Inspection on 23/10/07 for The Haven

This inspection was carried out on 23rd October 2007.

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 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 30/09/09

The Haven 14/08/06

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 BN10 7DX Lead Inspector Elizabeth Dudley Key Unannounced Inspection 10:00 23rd October 2007 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.V348333.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.V348333.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 29 Telscombe Cliffs Way Telscombe Cliffs East Sussex BN10 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 haveneveryone@bupa.com ANS Homes Ltd 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.V348333.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. 14th August 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 conditions of registration will be reviewed by the South East Regional Registration Team as part of the “ Modernising Registration Agenda”. The home is situated at Telscombe Cliffs, approximately half a mile from the sea front and the local shops, has space for car parking and is served by public transport. Previously a family home, it has been converted to provide accommodation for residents on two floors consisting of twenty-five single rooms and nine double rooms, communal accommodation comprises two lounges and two dining rooms and assisted bathing facilities. All areas of the home are accessed by a shaft lift and there are gardens to the rear of the property, which are accessible to residents. Previously part of a group of owned by ANS Homes plc, it has now been purchased by BUPA. The home is situated at Telscombe Cliffs, approximately half a mile from the sea front and the local shops, has space for car parking and is served by public transport. Fees charged as from 1 April 2007 range from £550 to £750 per week, additional charges are made for extra services such as chiropody, hairdressing, newspapers and toiletries. Details are available from the management. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 23rd October 2007 over a period of six hours and was facilitated Mrs C Thomas, the home manager. During the course of the inspection a tour of the home took place, eight residents, seven members of staff and three visitors were spoken with, and documentation including care plans, health and safety records and training programmes were examined. All residents were seen during the day. Prior to the inspection, additional information was received in the form of responses to questionnaires, which had been sent out to ten residents and relatives and two health care professionals. These provide valuable insight into the daily life in the home by the people that are using it, and inform the judgements made about the home in this report. The majority of the comments made about the home were positive with both residents and visitors saying, “ The standard of care is good and conscientious”. “ Staff speak respectfully to my (resident)”. “ I visit my (relative) often and her room is near the nurses station, I have never heard a member of staff speak inappropriately about a resident” “I received good information before I came to look around the home and staff are warm and welcoming. What the service does well: The Haven provides nursing care for up to 48 older people and admits residents with complex needs. The home employs two activities co-ordinators who working together enable a range of activities to be delivered which suit the varied abilities and aptitude of the residents. Morning activities generally involve spending one to one time with people that are not well enough to come out of their rooms. Residents receive a varied menu, offering choices at each meal. Meals are nutritionally balanced and reflect the tastes and preferences of residents living at the home. All residents said that they enjoyed the food and that there was always sufficient to eat. The home also has a snack menu for preparing during the night to any resident that requests this The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 6 The majority of residents spoken with said that they enjoyed the food offered by the home. A relative said that the food always looks well presented and appetising. What has improved since the last inspection? What they could do better: One questionnaire and two visitors to the home spoke of the lack of room for permanent seating for visitors in residents rooms due to the amount of equipment required for residents. Discussions were held with the manager regarding the provision of folding chairs or an alternative form of seating. Comments received prior to and during the inspection indicated that at times there are insufficient staff during the evenings to meet residents needs in a timely manner, the manager should keep staffing at these times under review. The door to the balcony in the dining room on the first floor is kept locked, this could be used as a fire exit as it exits onto the fire escape, and the key is kept The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 7 with the registered nurse on the floor. In the event of fire it may take time to access the fire escape and the manager stated that this would be addressed. No requirements were made at this inspection. 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 DS0000013995.V348333.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 DS0000013995.V348333.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. People who use the service experience good quality outcomes in this area. Prospective residents receive sufficient information to enable them to make an informed choice of whether to live at the home. A preadmission assessment provides a comprehensive overview of the resident’s needs, thus informing staff of the initial care required following their admission to the home, and reassuring the prospective resident that their care needs and expectations can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides prospective and existing residents with a Service User Guide that includes photographs of the home and existing staff. The guide is presented in a manner, which is easy to read, and includes necessary information about the daily life in the home whilst complying with the National The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 10 Minimum Standards and associated regulations. Residents spoken with said they had sufficient information prior to them deciding to move into the home. The Statement of Purpose requires amendments to reflect the address of the current providers and the CSCI, and to contain the current complaints policies and staffing details. The manager gave assurances that this would be addressed. All residents receive a statement of terms and conditions. These also require amendment to include the current address of the CSCI. Prospective residents are assessed by the manager or the senior registered nurse prior to their admission to the home, to ensure that the home can meet their needs and expectations. Two assessments were examined, these were comprehensive and included information about the physical, psychological and social needs of the prospective residents. Initial care plans are formed from the information included in the assessment, and staff stated that they were able to get an overview of the care required prior to the admission of the resident. Residents and their representatives can visit the home prior to them committing to live at the home, the first four weeks of admission are a trial period for both the resident and the home. Discussions were held with the manager regarding informing the prospective resident or their representative in writing over whether the home can meet their needs, as required by Regulation 14. The manager said that this would be commenced. The home admits residents for permanent, respite and continuing care, but not for intermediate care. The Haven DS0000013995.V348333.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): 7,8,9,10,11. People who use the service experience good quality outcomes in this area. The standard of care planning guides staff to provide care, which addresses the residents’ current health and social care needs. The standard of medication administration safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new care plan format has been introduced which guides staff to provide comprehensive documentation and records of their actions when providing care. This has been in place for three months. During the inspection a total of five care plans (12.5 ), belonging to residents living on both floors in the home, were examined in depth. Care plans had been reviewed on a regular basis formed in conjunction with the resident or The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 12 their representative, where possible, and included risk assessments, wound care plans, nutritional assessment and continence care plans. Care plans also included a ‘ life map’ which were dictated by either the resident or their representative and illustrated the key events in peoples lives including their preferred present and past social interests, areas of work and significant persons in their lives. Difficulties in communication or other sensory or physical disabilities were identified and the actions required to address these were recorded. The actions required to ensure that the needs of the resident were met, were recorded and gave clear instructions to staff that were responsible for giving care. There was evidence of pressure relieving equipment and that relevant health care specialists had been contacted for advice regarding wound care and pressure damage and some registered nurses had undertaken extended study in this field. Staff should ensure that when instructions to review wound care are in the care plan that this review takes place within the time scales given and the current status of the wound is documented. Not all night care plans included the residents preferred time of rising and retiring, and the manager said that this would be addressed. Residents have access to other health care professionals including General Practitioners, nurse specialists, speech and language therapists, physiotherapists, chiropody and opticians. A comment received was that staff have to be directed to call a doctor for more minor issues at times. The standard of medication administration and recording protects the residents, and meets the regulations and the guidance from the Nursing and Midwifery Council. All residents in their rooms had call bells within reach, and there were staff in the lounges with the residents to attend to those without a call bell near to them. Staff addressed residents in a pleasant manner, which upheld their dignity. Three registered nurses are at present undertaking training in the Gold Standards Framework, a tool for ensuring that the end of life care given to residents is in accordance with national guidelines and the home is commencing the Liverpool care pathway (a tool to ensure those residents who The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 13 are terminally ill have the benefit of prompt and efficient pain control). Staff spoken with were knowledgeable about the care required at the end of life. The Haven DS0000013995.V348333.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, People who use the service experience good quality outcomes in this area. There is sufficient flexibility in the homes’ routine to ensure that residents are able to make choices in the activities of daily life with a comprehensive programme of leisure and social activities catering for the varying abilities and interests of the residents. Meals are attractively presented, offer choice and variety, and are nutritionally balanced to meet the dietary requirements and preferences of residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Various activities taking place within the home, which are provided by two activities coordinators. The programme of activities is displayed and shows activities taking part both in the mornings and the afternoon. A quarterly newsletter is produced for residents. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 15 Residents spoken with said that they could choose their daily routines including their times of rising and retiring, these times were written in some care plans. There is an open visiting at the home, with relatives and friends being able to visit at any time. There is input from ministers of religion, once a month there is a Church of England Service and the Roman Catholic minister visits once a week. The manager said that other ministers of religion from ethnic and minority groups have visited the home as required. Residents can take their meals either in their rooms or in one of the two dining rooms. The menu showed a choice of food at each meal, including a choice for those residents who require pureed food, and the chef was able to demonstrate that residents were able to choose from a range of suitable nutritious food, he stated that they would also provide options not shown on the menu if the resident asks for them. Records of alternative choices required by residents are recorded. One relative said that there could be more fruit and vegetables, but the kitchen store showed that sufficient were brought in three times a week and menus showed that these were included in the diet, with residents being offered fresh fruit at meal times. Pureed food was attractively presented and staff were seen to be assisting residents with meals in an empathetic manner. The home runs a ‘night bite’ menu, which provides a selection of various snacks for residents throughout the night. All documentation regarding cleaning, mandatory checks and training were in place in the kitchen and all members of catering and care staff have the food hygiene course. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. Residents are protected by the homes complaints policy and manner of dealing with complaints and concerns. Staff are aware of their responsibilities in the safeguarding those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy, which is on view in the hallway and included in the service user guide and statement of purpose. Amendments are required to ensure that the BUPA complaints procedure supersedes the previous company’s complaints procedure in the Statement of Purpose with the relevant changes of address of both the current owners and the CSCI included. Six complaints have been received in the past year, of which all were substantiated. Records were in place to show that the manager had addressed these in a timely manner and actions taken to resolve these had been to the satisfaction of the complainants. All staff have undertaken adult safeguarding training. There has been one adult safeguarding issue in the past year, which was substantiated. The procedures The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 17 undertaken by the manager to investigate this were in line with the protocols identified by the lead authority responsible for safeguarding of adults. Whilst the investigation is now complete, the manager is in the process of completing the procedure. The manager showed knowledge of the Mental Capacity Act 2007 and has amended some working procedures within the home to incorporate this, particularly on the administration side. The home does not have the up to date version of the multi agency guidelines and it was recommended that a copy of this be obtained. Staff spoken with, were aware of their responsibilities towards those in their care. All residents and relatives spoken with were aware of how to make a complaint. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 People who use the service experience good quality outcomes in this area. The Haven provides a pleasant, well-maintained and clean home for residents. There are sufficient aids and equipment to enable residents to maintain independence. Lack of suitable seating for visitors could result in residents becoming isolated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Haven provides a pleasant and well-maintained environment for those who live there. Redecoration of residents’ rooms takes place on a rolling programme, some new furniture has been purchased and there are plans in place for the renovation of the kitchen area. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 19 Communal accommodation consists of a large lounge and dining area on the ground floor and a combined lounge and dining area on the second floor, a large garden to the rear is accessible to all residents. Residents’ rooms are comfortable and residents can bring in their own possessions to make them feel at home. All have lockable doors, with residents being provided with keys if they wish to have one, some have lockable drawer facilities for residents’ valuables. The manager said that furniture is being renewed and it is anticipated that all residents will have the benefit of a lockable storage facility. Twenty-eight variable position beds have been purchased recently. Individual rooms now benefit from radiator valves allowing the resident to adjust the temperature of the room. Lack of these had been mentioned in a comment card received. Window openings are restricted and radiator guards are in place. Comments were received that chairs for visitors were removed from resident’s rooms. The manager said that this was due to the amount of equipment required in rooms for the purpose of nursing the residents, and that she is considering providing folding chairs for this purpose. There are five assisted bathrooms, which include a wet room with assisted shower and specialist shower seat. The majority of rooms have ensuite facilities, which generally consist of a washbasin and WC, and all rooms have a washbasin. The temperature of the hot water supplied to residents is monitored and recorded by the maintenance person on a regular basis, and these were within recommended parameters. The home has received the benefit of advice from qualified persons in providing equipment and aids for disabilities and there were sufficient grab rails, assisted baths, full body and standing hoists and other equipment to enable people to maintain independence. The home was clean throughout including clinic rooms; laundry and kitchens, housekeepers and other domestic staff have had the relevant mandatory training. There are policies and procedures relating to control of infection and the majority of staff were aware of the role they play in reducing opportunity for cross infection. During the inspection it was seen that one member of staff was not aware that her actions could lead to cross infection, and this was discussed with the registered nurse and the manager. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 20 The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. There are sufficient staff on duty with suitable training to meet the assessed needs of the residents during most of the twenty-four hour period. A robust recruitment procedure safeguards the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs thirty-two care staff and nine registered nurses, on a full or part time basis. The rota identified that staffing were employed in sufficient numbers over a twenty four hour period to meet the needs of the residents, and staff and residents said that there were generally sufficient staff on duty. Previous concerns raised about there being less staff in the evenings have been partially resolved by the use of a member of staff working specifically from six until 10 pm, but comments received both prior to this inspection and during the inspection, from residents and relatives, were that ‘ sometimes staff are very busy in the evenings’, ‘evenings can be difficult, its sometimes hard to get hold of the staff’. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 22 Care staff are supported by five domestic staff in the morning and catering staff and a laundry person during the afternoon and including weekends. Fifteen members (49 ) of the care staff have attained the National Vocational Qualification level 2 in Care, and staff and management stated that the home receives support from the owners, with regular training sessions across all areas required, being provided. Extra training for staff is also in place with staff have recently attended training in Motor Neurone Disease, and registered nurses have been encouraged to maintain their training in line with the requirements of the Nursing and Midwifery Council, three are currently receiving training in the Gold Standards Framework and Liverpool Care Pathway (end of life care). All staff undertake induction training relevant to their role and completed copies of this were seen. There is a training programme and matrix in place which identified that all staff have undertaken mandatory health and safety training, which is regularly reviewed and updated. Staff are provided with a staff handbook, which contains details of the company policies. Four staff files (8 ) belonging to all grades of staff were examined and these showed that recruitment systems were robust. Staff have not received the General Social Care Code of Conduct handbook but actions to obtain copies of these was commenced during the inspection The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 23 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): 31,32,33,35,36,37,38. People who use the service experience good quality outcomes in this area. The registered manager has the qualifications and experience to run the home in an effective manner that meets the expectations of residents and promotes their safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for ten years, is a registered nurse and is registered as manager with the CSCI. She has obtained the Registered Managers Award. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 24 Staff and residents spoken with said that the atmosphere in the home was comfortable, with residents said that they were able to make their needs known and felt listened to. Staff supervision takes place at intervals as directed by the standard and staff meetings are taking place every two months. Regulation 26 visits (providers monthly visits as required by regulation) take place on a monthly basis and reports are kept in the home. There are adequate systems in place to monitor the services offered by the home. Questionnaires to residents and relatives are sent out on an annual basis, and relative and residents meetings take place. The Annual Quality Assurance Assessment received by the CSCI reflected the situation in the home and the planning for the future. The home collates the feedback from questionnaires received and this is used to assess services in the home. The Annual Quality Assurance Assessment identified that policies and procedures required by the home have been reviewed. The manager is appointee for the finances of one resident in the home, and the home also keeps money for resident’s use. There is a robust system of financial control and all records relating to individual’s finances were seen to be in place. The Annual Quality Assurance Assessment recorded that all utilities and equipment have been serviced, and that staff have received the mandatory training in health and safety aspects. A door which accesses the balcony and fire escape in the first floor dining room is kept locked; although not a fire exit door, this could be used as such in the event of fire. Concerns from staff regarding accessing this key in the event of fire were raised with the manager who will address this. The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 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 x 3 3 3 3 The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Haven DS0000013995.V348333.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local 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 DS0000013995.V348333.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!