Inspection on 11/07/05 for The Haven

This inspection was carried out on 11th July 2005.

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

Other inspections for this house

The Haven 31/07/06

The Haven 21/11/05

The Haven 30/12/04

The Haven 12/10/04

The Haven 23/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Haven Radley Road Abingdon Oxon OX14 3PP Lead Inspector Julian Griffiths Announced 11 July 2005 10:00 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 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 Stationary 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. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Haven Address Radley Road, Abingdon, Oxon, OX14 3PP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01235 521801 01235 521801 haroon@caretech-uk.com Caretech Community Services Limited - Haroon Sheik, Responsible Individual Ms Julie Firth Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 30 December 2004 Brief Description of the Service: The Haven is a home for six adults with learning disabilities and physical disabilities. The home provides 24 hour support for the residents to meet their assessed needs. It is run by CareTech, a large private company which specialises in services to people with learning disabilities, although the actual house itself is owned by a housing association. The home is detached and located in the outskirts of Abingdon, a market town seven miles south of Oxford. The home is domestic in appearance and has a big garden. The residents are helped to use local services and facilities. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which means that it was planned in advance with the home. The inspector was in the home from 10am until 6.30pm during which time he spoke with residents and the close relatives of some residents, he spoke with staff members and the manager, he observed staff at work and he looked at records and other documents. Residents and staff were welcoming and helpful throughout. Staff members seen during the inspection were courteous and respectful towards residents and provided a high standard of support. Relationships between staff and residents seemed good, and residents who talked with the inspector said that they were very happy living at The Haven and that the staff were helpful. The service is improving with the employment of more staff and the consequent reduction in the use of agency staff. A new and better way of organising the home around individual residents’ needs is starting to be introduced. There has been room to improve the opportunities available for residents to pursue activities and this is being done. One resident told the inspector that she would like more opportunity to go out. There is a serious safety concern about one resident’s use of the stairs. CareTech and others are looking at ways to overcome this but a visitor speaking on the resident’s behalf expressed anxiety that the eventual solution should be in the best interests of the resident and not simply the easiest solution for the company. What the service does well: The home has carefully assessed each resident’s needs and wishes and written these into an individual plan of care. Residents are enabled to stay in contact with their families. Residents have good access to healthcare. There are enough staff working in the home to meet the needs of the residents. The home carries out all the required checks on new staff to ensure that residents are protected. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 6 There is training and support available to staff to ensure that they can provide residents with a high standard of care and support. Residents’ medication is well managed, ensuring their safety. The home takes action to ensure that residents are protected from abuse. There are enough staff working in the home to meet the needs of the residents. The home carries out all the required checks on new staff to ensure that residents are protected. There are good relationships between staff and residents, and staff are respectful towards residents. The manager was working towards a recognised qualification in care home management. Residents’ views are sought and influence the running of the home. There are systems in place to protect the health and safety of residents and staff. What has improved since the last inspection? What they could do better: The home does not provide residents and prospective residents with all the information that the law requires. Whether or not each resident is protected by a contract with terms and conditions of residence is unclear and needs to be clarified. Residents are supported to take risks as part of an independent lifestyle, but risk assessments need to be improved. The scope and frequency of activity opportunities for residents could be improved. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 7 Private space for residents to receive visitors in the home is confined to their bedrooms. The home needs to ensure that all residents’ healthcare is recorded so that their health can be properly monitored. The manager is recommended to request from their GPs at least annual health checks for residents who wish. The home responds to complaints but needs to give clearer information to residents and their representatives about how to complain. Action needs to be taken to ensure that the safety of a resident is not put at risk by the home’s stairs, which do not meet her needs. CareTech needs to visit and report on the home at least at the minimum legal frequency. Fire fighting equipment needs to be inspected and tested at least annually. 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 Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 5 The home does not provide residents and prospective residents with all the information that the law requires. Systems are in place to ensure that the needs of prospective residents are properly assessed. Whether or not each resident is protected by a contract with terms and conditions of residence is unclear and needs to be clarified. EVIDENCE: The home has a “Statement of Services” document which does not include some of the information, for example details of the staff and manager, required to be included in a Statement of Purpose. The home also has a “Welcome to The Haven” document which does not include all the information required to be in a Service User Guide. The registered persons must produce a Statement of Purpose and Service User Guide in appropriate formats, which include all the information specified in Regulations 4 and 5, and must make these available to those persons listed in the regulations. The home provides long-term accommodation so that no new residents have been admitted for many years. Regarding assessment of prospective new residents there is no change from the report of 12/10/04 which stated: “The organisation has good quality, clear and detailed assessment documentation The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 10 for any new admission that is person-centred and requests information from a variety of sources. The manager stated that if there was a vacancy at the home then she would liaise closely with her manager and the appropriate documentation would be completed.” The manager said that there was a contract for services between Oxfordshire County Council on behalf of the residents, and CareTech, but a copy could not readily be found for inspection. There was an agreement in the form of a Statement of Services, and an example was seen to have been signed by a CareTech representative and a resident. However the status of this document was unclear and the manager said that some residents’ relatives, on the advice of a representative of Oxfordshire County Council, had refused to sign the document on residents’ behalf. Whether or not residents’ rights are protected by a valid contract with CareTech was, then, unclear. The registered persons need to take action to clarify this and ensure that the rights of each resident are protected by a valid contract with CareTech. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The home has carefully assessed each resident’s needs and wishes and written these into an individual plan of care. Residents’ rights to make choices in the routines of their daily lives are respected. Residents are supported to take risks as part of an independent lifestyle, but risk assessments need to be improved. EVIDENCE: Each resident has an individual plan of care reflecting her own needs, wishes and circumstances, and an example was looked at in some detail by the inspector. The information was recorded using organisational templates that were prescriptive with regard to the information required. The home has worked well with the format and has made the plans as person-centred as possible in the framework dictated. A move to a more person-centred system of planning and meeting individuals’ needs was said by the manager to be imminent. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 12 As a result of a service user’s close relative commenting on lack of information provided to her the manager gave all close relatives access to care plans and invited them to sign them. An example was seen of one that had been signed. A record was seen of monthly in-house review of the plan. The inspector saw documentation relating to a restriction of liberty for one resident. This related to a bolt on the front door to ensure that the resident did not go out unaccompanied and expose herself to risk. It had been recently reviewed and signed by the manager and the resident’s close relative. The manager and staff spoken to stated that there were no other restrictions and none was observed. Residents moved around the home and garden freely and staff offered choices about what to do or what to eat. The home has a process of risk assessment to ensure that the risks associated with residents’ everyday lives are identified and as far as possible minimised. Examples seen, regarding “undertaking activities at home or in the community”, and “using the bathroom” were so vague and general as to be limited in their usefulness. They clearly had not been produced with individuals in mind. The manager explained that the examples seen represented a new system, just introduced by CareTech, whereby a general risk assessment was produced and further detail added by staff in the home to reflect the needs of the individual. Little detail had been added to those seen. All risk assessments relating to individual residents need to be checked to ensure that they fully reflect the particular needs of the resident concerned. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Residents have opportunities to take part in activities in the home and outside in the wider community, but the scope and frequency of these could be increased. Residents are enabled to stay in contact with their families, though private space to receive visitors in the home is confined to bedrooms. EVIDENCE: Discussions with residents, staff and the manager showed that three residents were attending an art group; the inspector saw some impressive craft work associated with this. Others regularly used two local activities venues for structured activity, one attended a weekly women’s’ group which she said she enjoyed, and two residents were using a local sensory room on a weekly basis. A resident’s social diary was seen. This only indicated four out-of-house activities for the whole month of June 2005 (two trips to town and Milletts Farm, a walk and coffee out and shopping in town). The in-house activities The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 14 record for the same person showed five activities for the same period, one of which was “relaxing”. Residents’ relatives spoken to talked of an apparent lack of activity at weekends. Three residents’ daily diaries were looked at with specific reference to four weekends in June 2005. These showed a mixed picture with one diary recording a variety of in and out-of-house activities, one showing no out-ofhouse activities at all and few in-house ones. The third was somewhere in between. The manager said that the needs and wishes of each person with regard to activities were different, and some did not want as much as others. A resident told the inspector: “I would like to go out more if I could”. A staff member expressed the opinion that a change in the shift pattern at weekends could make it easier to provide activity opportunities for residents. Residents’ relatives expressed concern that the home’s own sensory room was not used, but that residents had to go out to a sensory room for which they had to pay. The manager said that the external room was much larger and better able to meet residents’ needs. A staff member said that staff had acknowledged the need to be more proactive in providing residents with activities and involving them in the running of the home. The March 2005 staff meeting record had an entry to this effect. The staff member said that things had improved since then. Staff and the manager also commented on the effect on activities of using large numbers of agency staff, who could not be left in the home on their own to look after residents. They said, and records seen supported this, that use of agency staff was reducing so alleviating this problem. The home relies to some extent on Activities Support Workers (ASWs), working for another organisation under contract to CareTech, to facilitate activities for residents. The manager said that this service had been erratic. The inspector looked at the ASW record for the month of June 2005 and found that this was indeed so, with numerous entries indicating that the ASW did not arrive for a variety of reasons. One resident had in the past been a regular churchgoer, relying on the willingness of an ASW to come to the home and take her to church on a Sunday. The manager told the inspector that, since the ASW had left, the home no longer had the staff resources to continue this. She said however that the recent recruitment of new staff meant that the resident would once again have the opportunity to go to church. The manager is reminded that, as far as practicable, it is a legal obligation to give residents the opportunity to attend religious services of their choice (Regulation 16(3)). It is recommended that the manager take action to improve the availability of activity opportunities for residents. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 15 The manager stated, and discussion with staff and relatives and inspection of records confirmed, that most residents maintained close contact with relatives, making and receiving visits and phone calls. The only place in the home for residents to see their visitors in private is their bedrooms and relatives made the point that this is not always appropriate. The inspector is aware that CareTech is looking into the possibility of alterations to the home to address this among other problems. The manager has taken active steps to seek advocacy for a service user with no family. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Residents have good access to healthcare. The manager is recommended to request from their GPs at least annual health checks for residents who wish. All residents’ healthcare needs to be recorded so that health needs can be properly monitored. Residents’ medication is well managed, ensuring their safety. EVIDENCE: Records seen showed that residents had access to a range of health professionals, for example the GP, nurse, dentist and physiotherapist, as needed. A resident happily told the inspector about a recent very positive visit to her dentist. The inspector saw in a resident’s records an entry following a dentist visit in September 2003 stating that the resident should return within a year. There were no further entries. The manager expressed confidence that this represented a failure to record rather than a failure to take the resident back to the dentist, but other records could not be checked to confirm this because they were in the attic. The manager is asked to check records to ensure that The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 17 the follow-up dental check took place and confirm this to the Commission in writing. The manager said that the residents’ GP practice had declined to undertake annual health checks (see National Minimum Standard 19.4), unless there was a specific concern that necessitated it. The manager is recommended to request this in writing, and to keep a record of the response. The inspector watched staff administering medication to two service users, looked at some records and looked at medication in storage. Staff training records and records of pharmacists’ visits to the home were also inspected. The conclusion was that all staff who administered medicines were trained to do so, that medicines were properly labelled and securely stored, that there was a proper system of stock control, that no non-prescribed medicines were used, that medicines were carefully and safely administered and that there was periodic oversight and guidance from the community pharmacist. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home responds to complaints but needs to give clearer information to residents and their representatives about how to complain. The home takes action to ensure that residents are protected from abuse. EVIDENCE: The inspector saw that the home has a satisfactory complaints procedure with leaflets that give guidance about how to complain. One leaflet, in a simpler format, gave no details of the Commission, and the other gave out of date details. The procedures need to be completed and brought up-to-date with full details of the Commission for Social Care Inspection. The home’s complaints record was seen. It was apparent from discussion with the manager that full details of the manager’s response to the latest complaint had not been included in the record. She completed the record during the inspection. The manager must ensure that full details of complaints, including all action taken in response, are recorded. Records showed that staff and the manager had received training in the protection of vulnerable adults from abuse. The Oxfordshire Codes of Practice on adult protection were seen to be in the home and a staff member spoken to demonstrated her awareness of them. The home’s staff meeting records showed that its Managing Abuse policy was read to staff by the manager at the June team meeting. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The stairs are dangerous for one service user who has to use them to get to her bedroom EVIDENCE: Environmental standards at the home were not inspected on this occasion. The issue of the stairs was however brought to the inspector’s notice by residents’ relatives and discussed with them, the home manager and staff. One resident is becoming increasingly unsteady on her feet and is increasingly prone to falls. Her close relative and staff at the home are clear that the accommodation as it is no longer meets her needs and that something must be done soon. The residents’ relatives spoken to were forthright in expressing their view that the solution must meet the needs of the individual and the group as a whole and that simply to move the resident in question to other accommodation would be, in their words, “cruel, unkind and insensitive”. Their preferred options were to extend and alter the existing home to make it suitable for all, thereby also solving the issue of lack of private space for visitors, or to find suitable local accommodation so that all the residents, who had been together almost since the home opened 13 years before, could move The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 20 and stay together. The manager said that no decisions about how to proceed had yet been made. A staff member said that while every effort was made to ensure that the resident in question did not use the stairs unaccompanied, given staff responsibilities to other residents this was in practice impossible to achieve for 100 of the time. It is a requirement that the registered persons take action to ensure that the environment of the home is safe and suitable for all residents. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 There are enough staff working in the home to meet the needs of the residents. Staff and residents get on well together and staff are respectful towards residents. The recent reduction in the use of agency staff means that the standard of support to residents will improve. The home carries out all the required checks on new staff to ensure that residents are protected. There is training and support available to staff to ensure that they can provide residents with a high standard of support EVIDENCE: The duty rota seen during inspection showed that there were always three staff members working with residents during the day, the minimum level specified in the home’s staffing statement. Staff spoken to and the manager stated that this was enough to meet residents’ needs and to provide opportunities for activities in and out of the house. A staff member suggested that a change to The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 22 the weekend shift pattern would enable more activity opportunities to be offered. Discussions with residents’ relatives, staff and the manager indicated that very heavy use of agency staff had been made until quite recently. Because of limitations imposed by CareTech on the duties that can be carried out by agency staff, a predominance of such staff on shift had adversely affected the quality of support for service users. Residents’ relatives spoken to also suggested that some agency staff members they had encountered had appeared to lack initiative and communication skills. However recent recruitment had improved matters and the projected duty rota for the month of July showed no more than one agency staff member on duty at a time on fewer than 30 of shifts. All but one of the agency shifts shown were to be worked by the same two people, thus making for consistency. There are a number of staff who have worked in the home over a period of years and provide an experienced core team who know residents and understand the home’s way of working. A staff member who was asked demonstrated a very good understanding and knowledge of a resident’s needs, in particular regarding communication, which was consistent with the information seen in the resident’s service user plan. Staff members were seen to speak respectfully and courteously to residents, and interactions that the inspector saw indicated relationships of warm familiarity between staff and residents. Residents seemed to be comfortable and at ease with staff. A resident told the inspector that the main quality of the staff was their helpfulness. Staff members were seen to offer residents choices and to involve them, for example in the preparation of a meal. Records showed that there were monthly staff team meetings at which matters affecting the running of the home were addressed. A sample of files relating to staff members was inspected and showed that the home carried out all the required checks before employing new staff. Records also showed a structured programme of induction and foundation training for new staff, that was consistent with the Learning Disability Awards Framework (LDAF), and on-going training in relevant core and specialist skills, such as moving and handling, attitudes and values, epilepsy awareness and challenging behaviour. A new staff member confirmed that she had completed her initial induction. Regarding agency staff the inspector saw written evidence of the home’s policy that new agency staff were not admitted to the home unless they brought with them a copy of their Criminal Records Bureau check and a record of the training they had received. Documents were seen relating to the basic introductory training given by the home to new agency staff. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 23 Documentary evidence was seen of monthly individual supervision of staff by the manager, and of formal annual appraisal. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 24 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42. The manager was working towards a recognised qualification in care home management. Residents’ views are sought and influence the running of the home. CareTech was not visiting and reporting on the home at the minimum legal frequency. There are systems in place to protect the health and safety of residents and staff. Fire fighting equipment was not being adequately inspected and tested. EVIDENCE: The manager said that she was doing the Registered Manager’s Award qualification which she planned to have completed by November 2005. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 25 CareTech has a comprehensive and detailed Quality Assurance and Monitoring system whereby all aspects of the home are regularly assessed against a set of standards. The manager said that residents’ close relatives were now invited to contribute to the process. The inspector saw the reports of the last two quality inspections. Records were seen of monthly residents’ meetings at which information was given to residents and their views sought, for example on choosing new furniture and social events. Pictures were used as aids to communication. Residents’ relatives said that they were invited to twice yearly meetings with CareTech to discuss the care of residents. Booklets were seen which recorded the manager’s monthly “1:1 time” with each resident. These showed the manager discussing with residents the colour a room was to be painted, the planning of a dental check-up, a review, how a resident felt about making her own lunch and the planning of a birthday celebration. Reports of CareTech’s statutory monthly visits to the home were seen. No report was available for November 2004, although the home’s visitor’s book suggested that the visit may have been carried out. It is required that a representative of CareTech visit the home at least once in every month, report in writing on its conduct and send a copy of each such report to the Commission. Records were seen which showed that there was a positive and active approach to health and safety in the home, for example a monthly health and safety checklist, an up-to-date gas safety certificate, a very positive environmental health report, hoist servicing within the last 12 months, regular testing of fire alarms and emergency lighting and frequent fire drills. However it was noted that fire-fighting equipment had not been inspected and tested since March 2004. It is required that fire fighting equipment be inspected and tested at least annually. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Haven Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 27 Yes 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 1 Regulation 4&5 Requirement The registered persons must produce a Statement of Purpose and Service User Guide in appropriate formats, which include all the information specified in Regulations 4 and 5, and must make these available to those persons listed in the regulations. All risk assessments relating to individual residents need to be checked to ensure that they fully reflect the particular needs of the resident concerned. The manager must ensure that full details of complaints, including all action taken in response, are recorded. The homes complaints procedures need to be completed and brought up-to-date with full details of the Commission for Social Care Inspection. The registered persons must take action to ensure that the environment of the home is safe and suitable for all residents. It is required that a representative of CareTech visit the home at least once in every month, report in writing on its Timescale for action 30/09/05 2. 9 13(4) 30/09/05 3. 22 17 31/07/05 4. 22 22 31/07/05 5. 24 23(2) 30/09/05 6. 39 26 31/07/05 The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 28 7. 42 23(4c) conduct and send a copy of each such report to the Commission. It is required that fire fighting equipment be inspected and tested at least annually. 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 5 13 19 19 Good Practice Recommendations The registered persons should take action to ensure that the rights of each resident are protected by a valid contract with CareTech. Take action to increase the availability of in and out-ofhouse activity opportunities for residents. The manager is asked to check records to ensure that a residents follow-up dental check took place and confirm this to the Commission in writing. The manager is recommended to request residents annual health checks from the GP practice in writing, and to keep a record of the response. The Haven v228151 h57-h08 s13091 the haven v228151 110705 stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Burgner House, 4630 Kingsgate, Oxford Business Park South, Cowley, Oxford. OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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