help when I need it”. Another person spoken to on the site visit said they are helped to visit the local GP surgery and always have an escort on the trips to hospital. There was good follow through in the care documentation that other healthcare professionals are involved in the decision making for each individual in the Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 16 home. Local healthcare professionals spoken to by telephone also confirmed that they are contacted about a person’s care and feel the home is always knowledgeable about each person. The section on ageing and death in the care plan documentation had not yet been completed but policies were seen so staff can refer to them if the need should arise. A senior member of staff went through the procedures for drug administration, which appeared to be very thorough. All records seen appeared to be accurate and staff had a detailed knowledge base on each person’s needs. At the time of the site visit there were no people who could self-administer medication and relevant care plans were in place for each person detailing how this decision had been made. The records showed safe practises were in place to protect people from harm. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 22 and 23 were checked. Robust systems are in place to ensure any concerns and complaints are dealt with promptly and people are protected from harm. EVIDENCE: Since the home opened 6 months ago there have been no complaints or concerns raised to The Commission about the home. The Complaints log was seen on the site visit and none had been recoded at the home. One relative spoken to was still having discussion with the home management team about their loved ones care but were aware, when questioned the processes to follow should the need arise. This was past on to the Area Manager who was present during the site visit. Staff spoken to and on surveys returned by staff, stated they had received up to date protection of vulnerable adults training as part of their induction to the Company and this was documented in their files. This will ensure people are protected from harm and staff are aware of how to recognise abusive situations. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 24,25,26,27,28,29 and 30 were checked. People live in a safe and secure environment suited to their needs. EVIDENCE: We were able to have a full tour of the home with the Area Manager and also a walkabout on our own. As this home was only registered just under 6 months ago all certificates of safety for equipment in use and health and safety policies remain the same as when the Registration team for CSCI visited. The home consists of 4 10-bedded units each, which can be totally self contained, having bedroom, toilets, bathrooms and sitting/dining areas. Care has been taken to have muted colour schemes until such time as people living in the home can help make choices as to the colours they want. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 19 Each of the people resident in the home at the time of the site visit allowed us to view their rooms and their was good evidence that they had been allowed to personalize them to suit their needs and tastes. The home also has a sensory room for people to use to help their well-being and some of the bathrooms also have sensory equipment to make bathing a relaxing time. One room had been left fairly empty of furniture as the home would like to establish a themed room/library room, but will wait until such time as there are more people resident to decide its future. Each wing is named and the names chosen by a competition which was held at a local school to start to make it more of a community establishment. This has also helped people living in the home to have a proper address as opposed to just say they are living in a home. The CSCI Registration team visited at the beginning of the year and deemed the home had enough communal areas to meet everyone’s needs. As well as staff areas such as training room and staff sitting room. All the garden areas are accessible for wheelchair users and had been divided into small areas so groups of people could meet but there was also ample space for people to use the garden to reflect on their own. One person stated, “I feel I can sunbathe in peace”. Havenmere had many homely touches such as subtle pictures and flower arrangements around the home and the furnishings and equipment were of a high standard. Safety had also been taken into consideration with hand wash in the reception area as people sign in and notices explaining why some areas, such as the kitchen were out of bounds for visitors. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 31,32,33,34,35 and 36 were checked. Robust systems are in place to ensure staff are safe to work with people prior to commencement of employment and are then trained and supervised to do their jobs. EVIDENCE: 8 staff were spoken to during the site visit and 4 had previously returned surveys sent to them by The Commission. All staff made very positive comments about the support they were receiving in the home from each other and the management team and wider Company. Making such comments as “feel very supported here” and “the Company put a lot of time into ensuring we are trained to do our jobs”. Another stated, “its different from any type of care home I’ve worked in in the past, but I love it”. Minutes of staff meetings were also seen to show that a variety of topics are discussed and everyone can contribute The only time a negative comment was stated by staff was about staffing levels when respite residents are in the home. This has not always been Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 21 calculated on a weekly basis, so the management should ensure some method is put in place to ensure correct staffing levels are adhered to at all times to meet everyone’s needs. 7 staff personal files were tracked in depth and all found to have suffiecnt information to ensure they were safe to work with people prior to commencement of employment. This included questions being recorded at interview and full-enhanced Criminal Records Bureau checks made prior to commencement of employment. A list was also seen where the management team were also keeping a record of the Registrations of all professionally trained people with the Nursing and Midwifery Council to ensure they were in appropriate roles within the home. After employment the training records of each person were already very full and staff had stated they felt all training so far was appropriate to help them understand the needs of people they were caring for. As some staff had been recruited for several months the supervision records were very poor. The Area manager had already identified this as an action for the home on the Regulation 26 reports, which were open for inspection. Failure to supervise staff could result in them not using correct techniques when caring for people in the home and putting them at risk. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 37,38,39,40,41,42 and 43 were checked. Documented evidence showed the care home is fulfilling its stated purpose to meets the needs of people living there and the home is monitored regularly to ensure it keeps to its aims and objectives. EVIDENCE: At the time of the site visit the home’s Acting Manager was not available but the Company area manager was on site and along with senior staff in the building assisted us during the visit. All staff were very cooperative and there appeared to be a very open and transparent form of management in the home. The application for the Registered Manager’s position has been submitted to The Commission. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 23 There was suffiecnt written documented evidence to show that the home is consulting with people who use the home and other stakeholders such as relatives and health professionals, to ensure the home is run for the people who are resident. This included minutes of residents meetings, monthly auditing tools, (where discussion had taken place with people) and visits recorded by Company representatives. On reading the surveys returned to us by people who use the service, relatives and staff they all made positive comments about the way they are informed of events in the home and about their loved ones. Comments were made such as “ I like to get involved and staff help me to do so” and also “decisions about the home are made with me not for me”. The Company has a tried and tested quality assurance system in use which it uses in sister homes to this service. This appears to give them the necessary information about the home to ensure the home develops for the benefit of people using it. Although not in place for a full year there was suffiecnt written evidence to show progress was being made to action any points raised by people using the home or other stakeholders. For example suggestions for a themed room, use of the dining room, staffing levels changed and certain equipment changed to suit individuals needs. The full business plan submitted to The Commission Registration team six months ago remains the same, as do all the policies and procedures. This gives guidance for staff to work towards and ensures people using the service that the Company is looking forward and is currently financially secure. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 3 3 3 3 3 Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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 YA36 Regulation 18.2. Requirement The Registered Person must ensure that all staff receive supervision to ensure they are safe to work with people using the service. The Registered Person must ensure that the a Registered Manager is in position to ensure the smooth day to day running of the home. Timescale for action 02/01/09 2 YA37 8.1.a. 02/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA11 YA31 Good Practice Recommendations The management team should ensure that all information gathered on people using the home is imparted to all parties to ensure all their needs are being met. The management team should ensure that a process is in place to ensure when respite clients are resident the staffing matrix is looked at in case it needs adjusting to meet everyone’s needs. Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Havenmere DS0000071588.V368801.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!