Inspection on 14/08/06 for The Haven

This inspection was carried out on 14th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 30/09/09

The Haven 23/10/07

The Haven 07/02/06

The Haven 15/09/05

The Haven 09/02/05

The Haven 12/07/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE The Haven 29 Telscombe Cliffs Way Telscombe Cliffs East Sussex BN9 7DX Lead Inspector Debbie Calveley Key Unannounced Inspection 14th August 2006 13:00 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 The Haven DS0000013995.V303614.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. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 29 Telscombe Cliffs Way Telscombe Cliffs East Sussex BN9 7DX 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) 01273-587183 01273-589428 ANS Homes Limited Mrs Caroline Anne Thomas Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (48) of places The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fortyeight (48). Service users must be aged sixty-five (65) years and over on admission. Service users may have a physical disability and be aged forty-five (45) years and over on admission. 7th February 2006 Date of last inspection Brief Description of the Service: The Haven is a registered care home for older people, which provide nursing care for up to forty-eight residents. An additional variation also allows the home to provide care to residents under the age of 60 years with a physical disability. The home was part of a group of homes previously owned by ANS Homes plc, and has been recently purchased by BUPA. The home is a converted family home and provides accommodation on two floors, which consists of twenty-five single rooms of which twenty-three have an ensuite bathroom, and nine double rooms, one with an ensuite bathroom. There is a lift, which is serviced regularly which ensures level access to all areas of the home. There are adequate communal bathrooms/showers to meet the residents’ needs. The home has equipment to support and assist residents in their daily lives, such as toilet raisers, air mattresses, hoists and assisted baths and showers. The home have communal areas on both floors, one lounge/ dining room on the upper floor, and a lounge and dining room on the first floor. The lower floor is for staff use only and comprises of a staff room and laundry facilities. The home is situated at Telscombe Cliffs, approximately half a mile from the sea front and the local shops. The home is situated on a central bus route. Car parking facilities are provided to the rear and front of the building, and a welltended garden area is accessible to all service users. The service provides prospective service users with a copy of the service users handbook and a brochure as part of the pre-admission process. Copies of inspection reports and the homes Statement of Purpose are made available if requested. Fees charged as from 1 April 2006 range from £524 to £736, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at The Haven Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit included a meeting with the registered manager who received the inspector’s feedback during the inspection. On the day of the home visit the inspector spent most of her time meeting with residents and their visitors, speaking with staff and observing practice in the home. During the inspection visit ten residents care documentation was reviewed in depth. A further selection of documentation was reviewed as part of the inspection process and this included the statement of purpose and service users guide, staff duty rotas, training records, 5 recruitment files, records relating to health and safety and a number of policies and procedures. Six staff members were also interviewed in private. In addition service users surveys were given to 10 residents or their representatives and 10 staff surveys were sent to the home for staff to return. The information contained in the returned surveys has been incorporated into this report. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents and relatives the information required enabling them to make an informed choice about where they live. The residents and their representatives were complimentary regarding the standard of care they receive. The home was found clean, safe and well maintained, which is appreciated by the residents and their relatives. The Haven provides an environment that is comfortable and homely and gives residents the opportunity to personalise their rooms. The atmosphere of the haven is pleasant with good interaction seen between residents and staff. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at The Haven. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 6 There is a variety of good nutritious food offered and fresh fruit is readily available. What has improved since the last inspection? What they could do better: 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 DS0000013995.V303614.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available in the front entrance area. A social care professional who had recently visited the home confirmed that relevant information was provided to a prospective resident. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. Nine of the ten assessments were found to be completed in full and were used The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 9 to ensure new admissions to the home were suitable and that the home have the staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses and carers employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The manager confirmed that selffunding residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Intermediate or rehabilitative care is not provided at The Haven Care Home. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Medication practices at present are satisfactory. EVIDENCE: The care documentation pertaining to ten residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, and personal histories and risk assessments. On the whole the care documentation was seen to be improved and demonstrated that the care was reviewed and evaluated on a regular basis, however it was noted that the plans of care did not always cover all the care needs of residents. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need. There was evidence of a nutritional risk assessment being performed on all residents, however two were not completed accurately or in full, and so were not an accurate reflection of the residents nutritional status at this time. It was noted that water jugs and The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 11 glasses were accessible to residents throughout the day, an area that was highlighted from talking to residents and relatives is that squashes provided by the relatives/residents are not routinely offered despite being preferred, this would improve fluid intake especially during the warm weather. There are a lot of separate folders in use at present for various aspects of a residents’ individual care needs. Some were found to be stating different information than the risk assessment and main care plan, which could be misleading when evaluating the residents’ care. There was evidence of tippex being used on resident’s documentation and this needs to cease, for legality reasons. These areas were fully discussed during the inspection. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in a filing cabinet at each nurses’ station. There is a folder with the daily care delegation and all care staff have to sign on completion of their shift. There was little evidence in some care plans of resident/representative involvement in the formation of care plans or in monthly reviews. A new care plan system is being considered by the organisation. Discussion with a visiting health professionals confirmed that the home communicates well with other professionals as necessary with regard to the care of residents. Two surveys received from visiting professionals commented that “ I have no concerns regarding the care of residents” and “ the residents seem content and the staff are knowledgeable regarding the residents health problems”, one survey stated that further training would be beneficial for junior staff. Relatives spoken to were satisfied with the care provided at the home one saying that the home ‘the staff are very caring’. Residents spoken to were also satisfied comments included’ I am happy and content here’ ‘ I think I am well looked after’. The clinical rooms were found clean and tidy, with all the cupboards and clinical fridges appropriately locked. The equipment was found clean and well maintained. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication; they were last updated in August 2005. A selection of medication administration charts were viewed and were in the main completed correctly. A recommendation of good practice is that any verbal orders or short courses of medication brought over from previous month should be signed and dated, preferably by two persons in case an error is made regarding dosage or instruction. During the inspection the residents were seen being cared for with respect and kindness and their dignity being protected at all times. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Meals remain good in respect of both quality and variety that meets service users tastes and choice. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The inspector observed residents being able to spend time where and how they wanted moving around the home freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. This was confirmed during chats with the residents living in the home. Residents are able to choose whether they wanted to join in the activities provided which are available in the afternoons at 2.30 pm and include bingo, skittles, visiting singers, bowls and games. There were nine residents partaking in skittles on the afternoon of the inspection. Residents and their representatives felt the activities and entertainment provided was satisfactory. From talking to residents, a number of residents chose not to attend the activities provided. The activities provided did not demonstrate any creative The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 13 sessions, such as flower arranging, painting or video sessions and it would be beneficial to all residents if a survey was sent to all residents for their input. Three surveys received via post, would like more outside trips arranged. It is acknowledged that there is a new activity co-ordinator in post, and that she is still getting to know the individual preferences of the residents that live in the home. On speaking to residents and visitors it was clear that visiting is very positively encouraged with no restrictions being imposed. One visitor expressed a satisfaction that staff made an effort to be aware of who she was even though she does not visit the home on a regular basis. The meals viewed by the inspector were found to be well presented with an emphasis on home cooking and fresh ingredients. Residents were able to have their meals where they wanted to and to have extra portions if they desired. Most residents and visitors praised the food, and the vegetarians in the home were well catered for. Some residents were less forthcoming in the view on the home, saying it was “O.K” “satisfactory” and “all right”. The comments received during the inspection from the residents were mainly concerning the supper menu. The upstairs lounge/dining area has three tables that were used for supper and all the eight residents were in wheelchairs which made the space available crowded and three residents had difficultly in reaching their meals appropriately. It is a recommendation that specialist advice is sought regarding table height and positioning of wheelchair users whilst eating. All staff are to be reminded about equipment available, such as plate guards, to enable residents to be as independent as possible. Two residents were seen experiencing difficulty in managing their food. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users Guide and is available to residents and their families enabling them to share their concerns formally and confidentially. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse. EVIDENCE: There are appropriate policies and procedures in place regarding complaints, and it was confirmed that these are followed when investigating any concerns raised at The Haven. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. The staff interviewed were knowledgeable regarding the complaint procedure and of how to start the process if the manager is not available. No complaints have been received by the CSCI since the last inspection. Four of the six surveys received stated that they were aware of the complaint procedure and would have no problem with raising a concern if they wanted to. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. There is on-going training for all staff in Protection of The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 15 Vulnerable Adults. The training matrix indicates that 34 of staff have been trained so far this year with further training sessions planned. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in an attractive home that is well maintained and clean in most areas. Infection control practice was seen to be pro active. EVIDENCE: The inspection included a tour of the premises and the home was found well maintained and the décor was good throughout. The Haven provides comfortable and homely communal space, consisting of one large lounge area and a dining room on the ground floor and a dining room/lounge on the first floor. Resident bedrooms have been redecorated and carpets are being deep cleaned or replaced on a rolling programme. Residents are encouraged to personalise their own rooms and many have done so with ornaments, pictures and small pieces of furniture. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 17 There are toilet, washing and bathing facilities to meet the needs of the service users, including showers and assisted baths. There are plans to turn one underused bathroom into a wet shower room Random water temperatures were taken and were of the recommended temperature of 42 ° Celsius, the record book for the tests of water, fire alarms and call bells indicate that they are regularly tested. The maintenance person works full time in the home and is well organised. He has recently undertaken a hoist service course and all his records were available for inspection. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. A call bell facility is in place, and during the inspection the majority of call bells were found in reach of the residents. The residents in the dining areas and lounge areas did not have access to a call bell, those residents that can’t physically ring for help, need to have an appropriate risk assessment in place and a plan of action/monitoring to ensure their safety and comfort. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are adequate and suitable and ensure the needs of the residents living in the home are met at this time. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing levels for the morning shift comprised of two trained nurses and ten carers, which was seen to be sufficient to meet the resident’s needs at this time. This is in addition to domestic and kitchen staff. The staff spoken to said the staffing levels in the morning enabled them to give the standard of care required. Four residents said they felt the standard of care was good and they were well looked over. The afternoon shift demonstrated that staffing levels are halved and that there were two trained nurses and four carers on duty, with a floater carer from 6 pm until 11 pm. From discussions with staff and residents it is still the practice of the home to bathe all residents in the morning, no residents spoken with had a problem with the timing of baths. The staffing levels were sufficient to meet the needs of residents currently but must be kept under constant review to reflect any increased activity level in the home or dependency of residents. Five surveys received mentioned that the response to call bells was slow, some times waiting for up to fifteen minutes, and that staff were busy with other residents. Staffing levels need to reflect the needs of residents and respect The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 19 their choice of lifestyle. Increased staffing levels in the afternoon would allow staff to interact more with residents and allow more flexibility with seating arrangements of residents. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect service users and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept in a lockable facility within a locked room. The induction programme in place is more detailed than previously found and has been introduced for all new staff. Three members of staff spoken with had just completed the induction programme and confirmed that it had been helpful and senior nurses supportive. Staff interviewed confirmed a satisfaction with the training provided and stated that recent in house training was interesting and beneficial to performing their job. Staff and the training matrix seen confirmed that compulsory training such as manual handling, adult protection, first aid and fire safety are being undertaken. From the training matrix seen, not many staff have attended food hygiene training and this is to commence shortly by long distance learning as is resident welfare training, this will be followed by a course in dementia. A professional survey received felt that staff would benefit from attending a course of dementia. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Manager has the necessary experience and qualifications to run the home effectively. All aspects of resident’s health, safety and welfare were seen to be protected and promoted. EVIDENCE: The Registered Manager is a first level registered nurse and holds an orthopaedic nursing certificate. She has been the manager of The Haven for eight years; prior to this she has managed other nursing homes for nine years. She holds the NVQ D32/33 assessors course and is half way through the Registered Managers award course. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 21 The ethos of the home is to focus on the residents and staff were observed doing this. Resident and relative meetings are held three monthly, residents spoken with said they did not always want to attend the meetings, and one said his family went to the last one. The residents spoken with said were content and did not want to be more involved in the running of the home. There are suitable quality monitoring systems in place. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. Regulation 26 visits take place and documents are sent to the CSCI area office. All records required by regulation for the protection of the residents are in place and accurate. Individual records and home records are kept secure and up to date and are maintained in accordance with the Data Protection Act 1998. There is a training matrix, which evidences that mandatory training is being undertaken and the training is being planned to ensure that all staff undertake regular training. The home has a comprehensive set of policies and procedures, which govern the running of the home, however there was evidence to suggest that the policies and procedures are in need of reviewing. All relevant legislation and procedures are in place in respect of Health and safety. Good practice was observed throughout the inspection in respect of the safety of residents when being moved and transferred. Fire precautions were seen to be adhered to and staff showed a good knowledge of the mandatory training that is required. All staff need to be reminded that call bells are to be in reach of the resident at all times when I the lounge and dining areas or there is a system in place for staff to check the residents on a regular basis. On speaking to staff they acknowledge that when residents are transferred from bedroom, to lounge then to the dining room it is sometimes forgotten. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 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 3 3 3 3 3 3 3 The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) 13(4)(b) Requirement That a comprehensive plan of care is generated from a comprehensive assessment and drawn up for/with each service user, and it is reviewed at least once a month. (Previous time scales of 1/02/05 & 15/12/05 01/06/06 not fully met) Risk assessments must be undertaken for those service users with communication problems, at risk of falls and weight loss. Assessments must include the management of identified risks. That service users or their representatives are involved in the formation of care plans. 2. OP8 13(1)(b) 17(1)(a) That service users records comply with schedule 3 and that the nursing documentation complies with NMC guidelines. That tippex is not used on any legal document relating to service users. (Previous timescale of 01/06/06 not met.) DS0000013995.V303614.R01.S.doc Timescale for action 01/04/07 01/04/07 The Haven Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP3 OP12 OP15 OP27 OP37 OP38 Good Practice Recommendations That all residents have a full pre-admission assessment completed before admission to the home. That the activities are suitable for all the residents. That advice is sought regarding the positioning of residents in wheelchairs at meal times. That there sufficient staff are on duty at all times to meet the needs of the service users. That the policies and procedures in the home are updated regularly. That residents have access to a call bell at all times. The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Haven DS0000013995.V303614.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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