CARE HOMES FOR OLDER PEOPLE
Haversham House Longton Road Trentham Stoke-on-Trent Staffordshire ST4 8JD Lead Inspector
Norma Welsby Key Unannounced Inspection 23 January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haversham House DS0000008235.V322753.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. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Haversham House Address Longton Road Trentham Stoke-on-Trent Staffordshire ST4 8JD 01782 643676 01782 643674 havershamhouse@hotmail.co.uk 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) Haversham House Limited Miss Janet Christine Picken Care Home 43 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (28), Mental disorder, excluding learning of places disability or dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (43), Physical disability over 65 years of age (10) Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 10 MD - to be minimum of 55 years on admission 10 DE - to be minimum of 55 years on admission Date of last inspection 25th January 2006 Brief Description of the Service: Haversham House is a private residential care home registered for up to 43 older people, some of whom may be mentally frail or physically frail. At the time of this Key Inspection, Haversham House was fully occupied and had also received several recent enquiries and had a waiting list. The home has a specialist Elderly Mentally Infirm (EMI) unit on the first floor, which can accommodate up to eight residents, while the remaining residents, who have mixed dependency needs, occupy the ground floor communal areas that have been significantly improved during the past couple of years. In total there are 41 single and 1 shared bedroom, which was being used for single occupancy. Following the completion of the recent extension, the home now provides 10 of the single bedrooms with an en suite and the double bedroom is also equipped with an en suite. Further improvements have included the extension of the dining room, the provision of a walk in shower room in the extension, an additional bath hoist in a former domestic bathroom and the relocation of the laundry room. Haversham House is located off the busy Longton Road in Trentham and as such provides good access to a wide rang of community resources. The property provides an attractive and well maintained appearance with good car parking facilities. The large open plan lounge on the ground floor leads to a patio and enclosed garden. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Key Inspection was carried out on the 23rd of January 2007, between 9.30am and 5.30pm. The findings of this inspection were very satisfactory and the Registered Manager, Ms Janet Picken, staff on duty and residents, provided helpful assistance throughout the day. The majority of the National Minimum Standards were examined, some more thoroughly than others, and no new requirements were made, but the Inspector did make five new recommendations and also requested that the Registered Provider write to the CSCI with an Improvement Plan in respect of resolving the overcrowding issue that was apparent in the ground floor lounge areas. The previous Requirement and six recommendations from the last inspection of 25th January 2006 had been fully addressed. What the service does well:
Haversham House provides a very homely and comfortable home. Throughout this inspection the Inspector observed a very friendly and relaxed ambience, with positive interaction between staff and residents. There is a good management structure, with a manager and deputy and a team of senior carers. The staff team is well established with a very low turnover. There is a real sense of team work at Haversham House, which is commended by the Inspector. There are two senior carers on all day, one working upstairs and one based on the ground floor and at night there is always a senior night carer on duty. The former Registered Manager, Mrs Ann Hill, who is now the Managing Director, remains very involved and supports the management team and the home as a whole. The Registered Manager, Miss Janet Picken had achieved NVQ level 4 and the Registered Managers Award and 66 of staff have NVQ level 2 or 3 with more staff about to complete or commence further training. Social care is given a high priority at Haversham House. An Activity Assistant is employed for 25 hours per week and this is complimented by the home having its own adapted minibus and a Driver who is employed for 10 hours each week. Residents have regular opportunities to visit local places of interest as well as having a range of in house social activities and entertainment. Several residents told the Inspector that they valued having such a range of social opportunities and this was echoed by positive comments received from relatives.
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
The ground floor communal sitting areas, while spacious provide an unusual layout and as such present a congested and overcrowded appearance since the increase in registered numbers from 33 to 43. Some of the chairs are very closely arranged and in the TV room, which is very popular at certain times, not all are positioned in such a way that it is easy for residents to watch television comfortably. The problem generally is compounded at times when there are lots of visitors in the home and indeed Haversham House does have lots of visitors, which of course is positively encouraged by the staff team. Indeed this was a concern that was notified to the Inspector by three relatives/visitors, prior to this inspection and the Inspector saw the problem for herself during the inspection visit to the home. As well as comfort and appearance there is a health and safety issue, for both residents and staff that requires the matter to be improved as soon as possible. The dining room also presents some concerns, but it is hoped that the provision of new dining tables will help alleviate these and there were plans to order new round (extendable) tables. In respect of this issue the Inspector made a recommendation that the activity room is refurbished and promoted in part as a visitors room, if residents do not wish to use their private bedrooms. Secondly the Inspector also requested that the Registered Provider write to the CSCI to outline his proposals to resolve this problem and the timescale. The Inspector understands that consideration may be given to building a conservatory attached to the new lounge area and certainly this would appear to provide an appropriate solution.
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haversham House DS0000008235.V322753.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 Haversham House DS0000008235.V322753.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): 1,2 and 3 Standard 6 does not apply to this home as it does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents received detailed information about the home to enable an informed choice to be made about the suitability of the home for them. Each resident had a contract with the home and they were assured that the home could meet their assessed needs before moving into the home. No intermediate care took place in the home and therefore, standard 6 was not inspected. EVIDENCE: All residents have been provided with a copy of the homes Welcome Pack which is used as a Service User Guide. A copy of this was briefly examined during the inspection and was seen on display in the home and several residents made reference to them. One resident had been admitted on the day prior to this inspection and the Inspector consulted with her and her
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 10 relative, both of whom conveyed a positive impression of the information and help this had been given during this anxious time. The Inspector asked that a copy of the updated Statement of Purpose (following the home’s increase in registration) be forwarded to the CSCI and the Registered Manager agreed to do this. All residents also have a contact detailing a statement of the terms and conditions of residency. When a sample of residents were asked, they confirmed their knowledge of the contract and also that they are notified in writing of any changes. The pre-admission assessment of residents is well established at The Haversham House, with the Registered Manager taking the lead role, but also involving the Deputy Manager and senior carers. Documentation evidencing the home’s needs assessment and Care Management Assessments were stored in each resident’s personal history file and form the basis of the written plan of care in operation for each resident. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care planning processes within the home provided staff with sufficient information to meet resident’s needs satisfactorily. Health care needs were met very well and comments received from residents confirmed that they were afforded a high standard of personal care. Medication records and procedures were examined and were satisfactory. Residents were treated with respect and their right to privacy upheld EVIDENCE: Residents care plans were examined and found to provide a range of information about activities of daily living. Each care plan was reviewed monthly and risk assessments were completed and also reviewed monthly. The daily report was completed and provided an up-to-date picture of the current status of the individual resident. The quality of record entries has improved since a recommendation was made at the last inspection and the Inspector was pleased to note this improvement. The Deputy Manager also
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 12 intends to introduce a 24 hour daily plan of care and this will further enhance the quality of care planning at Haversham House. In respect of three residents who are mainly confined to bed, the Inspector was pleased to observe their comfort and attention they were receiving from staff. However it was recommended that more comprehensive records are maintained – in respect of turns, diet and fluid intake. Access to a range of health care professionals was recorded and evidenced that residents’ health care needs were met well. It was evident that the home had established a very good rapport with health professional and several staff referred to the support and assistance they receive, which is much appreciated. A Nomad Monitored Dosage System of Medication has recently been changed to a blister system dispensed by Priory Pharmacy and this was felt to work very well. Medication is administered by 9 staff, all of which have had Safe Handling of Medicines Training. The Inspector observed the lunchtime medication being given to residents in the dining room on the ground floor and this was found to be satisfactory. Storage arrangements were satisfactory and quality control measures were also in place. Medication administration records were examined and were satisfactory. There is a small medical fridge in use. The Inspector noticed that the medication store room was very warm and a recommendation was made that the home use a room thermometer to monitor room temperature so ensure that medication is stored at the appropriate temperature and if any problems are identified then appropriate action should be taken. Throughout the period of the inspection the Inspector had extensive discussions with residents, staff and a visitor to the home, along with making many observations. There was much evidence of high standards of care, including the promotion of privacy and respect. Indeed residents and staff spoke about each other with mutual respect. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Haversham House provides an excellent range of activities and entertainment in the home. Daily routines are flexible and residents are encouraged to maintain family and community links. Choice is promoted across many areas of daily life and a high standard of catering is provided. EVIDENCE: Haversham House continues to promote a wide range of social care activities and evidence of this was apparent on the day of this inspection. An activity assistant is deployed in the home for 20 hours each week and pursues a wide range of activities including newspaper coverage and local news. Reminiscence sessions and quizzes are also very popular and much use is made of the services of the local libraries. There are good links with local churches including volunteers who assist with a range of activities. The home also has the benefit of its own adapted minibus, which is shared with its sister home located just a couple of minutes away. A driver is
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 14 contracted to work 10 hours each week and on average there are two weekly outings. When asked several residents commented favourably to the Inspector about the provision of social care opportunities at Haversham House and regular trips out included Trentham Gardens, Stapeley, Bridgemere, Stafford Park, Museums and pub lunches. In the relatives/visitors comment cards received prior to the inspection, one relative was very complimentary about the social care and homeliness of Haversham House. “Haversham House is a very caring home. The staff really care about the residents and when I visit it’s like going to a family’s house. The staff make you welcome but most of all they have activities every day and trips twice a week.” Without exception, all residents who were consulted confirmed to the Inspector that they were very satisfied with the quality, quantity and variety of meals provided. Special diets are catered for as required; at the time of this inspection, this included just diabetic and soft diets. Six residents were in need of some degree of assistance at mealtimes, but this varied from day to day. The daily menu was found to be on display in the main foyer adjacent to the dining room and several residents confirmed that they had been satisfied with the provision of meals that day. The cook on duty was much complimented by several residents, who confirmed that they are always consulted about the daily menu and offered a range of alternatives. The four weekly menus are regularly reviewed in consultation with residents and adjusted to incorporate seasonal variations. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure had been issued to residents and was seen on display in the home. Procedures and training were in place for staff to ensure that residents were protected from abuse. EVIDENCE: The home’s complaints procedure was seen on display in the home and a copy is also included in the Statement of Purpose and Welcome Pack. During the past year the home has not received any internal complaints, nor has any been received by the Commission for Social Care Inspection. When asked a couple of residents confirmed to the Inspector that they were aware of their right to complain if dissatisfied and would feel comfortable about raising matters directly with senior staff. A couple of relatives had indicated to the Inspector, prior to the Inspection, that they were not aware of the homes complaints procedure and although this was seen on display in the home, it was recommended that the Registered Manager further brings this to the attention of all relatives and visitors, by including details in a newsletter. Staff have been provided with information, guidelines and training in respect of vulnerable adults and correct procedures to follow, including whistle blowing.
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 16 A training certificate was seen on file in all the staff files examined during this inspection. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 17 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): 19,20 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of Haversham House is suitable for its stated purpose. The home provides a comfortable and homely environment and there is an attractive enclosed garden/patio that provides residents with opportunities to sit outside in pleasant weather. A 10-bedded extension had been completed and was fully occupied. The ground floor communal space was overcrowded and ways are being considered to make improvements. EVIDENCE: During this unannounced key inspection a tour of the building was undertaken. All communal areas were visited, along with a sample of bathroom/toilets and bedrooms.
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 18 The home presented as clean, pleasant and hygienic and one resident told the Inspector that there were never any unpleasant odours and that the cleaning standards in the home were “very good”. Several residents confirmed to the Inspector that the home was generally warm, but that it sometimes felt draughty sitting by the windows in the dining room. The Inspector acknowledged the comments about the draughts, which indeed could be felt and it is a recommendation of this report that consideration be given to ways of alleviating any discomfort felt by residents. It was noted that radiators have been fitted with attractive radiator covers. Water outlets were randomly tested and found to provide hot water at a satisfactory temperature. Several mobile magnetic door closures were in use and had improved independence for residents. A random sample of bedrooms were visited and found to be satisfactory and two residents also showed their bedroom to the Inspector and both of these were very comfortable and personalised. The ground floor communal sitting areas, while spacious provide an unusual layout and as such present a congested and overcrowded appearance since the increase in registered numbers from 33 to 43. Some of the chairs are very closely arranged and in the TV room, which is very popular at certain times, not all are positioned in such a way that it is easy for residents to watch television comfortably. The problem generally is compounded at times when there are lots of visitors in the home and indeed Haversham House does have lots of visitors, which of course is positively encouraged by the staff team. Indeed this was a concern that was notified to the Inspector by three relatives/visitors, prior to this inspection and the Inspector saw the problem for herself during the inspection visit to the home. As well as comfort and appearance there is a health and safety issue, for both residents and staff that requires the matter to be improved as soon as possible. The dining room also presents some concerns, but it is hoped that the provision of new dining tables will help alleviate these and there were plans to order new round (extendable) tables. In respect of this issue the Inspector made a recommendation that the activity room is refurbished and promoted in part as a visitors room, if residents do not wish to use their private bedrooms. Secondly the Inspector also requested that the Registered Provider write to the CSCI to outline his proposals to resolve this problem and the timescale. The Inspector understands that consideration may be given to building a conservatory attached to the new lounge area and certainly this would appear to provide an appropriate solution. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Haversham House had sufficient staff with the skills mix to meet the needs of residents. On going training provide staff with opportunities to pursue qualifications. Robust recruitment procedures were in place, including POVA First and CRB checks. EVIDENCE: During this Unannounced Key Inspection there were good staffing levels on throughout the day. The Registered Manager was on duty and provided helpful assistance, as did all staff who where consulted during this inspection. Three staff, (namely the Deputy Manager, one senior carer and one care assistant) were interviewed privately and in addition other members of the staff team were also consulted during the inspection. Through these discussions and by extensive observations the Inspector was impressed with the care and commitment demonstrated by all staff. Without exception, all of the residents consulted were also very complimentary about
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 20 the staff team at Haversham House, as were visitors consulted on the day of this visit. Staff confirmed to the Inspector that staffing levels had increased with the increase in resident numbers and was felt to be very satisfactory. Regular supervision and an annual appraisal was in place and the on going provision of training was also praised. Staff reported that they felt very supported by the management of the home and the Inspector was impressed with their commitment to team working. The home benefits from a good staffing structure, which provides two senior cares on duty throughout the waking day and a senior night carer on waking nights. The Registered Manager’s full time hours are super numery to the 780 care hours deployed each week. Usual staffing ratios provide 7 care staff am/ 4 or 5 2pm-4pm, 5 during the evening and three waking night care assistants. Satisfactory numbers of catering and domestic staff, an activity assistant and driver, an administrator and handyman also compliment the care team. A sample of staff files were examined, each of which were found to be satisfactory. NVQ training continues to be provided – at the time of this inspection 67 of care staff had achieved either level 2 or 3, two more staff were due to complete level 2 and two more staff were due to start. Twenty four members of staff hold a current first aid certificate and staff files evidence a wide range of other courses attended, including mandatory training and specialist courses. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 21 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): 31,35 and38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager was fit to be in charge, responsible and of good character. The ethos and management approach of the home is open and transparent. The health, safety and welfare of residents and staff were upheld and protected – the only concern being the potential overcrowding of the ground floor lounge. EVIDENCE: The Registered Manager, Ms Janet Picken is well supported in her role by the former Registered Manager, Mrs Ann Hill, now a Managing Director and the Registered Provider Mr William Morris. The team of senior carers and deputy,
Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 22 along with all staff who have dedicated roles within the home also compliment the management of the home. Administrative support is provided in house and also at the nearby sister home. The Inspector examined a range of records and found these to be of a good standard. Residents’ financial records were examined and these were satisfactory. The Inspector noted that a previous recommendation that the Registered Manager should undertake a periodic audit of the management and record of residents’ personal allowance had been implemented. Several aspects of health and safety were examined including an inspection of the environment, servicing of equipment, staff training, COSHH awareness and risk assessment and these were found to be satisfactory. Staff were provided with appropriate aprons and gloves and these were observed in use during the inspection. Appropriate arrangements were also in place for the disposal of clinical waste. The only area of concern in respect of health and safety related to the potential over crowding in the ground floor lounge and the Inspector has requested that the Registered Provider write to the CSCI with proposals to improve this situation. Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 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 X X 3 X X 3 Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Ensure comprehensive records are maintained in respect of three ladies who are confined to bed – in respect of turns, diet and fluid intake. To monitor temperature in the medication storeroom to ensure that medication is kept at the appropriate temperature. To seek ways to reduce draughts from windows that may affect the comfort of residents sitting nearby. 2 3 OP9 OP19 Haversham House DS0000008235.V322753.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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
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