Inspection on 22/07/08 for The Haven

This inspection was carried out on 22nd July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Haven 25/05/07

The Haven 02/11/06

The Haven 24/01/06

The Haven 07/06/05

The Haven 31/01/05

The Haven 29/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Haven 191 Havant Road Drayton Portsmouth Hampshire PO6 1EE Lead Inspector Mick Gough Unannounced Inspection 22nd July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Haven DS0000011671.V363306.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 DS0000011671.V363306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 191 Havant Road Drayton Portsmouth Hampshire PO6 1EE 023 9237 2356 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) Mrs S M Spencer Mrs T Hall Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2007 Brief Description of the Service: The Haven is registered with the Commission for Social Care Inspection (CSCI) to provide care and support for 20 elderly persons, including people with dementia and is situated in a pleasant residential area of Drayton, a suburb of the City of Portsmouth. A detached property, the home is accessed via a short driveway. There is parking at the front of the home for approximately 8 cars. The home is situated close to the local shopping area and amenities and provides a homely environment for the people who live there. There are 18 single bedrooms and one double room. All bedrooms provide en-suite facilities. There is a large garden at the rear of the property, which is laid to lawn. A ramp for wheelchair users and steps with handrails, provide further access for people who live in the home. At the time of the visit fees at the home ranged from £415 to £463 per week, depending on the type and level of support required. An up to date scale of fees can be obtained by contacting the home. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This report details the evaluation of the quality of the service provided at The Haven and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out in May 2007. The inspection took into account the home’s Annual Quality Assurance Assessment (AQAA); and comment cards received from 4 users of the service and 2 members of staff. Included in the inspection was an unannounced site visit to the home, which took place on the 22 July 2008. For this visit the inspector was assisted for part of the inspection by an “Expert by Experience” (this is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in, or use the service). Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and users of the service. The expert by experience spent time talking to residents to obtain their views on how the service was meeting their needs and expectations. It was also possible to speak with 3 members of staff, the home’s manager and the registered provider. The home is registered to provide support for 20 residents and at the time of the inspection there were 20 people living at the home. What the service does well: The home provides care and support to enable service users to live meaningful lives. There is a well-established staff team willing to be flexible and who know a lot of the regular service users well. Residents spoken with confirmed this. The management ensure that staff receive appropriate training regularly and offer support and supervision to staff. Staff support residents in their day-to-day lives and they are treated as individuals and with dignity and respect. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 6 The home has a dedicated and stable staff team and they receive appropriate training to enable them to provide effective support to residents and there is a robust recruitment procedure, which helps protect residents. What has improved since the last inspection? What they could do better: There was 1 requirement made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report, general observations were: Currently care plans are reviewed monthly, however in some of the reviews there was no evaluation of how the care plan was working for the resident. In order to ensure that care needs are always met care plan reviews would benefit from a clear evaluation of how the care plan was working and should also provide evidence that the resident was involved in the review process. When residents are prescribed medication that says “1 or 2” to be given, the home must ensure that the correct dose given is recorded to provide a clear audit trail. The home keeps some controlled drugs “temazepam” and the law concerning the storage of controlled drugs has recently changed and the home must ensure that any controlled drugs are stored in a proper Controlled Drugs Cupboard, which meets the requirements as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 7 The home’s laundry area did not have hand washing facilities in the immediate vicinity and there was a need for a clear procedure to be drawn up to guide staff when laundering any soiled items. Currently the cleaner told us that she vacuums the communal areas every other day. However we wee informed by the manager that staff vacuums these areas after lunch and tea and again at night. The manager should review the cleaning schedule to ensure that the communal areas of the home are vacuumed and cleaned sufficiently to ensure that residents are protected from any possible risk of infection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential new residents have a needs assessment undertaken prior to moving into the home and this allows the home, the resident and their relatives to see if the home can meet the resident’s needs. The home does not provide intermediate care. EVIDENCE: The home carries out an individual needs assessment prior to residents moving into the home and there is a clear admission process and assessments were on file at the home and were looked at for the 3 residents. Needs assessments seen had information on Circulation, eating and drinking, elimination, skin hygiene, pain, mobility, medication, dressing/undressing, personal care, communication, daily routines, weight on arrival, sleep routines & leisure and interests. Assessments were made using a needs assessment form and therefore covered the same issues for everyone. The home’s AQAA told us that social service assessments are carried out when necessary and either the manager or proprietor of the home always visits any potential new residents The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 10 and carries out a pre admission assessment to ensure that the home can meet the assessed needs, this was confirmed by some of the residents spoken with on the day of the visit. Intermediate care is not provided at the home. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are set out in an individual plan of care and residents have access to all relevant health care professionals and their health care needs are met. The administration of medication is satisfactory, however the storage of any controlled drugs needs to be improved. Residents at the home are treated with dignity and respect and their personal care is given in private. EVIDENCE: Care plans were inspected for 4 residents. Care plans had information on care needs, however, the care plans for 3 residents did not contain a great deal of information about how the resident would like their care to be given. The manager explained that these residents were able to tell staff how they wanted care to be provided and all of the staff know each resident very well. The home does not use agency staff so there is never anyone giving care to residents who do not know them well. However the home should ensure that care plans contain sufficient information to enable staff to provide the type and level of care required for each individual resident. The care plan for one resident who was less able to communicate her needs contained more The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 12 information about the type and level of support required. Staff members spoken with said that they know all the residents well but still used the care plans to provide them with information to enable them to give the right type of support at the right time. Through discussions with the manager it was recommended that care plans had a communication section so that staff would know if the resident was able to inform staff of the support they needed. Daily recording takes place at the end of each shift and this provides information on what support has been given during each shift, looking back over recording, showed that residents who needed continence aids had these checked and changed regularly. Each care plan was reviewed monthly, however the reviews on some care plans simply said “no change” this was discussed with the manager and it was pointed out that monthly reviews would be more beneficial if they had more evaluation of how the care plan was working for the resident and this would give information on residents progress of lack of it as the case may be and could also provide evidence that residents were involved in the review process. Residents said that staff was always very helpful and one commented “ I am well looked after here” and another said “they help me whenever I ask”. One resident who had been at the home for only 2 months was very content and said, as she had a bad wrist, a carer was able to help her dress in the morning. We spoke to 2 visitors who said that they felt that their relatives’ care needs were met by the home. Residents are registered with a total of 6 different GP surgeries and have a number of different GP’s. District nurse visits are arranged though the individual surgery and the home keeps a record of any appointments or visits by any health care professionals. On the day of the visit one resident was having her medication reviewed. The home uses a continence nurse who advises on all residents at the home who need support. Some residents keep their own dentist and optician. The home has a visiting dentist and one resident told the expert by experience that she had asked that she had treatment in the home when she had 3 lower teeth removed and the home was able to arrange this for her. An optician service is available to all residents. A chiropodist calls every 4 – 6 weeks and any other relevant health care professionals are arranged through GP referral. The home has a policy for the receipt; storage, return and administration of medication and all staff at the home who are authorised to administer medication have undertaken training with regard to medication. The home uses a monitored dose system from a local pharmacy and the medication administration records sheets (MARS) were inspected and found to be up to The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 13 date. There was one resident who had been prescribed co-codamol “1 or 2” to be given, however it was not clear on the recording sheet what dose had actually been given and the home must ensure that the actual dose given is recorded to provide a clear audit trail. The homes medication storage was looked at and this was suitable for its purpose, however the home keeps some controlled drugs and these were kept in a locked cupboard inside the medication cupboard but this was not securely fixed to the wall. The law concerning the storage of controlled drugs has recently changed and controlled drugs must now be stored in a proper Controlled Drugs Cupboard. In brief, the requirements for CD storage are: • Metal cupboard of specified gauge • Specified double locking mechanism • Fixed to a solid wall or a wall that has a steel plate mounted behind it • Fixed with either Rawl or Rag bolts Suppliers of CD cabinets can confirm that a cupboard meets the legal requirements. During the visit staff were seen to behave appropriately with residents and we and the expert by experience observed staff interacting well with residents and using their preferred form of address. Staff were seen to knock on residents’ doors before entering and residents spoken to confirmed that staff treat them with dignity and respect. The expert by experience also noticed a good friendly rapport between the staff and residents. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for residents, which meet their expectations and the religious and recreational interests of residents are provided for. Residents are able to maintain contact with family and friends and visitors are welcome at any time. Residents are supported to exercise choice and control over their lives as much as possible and are provided with a wholesome and balanced diet in pleasant surroundings at a time convenient to them. EVIDENCE: The home provides a range of activities for residents, and most activities were run by the owner apart from a keep fit session once a fortnight. Residents have a list of the activities including knitting, art and craft, bingo and memory lane, games, sing-a-long and manicures and hand massage. Ladies were knitting tea-cozies to a pattern provided by the home during the visit. One lady said about the aerobics, ‘She’s a very nice girl who does it; it’s very popular’. We were shown some of the completed artwork and pieces of work adorned the dining-room wall. Nobody spoken to could suggest any other activity they would like to see. Some of the artwork like bookmarks would be used as Xmas presents later this year. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 15 The home keeps a life book and this records all activities that are arranged and details who took part. One resident goes out every morning in a taxi with her dog and another resident goes out independently to the local shops and to the pub. The manager told us that she used to arrange lots of trips out but residents now do not wish to do any outside activities. Questionnaires sent to residents did not indicate that they would like more trips out. A number go out with families but the manager told us that when the home has arranged trips no one wants to go. The home has monthly residents meetings and residents can bring up any ideas they may have for activities and these are then actioned. 2 residents go out every week to different churches and there is a weekly communion service in the home. The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway. Residents spoken to said that their visitors were always made welcome and we had the opportunity to speak with 2 visitor to the home who confirmed that visiting times were flexible and they had never experienced any restrictions. We observed staff supporting residents and they were consulted about life in the home through the residents’ meetings held every 4 - 6 weeks. Copies of these meetings were written up by the owner. There are about 5-6 residents attending the meetings, when refreshments are served as well! Things like change of mealtimes and swapping desserts on Saturdays and Sundays had been implemented as a result of the residents’ requests. The provider said she ‘listens to the residents as to what they want.’ One resident said, ‘If there’s something we like, we say, and if not, we’re not afraid to mention it. Residents spoken to confirmed that they are able to make informed choices and are able to control their own lives as much as possible, they said that they were consulted regularly and that staff at the home respected their views and that if they wanted anything all they had to do was ask. A number of residents had bought some of their own possessions into the home and rooms had been personalised The home operates a four-week rolling menu and the provider or the cook goes round in the morning to inform residents what the menu is and offers them a choice if they prefer. Today’s menu was not on public display. Residents spoken with were happy with the choice of food provided by the home. The lunch on the day of the visit was packeted vegetable soup followed by bought steak pie, fresh greens, carrots, parsnips, marrow, roast potatoes and gravy. This was followed by tinned creamed rice and jam. Jugs of water and juice were on tables and fresh fruit was in bowls on the table throughout the visit. Everyone was content with the food provided, apart from one gentleman who said, ‘The food could be better, the meat pie isn’t home-made.’ Other residents told us “ the food is very good” “ I always have enough to eat” and “there is nothing to complain about” Residents’ mealtimes were unhurried and staff provided suitable support for those residents who required it. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 16 Residents are able to eat their meals in the dining room or elsewhere if they prefer. Residents help to lay the tables at meal times and paper napkins were also put out. Residents were happy to help stack plates at their tables. An order from a local supermarket arrived during the visit and items delivered were of good quality and included packeted parsley sauce and tins of fruit. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures help protect users of the service from any form of abuse. EVIDENCE: The home has a clear complaints procedure, which contains all of the required information and a copy is issued to all residents and relatives when they move into the home. The expert by experience spoke to the majority of residents and several said, ‘I have no complaints’. One lady when asked whether she had any complaints answered, ‘So far, so good.’ She had been there 5 ½ years! Residents were aware of the Residents’ Committee Meetings and put any suggestions forward, mainly concerning mealtimes and food ideas. One resident said, ‘I’d leave if I weren’t happy. We’re all very contented together like a family.’ Staff members spoken to were aware of the complaints procedure and said that they would support any service user to make a complaint if they wished to do so. The homes AQAA told us that there had been no complaints received in the home in the past 12 months and the home keeps a record of all complaints and records confirmed that no complaints had been recorded. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 18 All staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. Residents have the specialist equipment they require to maximise their independence and the home was generally clean, pleasant and hygienic and free from offensive odours, however residents would benefit from an improved cleaning schedule. EVIDENCE: We had a look around the home during the visit and all areas of the home were clean and tidy and furniture was in a good state of repair. There is a large enclosed garden at the rear of the property and this was tidy and safe. There was a new patio area with tables and chairs and was shaded from the sun and access was via steps with handrails and also a wheelchair ramp. Whilst walking around the outside of the home we observed a raised slope (running North-South) on the left hand side of the building and this presented a possible trip hazard for residents, the provider told us that this area is very The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 20 rarely used and no one has ever fallen, however the home should consider having a white line painted on it to warn people about the edge. The home has a maintenance man who carries out routine maintenance and decoration and the manager stated that this works well. There has been new chairs ordered for the downstairs quiet lounge and new carpets have been purchased in some areas of the home. The home has a call system for service users to summon assistance and these were available in all rooms and were easily accessible. CCTV monitors the entrance and side access to the home and the front of the home has a balcony with seats where residents can sit and relax. There were hand gel dispenser situated in the entrance hall and in other areas around the home. One resident has a dog that has a basket in the main lounge in the home. The dog was seen to be well behaved and very unobtrusive, however the expert by experience did stand on his paw by mistake. One resident had fallen doing the same thing and a risk assessment has been put in place. One resident said, ‘I’ve never known such a quiet dog.’ Another said they had all filled in a form to say that they were happy to have a dog there. The dog went out daily for a taxi ride and subsequent walk. The dog’s water and food was in his owner’s bedroom downstairs. Whilst touring the home the expert by experience had some concerns with the level of cleanliness in certain areas of the home. The basins, baths and lavatories seen were clean, however the kitchen area was noted to be greasy on top of containers. The home does not have a dishwasher and the home should consider purchasing one to aid hygiene. It was also noted that carpets in some residents’ rooms would benefit from a good clean. We were informed that the maintenance man has a rota for cleaning all of the carpets in the home on a regular basis and a copy of the rota was kept in the office. One visitor told the expert by experience regarding her relative’s room “Sometimes, I feel I’d like to come round and give the room a jolly good clean”. Whilst walking around the home the expert by experience noticed some dog hairs on carpets in the lounge areas and a cleaner said she cleaned the upstairs and downstairs carpets in the open areas on alternate weekdays and that the residents’ rooms were vacuumed only once a week, with the exception of the dog owner’s room and one other. Cleaning was discussed with the manager and provider and the home should look at improving the cleaning schedule to ensure that the communal areas of the home are vacuumed and cleaned to satisfactory standards to meet residents needs. The home has a laundry, which is situated in the downstairs part of the home; this is equipped with domestic washing machines and tumble driers. There are no hand washing facilities in the laundry and we discussed the need for clear signs to be in place to direct staff to the nearest hand washing facilities. The home does not employ dedicated staff to carry out laundry duties and care staff carry out laundry duties, however some residents get family to help with some of their laundry. Some residents have laundry baskets in their rooms while others rely on staff bringing their clothes down to the laundry. The manager informed us that there is very rarely any soiled items, but it was pointed out The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 21 that a clear procedure for dealing with any soiled items would benefit staff and the manager told us that she would draw up a procedure immediately. All staff have received training with regard to infection control and the home was generally clean and tidy and there were no offensive odours. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff on duty to ensure residents receive the support they require. Staff were found to be well motivated and competent to do their jobs and residents are protected by the homes recruitment procedures. The home provides training for staff to enable them to carry out their roles effectively. EVIDENCE: The homes staff rota showed that there is a senior carer plus 1 other care staff member on duty between 0800 & 2100 and 1 awake staff members and 1 sleep in staff member on duty between 2100 and 0800. The homes manager and the registered provider are in the home most days and complement these numbers and they are also on call in the evenings and at weekends if required. There is also 2 cooks and 2 cleaners who work at the home. The majority of residents spoken with said that they felt that staffing levels were adequate. However one resident said, ‘It worries me that there aren’t enough staff at night, if something happened to me.’ Other residents told us that “the staff are very good” “there is always someone around” and “I am well looked after”. Staff spoken to also said that they felt that staffing levels were sufficient. Staffing numbers were discussed with the manager and she stated that she felt that staffing levels were sufficient, however staffing numbers would be kept under review. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 23 The home employs a total of 16 care staff and the manager stated that over 50 hold a minimum of NVQ level 2 with 4 members of staff working towards level 3. The manager told us that the home would support staff to obtain National Vocational Qualifications. The manager informed us that members of staff on average stay for a long time and staff turnover at the home is very low with the majority of staff being employed for over 3 years. The owner told the expert by experience that one staff member had been there for 20 years and she met one who had been there for 9 years and another for 4. The owner said that the home never used agency staff and that she could always call in staff when necessary, and they always obliged. Recruitment records were seen for two members of staff and both files seen contained all of the required information including application form, 2 x references, photo, passport, birth certificate, health declaration, Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and contract of employment. Staff training records were looked at and the manager showed us a training matrix, which showed that training is provided in; first aid, food hygiene, moving and handling, fire, infection control, adult protection, medication, health and safety, pressure areas, palliative care, dementia care and challenging behaviour. A suitable induction programme is in place and staff are expected to show that they are familiar with the homes procedures. Induction includes Communication, observation and reporting, adult protection and safeguarding, bathing, mobility, skin care privacy dignity & respect, manual handling, nutrition client care and also policies and procedures. Staff spoken to confirmed that they received a thorough induction and that they are provided with appropriate training in order to carry out their care tasks. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a person fit to be in charge and able to discharge her responsibilities fully. The home has a quality assurance system in place to seek the views of residents, relatives and other professionals to measure the effectiveness of the service. Staff are supervised as part of the normal management process and systems are in place for the safekeeping of residents personal spending money. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has been in post for over 10 years and has a city and guilds in care management and has completed the Registered Managers Award, she operates an open door policy and is able to manage the service effectively, and she told us that she undertakes regular training to update her skills. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 25 The home has an effective quality assurance system in place and questionnaires are sent out to residents, Responses to questionnaires are kept in a folder at the home and we were able to view these and they showed that people were happy with the service provided. Regular regulation 26 visits are conducted and the home holds regular staff meetings every month and these are conducted over 2 dates so that all staff are able to attend. Residents meeting are held every 4 - 6 weeks and minutes of these meetings provided evidence that any issues that are raised are taken seriously and are actioned by the home whenever possible. The home does not manage any residents’ money, however relatives do give the home money for residents personal items this is held on their behalf in an account, which is separate from the homes account and there is recording of all transactions, balances, deposits and withdrawals detailed and this provides a clear audit trail. There is an in date fire risk assessment for the building and regular health and safety monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for gas safety, fire alarms systems and equipment, private electrical equipment, passenger lift and fixed hoists. The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The home must ensure that any controlled drugs are stored in a controlled drugs cabinet that meets the legal requirements as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. Timescale for action 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Haven DS0000011671.V363306.R01.S.doc Version 5.2 Page 29 - 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. 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