Inspection on 15/09/05 for The Haven

This inspection was carried out on 15th September 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 30/09/09

The Haven 23/10/07

The Haven 14/08/06

The Haven 07/02/06

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 Unannounced Inspection 15th September 2005 07:20 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.V253041.R01.S.doc Version 5.0 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.V253041.R01.S.doc Version 5.0 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.V253041.R01.S.doc Version 5.0 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. 01/02/05 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. On the day of the unannounced inspection there were residents in the home. The home was part of a group of homes previously owned by ANS Homes plc, and has been recently purchased by BUPA. The relevant paperwork has just been completed. 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 Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 15 September 2005 by two inspectors. The inspection commenced at 07.20 am and was conducted over 7 hours. There were forty-four residents living in the home at this time. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for eighteen residents and informal interviews with sixteen residents, two relatives and eight members of staff. What the service does well: What has improved since the last inspection? What they could do better: The pre-admission documents need to be completed in full and dated so as to ensure the home can meet the needs of the prospective resident and to ensure that any specialist equipment is in place before admission. The care planning and documentation in respect of the residents had been identified on a previous occasion, as a concern as it does not reflect accurately The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 6 the work staff do to meet the residents needs. Work is on going to change the format of the care plans, however there is a need to ensure that whilst care plans are being changed over that they are kept up to date and correctly reflect the care that is required. The danger of not maintaining accurate records is always that staff may not provide safe and consistent care and that changes in needs, cannot be tracked. Detailed risk assessments need to be carried out and include the management of identified risk to enable residents to safely undertake risks in their daily lives. Recruitment practices needs to ensure that all staff have a Criminal Record Check and two references prior to appointment to protect residents. Residents would benefit from an appropriately supported and supervised staff team. Training for staff needs to be put in place to ensure the staff are competent in performing their job. The requirements relating to health and safety need to be addressed to ensure residents health and welfare is protected. 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.V253041.R01.S.doc Version 5.0 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.V253041.R01.S.doc Version 5.0 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. The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. A pre-admission assessment is undertaken on all prospective residents before admission, however this document was found to have omissions and were incomplete on several occasions, which does not evidence that the home would be able to meet the assessed needs. All prospective residents and /or their families are encouraged to visit the home before admission to meet other residents and staff and to ensure that the home meets their expectations in respect of facilities and ambience. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 9 EVIDENCE: The statement of purpose and service users guide were viewed, it was found to be up to date and contained information that prospective service users need to make an informed choice of where to live. There is a written contract/statement of terms and conditions that all residents receive on admission to the home. This contract is confirmation of the room booked, the type of admission, either respite or permanent and the fees to be paid. It was noted that several residents have changed rooms since admission and it is asked that the reasons for this be documented on the resident’s profile. These documents will be updated by the BUPA Organisation on a rolling programme. There is an assessment tool in place, which covers all the needs as defined in standard 3.3. Eighteen pre-admission assessments were viewed, of which eight were found not fully completed and were missing important information; some were not signed and dated. The assessment takes place at the prospective residents’ place of residence, and involves the relatives whenever possible and input from other relevant professionals is sought when required. Five residents spoken with, said they remembered someone from the home coming to see them before they left hospital and felt it was helpful to be able to speak to someone from the home and it also gave them confidence that they would at least know someone when they arrived. As previously mentioned pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. These can then be discussed with the resident and their representative to ensure that the home can meet their needs. The statement of purpose also gives information regarding the services they provide. Prospective residents can visit the home to meet residents, to look at rooms that are available and the facilities provided before they make any decision regarding accepting a place. One relative said they had visited the home before their family member was admitted, and had made the decision for them. Two residents said that they had visited the home and had liked the rooms and the staff had been friendly. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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. There is no clear or consistent care planning system in place to adequately provide staff with information they need to satisfactorily meet service users needs. From the documentation available, it is not possible to evidence that the health needs of service users are met. The home has failed to improve their procedures for the administration and recording of medication thus placing service users at risk and harm. EVIDENCE: Eighteen care plans were viewed and did not fully meet the identified needs of the residents. It was noted that the positive outcomes observed at this time are still dependent upon staff knowledge and memories rather than full and detailed recording. There has been some changes made to the care planning system in use and when all the care plans are changed to this format it is expected that they will be easier and more user friendly. As explained in detail on the day of the inspection, the new care plans need to be signed and dated so as not to confuse admission dates and reflect that it is a new assessment. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 11 In some files, gaps of four months were noted between the admission profiles and the formation of care plans, when asked the reason, the old care plans were retrieved from the archived files. There were omissions in care plans regarding dementia and communication, wound care and weight loss. The risk assessments did not reflect what action was required for dealing with aggressive behaviour, prevention of pressure sores, falls and smoking. Some care plans had not been updated since end of January 2005. There was no evidence in the care plans inspected to suggest that residents or their representatives were consulted about the care process. Six of the residents spoken too, did not remember discussing the care plans with the staff. A relative spoken to said they “were kept informed of the care given, but had not been involved in any aspect of the care planning”. The clinical rooms were seen to be clean and well stocked, there were up to date policies seen regarding the administration, recording and storage of medicines. The lower clinical room smelt strongly of damp and there is a concern that it might affect the stock stored. The medicine administration charts were viewed, there were some identified gaps, and there was also a large amount of crossed out signatures, which were then resigned, some above and some below the crossed out signatures, this questions the procedures followed for administering medicines. Oxygen bottles need to be set up ready for use and securely stored. The care staff were seen to be treating residents with respect and dignity whilst attending to their needs. It is recommended that cleaning chores be performed in communal areas before residents are taken to these areas. The residents spoken to were complimentary regarding the staff, one said that “staff were very nice and treated her kindly”, another said “I like it here”. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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. The residents are enabled to exercise the choice and control of their every day life. The activities in the home are not meeting the individual preferences of the residents. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents. EVIDENCE: Some activities are provided and the residents’ mentioned games and the occasional outing. However, a planned programme of activities based on resident’s preferences needs to be created and implemented. This would ensure residents are given the opportunity to continue with past hobbies and pastimes. Residents social and leisure interests need to be record in both preadmission documents and in care plans. Two residents said that they would like more activities, one resident said he did not attend activities as they didn’t interest him. One resident said she attended activities and went out occasionally. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 13 On the day of the inspection some residents remained in their rooms while others sat in the lounges and dining areas watching television. Residents told the inspector that there was often not much to do although all said that staff try to spend time chatting when they were not as busy. All residents spoken with said that the food was good and that they are given a choice of meals. They also said that they are encouraged to eat in the dining room but may take meals in their rooms if they wish. Menus showed that balanced and varied meals are offered. Records are held detailing daily food choices for each resident. The meal served on the day of the inspection was enjoyed by all and well presented. Two residents said that the food was “lovely”. Another said, “It was always good tasty food”. Environmental Health visited the home on the day of the inspection and did not leave any requirements, only recommendations. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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. 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. The recruitment process at this time did not ensure the protection of the residents. 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. 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 Vulnerable Adults. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 15 During the inspection process five staff files were viewed and did not contain the necessary two references, and two did not have Criminal Record Checks. These checks are necessary to safeguard the residents. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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. The standard of the environment within this home is generally good providing residents with an attractive and homely place to live in. Improvements need to be made in regard to certain identified rooms. Resident’s bedrooms are comfortable and they are able to bring in their own possessions. There is specialist equipment in the home for residents’ use to maximise their independence, However to ensure the residents’ safety and comfort, call bells need to be accessible. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is good throughout. There were certain rooms that needed to be redecorated due to damaged walls, and some carpets that were badly stained, these were discussed with the maintenance person who was able to discuss the maintenance programme in depth. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 17 The Haven provides comfortable and homely communal space, consisting of two lounge areas and a dining room. The upstairs lounge/dining room was being redecorated on the day of the inspection. It was observed that the main lounge on the first floor was underused, and that residents were being taken to the dining room instead, which became crowded during the course of the morning. Staff were asked why residents were not making use of the lounge and it was said that access was difficult. It would benefit residents if this area was used to its full advantage. Residents are encouraged to personalise their own rooms and many have done so with ornaments, pictures and small pieces of furniture. Some rooms did not have bedside tables, and the reason for this needs to be reflected in their plan of care. There are toilet, washing and bathing facilities to meet the needs of the service users, including showers and assisted baths. It was noted that chairs and belongings are stored in the bathrooms and this practice needs to be reviewed and a dedicated space found. Random water temperatures were taken and were below 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 and these low results were passed on to the maintenance person. 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, however during the inspection the call bells were not all found in reach of the residents. One double room had only one bell, and another resident was placed on the opposite side of the room to the call bell, even though he would be able to use the facility, these were discussed at the time of the inspection. The residents in the dining area 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. The home has a team of domestic staff that work hard to keep the home clean and free from offensive odours. During the tour of the building certain areas were found below the expected standard, windows in identified rooms were very dirty and two rooms were found malodorous, grubby and tables sticky. The commodes were found stained and dirty in the sluice, which also compromises infection control procedures. It was found that there is no dedicated task list for the staff to follow and this would be beneficial to ensure that all areas are kept clean and monitored. The policy for specific infections, such as MRSA, need to be enlarged so all staff are clear on the procedures to follow regarding shared rooms. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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. On the morning of the inspection, staffing levels were seen to be adequate to meet the needs of the residents. The recruitment practice at this time was not robust and does not provide sufficient safeguards for the protection of service users. The records regarding the induction process and training were insufficient to assess that staff are trained and competent to perform their jobs. 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. The staff spoken to said the amount of staff enabled them to perform care to a good standard, but sometimes in the mornings it did become very busy depending on how many were poorly. Three residents said they felt the care was very good and they were well looked over. The afternoon shift demonstrated that staffing levels are halved and that there were two trained nurses and five carers on duty. Staff said that they found it difficult to maintain the standard of care they would like to give, as they were too busy. One resident said that she would like a bath in the afternoon instead of a shower in the morning but can’t because there are not enough staff. Staff confirmed there are no baths offered in the afternoon as staffing levels do not allow it. This is a concern because it reflects upon choice and lifestyle of individual residents. Staffing levels need to reflect the needs of residents and respect their choice of lifestyle. Extra staff in the afternoon would allow staff to The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 19 bathe people according to their wishes and free staff in the morning to interact more with residents. The recruitment files seen identified that not all staff had provided two references and not all staff had had a Criminal Record Check before commencing work. These issues must be addressed without delay to ensure residents are protected. The training records were found to be lacking in induction and foundation training and not all staff had attended mandatory training in moving and handling and infection control training. The administrator was not able to confirm from records that staff had attended the training. It was discussed that a training matrix needs to be developed which will make it easier to track and alert management as to the training they need to attend. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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): 36 and 38 The staff supervision records indicated that appropriate supervision is not in place. All aspects of resident’s health, safety and welfare need to be protected and promoted. EVIDENCE: The supervision records of five staff members were viewed and were not in place. Staff spoken with were unsure if they were receiving formal supervision and annual appraisals. This needs to be commenced immediately so all staff receive supervision and support whilst performing their jobs. During the inspection some concerns were found in respect of health and Safety. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 21 Residents were being wheeled in wheelchairs without the necessary footrests attached; this could cause injury to the resident. Door wedges were found keeping doors open and were removed. A fire door had an inappropriate high bolt in place, restricting opening in the event of an emergency. This was removed during the inspection. Oxygen cylinders in the treatment rooms need to be appropriately stored and ready for use. Call bells need to be in reach of all residents, one double room had only one call bell, another resident was placed on the opposite side of the room to the call bell, none of the residents in the dining area had access to a call bell. Those residents that do not have the capacity either physically or mentally to use a call bell need to have a risk assessment done which demonstrates how staff meet their needs, and monitor their safety. Cupboards containing cleaning fluids were found unlocked, and the cleaning trolley was found unattended for some length of time. Fire extinguishers need to be fixed to the wall. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 x 2 The Haven DS0000013995.V253041.R01.S.doc Version 5.0 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 7 Regulation 15(2)(b) 12(1) 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 scale of 1/02/05 not met) Risk assessments must be undertaken for those service users at risk of falls, at risk from pressure damage and weight loss. Assessments must include the management of identified risks That service users records comply with schedule 3 and that the nursing documentation complies with NMC guidelines.( previous time scale of 1/02/05 not met) That the medication charts are completed properly as Per NMC guidelines. That all oxygen bottles are secure and ready for use. That leisure and social activities are subject to review and further DS0000013995.V253041.R01.S.doc Timescale for action 15/12/05 2 8 13(1)(b) 17(1)(a) 15/12/05 3 9 13(2) 15/09/05 4 12 16(1)(m) 15/12/05 The Haven Version 5.0 Page 24 5 6 7 3 22 22 & 38 8 9 10 24 25 26 11 12 27 29 development, taking in to unt the service users personal references. 14(1)(a-c) Pre-admission documents must (2)(a&b) contain all aspects as listed under the standard. 23(2)(1) That suitable provision is made for the storage of equipment for the purposes of the care home. 16(1)(2) That call bells are in reach for all (c) service users and a risk assessment and plan of action is put in place for those that can not use a call bell. 16(1)(2) That all residents have the (c) necessary bedside tables in their private accomodation. 13(3) That all water temperatures are of the correct temperature 42 ° C 16(1)(92) That the home is kept clean and (j)(k) hygenic. That all commodes are kept clean. That a task list is devised for cleaning duties. That the policies for infection control – MRSA are developed further. 18(1)(a) That there sufficient staff are on duty at all times to meet the needs of the service users. 19(1-5) All staff need to provide the required documentation listed in Schedule 2 of the Regulations prior to appointment. 18(1)(a) (c)(i)(ii) That the training is appropriate to work they are to perform. 15/12/05 15/12/05 15/09/05 15/12/05 15/09/05 15/12/05 15/12/05 15/11/05 13 30 15/12/05 14 15 36 38 That the induction programme is in line with the TOPPS certified training programme. 18(1)(2) That all care staff receive formal 19(1)(a-c) supervision at least six times a year. 23(2)(4) That all wheelchairs are used safely with appropriate foot DS0000013995.V253041.R01.S.doc 15/12/05 15/09/05 The Haven Version 5.0 Page 25 rests. 16 38 23(4) That the practice of propping open doors ceases in line with the latest guidence from the fire service. That fire doors are not bolted. That fire extinguishers are firmly attached to walls. That all cleaning fluids are kept locked and safe at all times. 15/09/05 17 38 12(1)(a) 15/09/05 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 Refer to Standard 23 Good Practice Recommendations That the lounge areas are utilised for the comfort of residents. The Haven DS0000013995.V253041.R01.S.doc Version 5.0 Page 26 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. 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